Karen L. Hannah

Quality of ambulatory care for diabetes and lower-extremity amputation.

Lower extremity amputation (LEA) is a serious complication of diabetes. We sought to determine whether quality of ambulatory care affects risk of LEA. We conducted a claims-based case-control study of 409 Medicare beneficiaries younger than age 75 with diabetes and LEA between January 1, 2003, and December 31, 2005. They were matched with controls with diabetes without LEA, on age, gender, number of diabetes outpatient visits, and (for those with hospital admissions between January 1, 2000, and December 31, 2002) number of comorbid conditions, diabetes complications, and peripheral vascular disease. Quality-of-care measures for cases and controls covered the period April 1, 1999, through March 31, 2001. LEA patients were less likely to have had lipid screening than controls (odds ratio = 0.73; 95% confidence interval = 0.53-0.99), and controls were more likely to use physicians with high performance in lipid screening (χ 2 = 6.631, P = .012) and hemoglobin A1c testing (χ 2 = 6.079, P = .014). (Am J Med Qual 2007;22:410-417)

Improving Self-Reporting of Adverse Drug Events in a West Virginia Hospital

Adverse drug events significantly increase length of stay and costs of hospitalization but are underre-ported in health care institutions. We hypothesized that hospitals could improve the accuracy of adverse drug event self-reporting by comparing adverse drug events recorded in an occurrence reporting tool with those detected by surveillance of “rescue” drugs administered to treat adverse drug events. We conducted a prospective cohort study of all adult inpatient discharges from a 200-bed rural acute care hospital in West Virginia during a 6-month period. We performed 3572 chart audits, of which 1011 included rescue drug administration. Our outcome measure was the proportion of adverse drug events in the rescue drug surveillance that were found in the occurrence reporting tool. We found that less than 4% of all adverse drug events involving use of rescue drugs were reported. We concluded that underreporting of preventable adverse drug events in this hospital is comparable to published rates and that surveillance of adverse drug events to detect underreporting is feasible.

Impact of the 2004 Influenza Vaccine Shortage on Repeat Immunization Rates

PURPOSE We assessed the impact of the severe influenza vaccine shortage of 2004 on individual physicians’ immunization performance. METHODS Using 1998–2004 Medicare claims data, we monitored the physician continuity rate (proportion of patients receiving influenza immunization from a physician in 1 year who received a subsequent immunization from the same physician the subsequent year) and other clinician rate (proportion of patients with claims from 1 physician in 1 year with a claim from another clinician the subsequent year) in West Virginia Medicare beneficiaries from 2000–2004. We examined vaccine claim trends by clinician and surveys of self-reported immunization to determine whether patients received vaccine from nonphysician clinicians or went without immunization each year. RESULTS Claims-based influenza vaccination rates increased from 35.5% to 41.3% from 2000–2003, reflecting historical trends, before declining 14.1% in 2004. Median continuity rates among the 723 to 849 physicians claiming 25 or more influenza immunizations from 2000–2003 increased from 47% in 2000–2001 to 54% in 2002–2003; then fell to 3% in 2003–2004. The number of physicians filing 100 or more claims declined from 337 in 2003 to 130 in 2004. More than 25% of physicians had no repeat vaccinations of the same beneficiaries in 2004. Trends in clinician type and survey data indicated a shift of many beneficiaries to mass vaccinators and institutional providers; however, compared with previous years, there was an estimated 8% increase in 2004 in the number of West Virginia beneficiaries who did not receive vaccine. CONCLUSIONS The 2004 vaccine shortage had a severe impact on influenza immunization rates in private physician’s offices, disrupting continuity of care.

Promoting Influenza and Pneumococcal Immunization in Older Adults

BACKGROUND Reducing the risk of influenza and pneumococcal disease in older adults is a long-standing goal of Medicares Quality Improvement Organization (QIO) program and parallels the Joint Commissions National Patient Safety Goal 10. ADDRESSING THE GOAL Since 1999 the West Virginia Medical Institute has worked with a statewide partnership of health organizations on a program to improve influenza and pneumonia vaccination rates in hospitalized Medicare beneficiaries. Methods included education, audit and feedback, toolkits, and training meetings. RESULTS During the first three years (1999-2001) of the effort, the rate of assessment for pneumococcal immunization at discharge increased from < 10% to 74.1% statewide and for influenza immunization from near zero to 63.4% statewide. Since 2002 pneumococcal immunization administration has increased from 16.1% to 41.1%, with similar improvement in influenza measures. LESSONS LEARNED/NEXT STEPS Hospitals--and, by extension, long term care facilities--can make dramatic improvements in quality performance in a relatively short time when key staff receive feedback about the need to improve and the tools to assist in improving.

Exploratory analysis of the relationship between home health agency engagement in a national campaign and reduction in acute care hospitalization in US home care patients

RATIONALE, AIMS AND OBJECTIVES To determine whether US home health agencies that intensively engaged with the 2010 Home Health Quality Improvement National Campaign were more likely to reduce acute care hospitalization (ACH) rates than less engaged agencies. METHOD We included all Medicare-certified agencies that accessed Campaign resources in the first month of the Campaign and also responded to an online survey of resource utilization at month two. We used the survey data and item response theory to estimate a latent construct we called engagement with the campaign. ACH rates were calculated from the Centers for Medicare & Medicaid Services Outcome and Assessment Information Set for pre- and post-intervention periods (March-November 2009 and 2010, respectively). RESULTS Staff from 1077 agencies accessed resources in the first month of the Campaign. Of these, 382 provided information about resource use and had 10 or more monthly discharges throughout the measurement periods. Dividing these agencies into quartiles based on engagement score, we found an association between engagement and reduction in ACH rates, P=0.049 (χ(2) for trend). Exploratory path analysis revealed the effect of engagement score on reduction in ACH rate to be partially mediated through reduction in average length of service rates. CONCLUSION We found evidence that early intensity of engagement with the Campaign, as measured through use of activities and resources, was positively associated with improvement. To continue the investigation of this relationship, future work in this and other campaigns should focus on further development of engagement measures.Rationale, aims and objectives To determine whether US home health agencies that intensively engaged with the 2010 Home Health Quality Improvement National Campaign were more likely to reduce acute care hospitalization (ACH) rates than less engaged agencies. Method We included all Medicare-certified agencies that accessed Campaign resources in the first month of the Campaign and also responded to an online survey of resource utilization at month two. We used the survey data and item response theory to estimate a latent construct we called engagement with the campaign. ACH rates were calculated from the Centers for Medicare & Medicaid Services Outcome and Assessment Information Set for pre- and post-intervention periods (March–November 2009 and 2010, respectively). Results Staff from 1077 agencies accessed resources in the first month of the Campaign. Of these, 382 provided information about resource use and had 10 or more monthly discharges throughout the measurement periods. Dividing these agencies into quartiles based on engagement score, we found an association between engagement and reduction in ACH rates, P = 0.049 (χ2 for trend). Exploratory path analysis revealed the effect of engagement score on reduction in ACH rate to be partially mediated through reduction in average length of service rates. Conclusion We found evidence that early intensity of engagement with the Campaign, as measured through use of activities and resources, was positively associated with improvement. To continue the investigation of this relationship, future work in this and other campaigns should focus on further development of engagement measures.

Letter to the Editor: Author's Response:

Big brother is watching. This is a postscript to the recent article by Ansell et al (September/October 2007). The monitoring of health care quality by the computer of a health insurance company has its limitations. Patients who check their prothrombin time, international normalized ratio (PT/INR) at home with a point-of-care instrument may appear as though their care is substandard. This is because medical claims for warfarin prescriptions are not matched by claims for laboratory PT/INR testing. Recently, I received a notification from a health insurance company regarding the quality of my patient’s care because of this issue. I replied on the form provided that my patient, on life-long anticoagulation, self-tests at home and confers with me by telephone as needed. However, my written explanation describing this management did not seem to make a difference and, after the second notification regarding this matter, I chose the other response option offered on the form and called a health professional at the insurance company. I spoke with a nurse and explained in detail about why home PT/INR testing, in selected cases, is high-quality care. Her response was totally unexpected; she asked me how she could get such a device for her son who is on warfarin and whose PT/INRs were seemingly out of control. I suggested that she discuss home point-of-care testing with his doctor and gave her the 800 number of a vendor of point-of-care instruments. But, I cautioned her that his health insurance company might not pay for this instrument. Although, very grateful for the information, she likewise cautioned me that more letters concerning the care of my patient were likely to come from her company’s computer.