Joanne Lynn

Value-Based Payments Require Valuing What Matters to Patients

Sylvia Burwell, Secretary of Health and Human Services, recently announced the department’s intention to tie most Medicare fee-for-service payments to value by 2018.1 Most commercial insurers already incentivize quality to some degree and encourage beneficiaries to consider quality and cost.2,3 Having payers aim for value should improve health system performance, certainly when compared with traditional incentives for the volume of services, which have failed to deliver the kind of care that is possible.4 Paying for value, though, requires measuring what actually matters to patients. Yet almost all current quality metrics reflect professional standards: eg, medications after myocardial infarctions, cancer screening according to guidelines, or glycated hemoglobin A1c levels being under control for patients with diabetes.5 These metrics are relatively straightforward to calculate with available data, and patients’ interests usually align with professional standards—people want medical services to help them live longer, prevent or cure illnesses, limit the likelihood of and morbidity from disease and injury, and avoid or effectively

Reductions in Medication-Related Hospitalizations in Older Adults with Medication Management by Hospital and Community Pharmacists: A Quasi-Experimental Study

To evaluate the association between a system of medication management services provided by specially trained hospital and community pharmacists (Pharm2Pharm) and rates and costs of medication‐related hospitalization in older adults.

Acute Decompensated Heart Failure Is Routinely Treated as a Cardiopulmonary Syndrome

Background Heart failure as recognized and treated in typical practice may represent a complex condition that defies discrete categorizations. To illuminate this complexity, we examined treatment strategies for patients hospitalized and treated for decompensated heart failure. We focused on the receipt of medications appropriate for other acute conditions associated with shortness of breath including acute asthma, pneumonia, and exacerbated chronic obstructive pulmonary disease. Methods and Results Using Premier Perspective®, we studied adults hospitalized with a principal discharge diagnosis of heart failure and evidence of acute heart failure treatment from 2009-2010 at 370 US hospitals. We determined treatment with acute respiratory therapies during the initial 2 days of hospitalization and daily during hospital days 3-5. We also calculated adjusted odds of in-hospital death, admission to the intensive care unit, and late intubation (intubation after hospital day 2). Among 164,494 heart failure hospitalizations, 53% received acute respiratory therapies during the first 2 hospital days: 37% received short-acting inhaled bronchodilators, 33% received antibiotics, and 10% received high-dose corticosteroids. Of these 87,319 hospitalizations, over 60% continued receiving respiratory therapies after hospital day 2. Respiratory treatment was more frequent among the 60,690 hospitalizations with chronic lung disease. Treatment with acute respiratory therapy during the first 2 hospital days was associated with higher adjusted odds of all adverse outcomes. Conclusions Acute respiratory therapy is administered to more than half of patients hospitalized with and treated for decompensated heart failure. Heart failure is therefore regularly treated as a broader cardiopulmonary syndrome rather than as a singular cardiac condition.

Reliable and Sustainable Comprehensive Care for Frail Elderly People

For most of history, people died young. Just a century ago, the median life expectancy was less than 50 years of age. Growing old was rare, and even more rarely did surgeons and physicians see much benefit in treating elderly people, except to relieve symptoms. Even half a century ago, when Medicare started providing coverage for older individuals, the median age at death was only slightly above the eligibility threshold of 65 years. Today, most people in the United States who survive infancy and avoid serious injury live into their 80s and beyond. Better nutrition, occupational and obstetrical safety, prevention strategies, and improved medical treatments have yielded more years of good health, and it is likely that science will continue to make progress in delaying the effects of aging. Nevertheless, death is inevitable. As the incidence of sudden and premature deaths has declined in the United States, the last part of most individuals’ lives has come to be marked by progressive chronic illnesses and diminishing physical reserves that engender self-care disabilities and frailty. Those who live past age 65 years now average 3 years of self-care disability at the end of life, needing long-term services and supports (LTSS).1 For those living past 85 years old, nearly half will have serious cognitive decline.2

Treatment for Multiple Acute Cardiopulmonary Conditions in Older Adults Hospitalized with Pneumonia, Chronic Obstructive Pulmonary Disease, or Heart Failure

To determine how often hospitalized older adults principally diagnosed with pneumonia, chronic obstructive pulmonary disease (COPD), or heart failure (HF) are concurrently treated for two or more of these acute cardiopulmonary conditions.

Report on milestones for care and support under the U.S. National Plan to Address Alzheimer's Disease

Under the U.S. national Alzheimers plan, the National Institutes of Health identified milestones required to meet the plans biomedical research goal (Goal 1). However, similar milestones have not been created for the goals on care (Goal 2) and support (Goal 3).

Strategies to Ease the Burden of Family Caregivers

In this issue of JAMA, Adelman and colleagues1 describe an older woman who attempted suicide to escape the overwhelming burdens of caring for her ill and debilitated husband. This case starkly illuminates the despair that family (and friend) caregivers can feel when supporting frail or disabled relatives, and the failure of US health care to support them. Half a century ago when Medicare began, few people lived long with disabling chronic illness and family supports were more readily available. Today’s 65-year-olds, and all who come after, are likely to experience several years of needing another person’s help in the last phase of life.2 Many will find such help difficult to obtain; few live near large extended families, and few have younger family members who can afford to leave paid work to provide unpaid care of indefinite duration.

Integrating Health Information Technology to Achieve Seamless Care Transitions.

Abstract Improving care transitions, or “handoffs” as patients migrate from one care setting to another, is a priority across stakeholder groups and health-care settings and additionally is included in national health-care goals set forth in the National Quality Strategy. Although many demonstrations of improved care transitions have succeeded, particularly for hospital discharges, ensuring consistent, high-quality, and safe transitions of care remains challenging. This paper highlights the potential for health information technology to become an increasing part of effective transitional care interventions, with the potential to reduce the resource burden currently associated with effective care transitions, the ability to spread improved practices to larger numbers of patients and providers efficiently and at scale, and, as health technology interoperability increases, the potential to facilitate critical information flow and feedback loops to clinicians, patients, and caregivers across disparate information systems and care settings.

Building an integrated methodology of learning that can optimally support improvements in healthcare

The methods for healthcare reform are strikingly underdeveloped, with much reliance on political power. A methodology that combined methods from sources such as clinical trials, experience-based wisdom, and improvement science could be among the aims of the upcoming work in the USA on comparative effectiveness and on the agenda of the Center for Medicare and Medicaid Innovation in the Centers for Medicare and Medicaid Services. Those working in quality improvement have an unusual opportunity to generate substantial input into these processes through professional organisations such as the Academy for Healthcare Improvement and dominant leadership organisations such as the Institute for Healthcare Improvement.

Standard set of health outcome measures for older persons

BackgroundThe International Consortium for Health Outcomes Measurement (ICHOM) was founded in 2012 to propose consensus-based measurement tools and documentation for different conditions and populations.This article describes how the ICHOM Older Person Working Group followed a consensus-driven modified Delphi technique to develop multiple global outcome measures in older persons.The standard set of outcome measures developed by this group will support the ability of healthcare systems to improve their care pathways and quality of care. An additional benefit will be the opportunity to compare variations in outcomes which encourages and supports learning between different health care systems that drives quality improvement. These outcome measures were not developed for use in research. They are aimed at non researchers in healthcare provision and those who pay for these services.MethodsA modified Delphi technique utilising a value based healthcare framework was applied by an international panel to arrive at consensus decisions.To inform the panel meetings, information was sought from literature reviews, longitudinal ageing surveys and a focus group.ResultsThe outcome measures developed and recommended were participation in decision making, autonomy and control, mood and emotional health, loneliness and isolation, pain, activities of daily living, frailty, time spent in hospital, overall survival, carer burden, polypharmacy, falls and place of death mapped to a three tier value based healthcare framework.ConclusionsThe first global health standard set of outcome measures in older persons has been developed to enable health care systems improve the quality of care provided to older persons.