L. Elizabeth Goldman

Comparison of change in quality of care between safety-net and non-safety-net hospitals.

CONTEXT Safety-net hospitals (ie, those that predominantly treat poor and underserved patients) often have lower quality of care than non-safety-net hospitals. While public reporting and pay for performance have the potential to improve quality of care at poorly performing hospitals, safety-net hospitals may be unable to invest in quality improvement. As such, some have expressed concern that these incentives have the potential to worsen existing disparities among hospitals. OBJECTIVE To examine trends in disparities of quality of care between hospitals with high and low percentages of Medicaid patients. DESIGN AND SETTING Longitudinal study of the relationship between hospital performance and percentage Medicaid coverage from 2004 to 2006, using publicly available data on hospital performance. A simulation model was used to estimate payments at hospitals with high and low percentages of Medicaid patients. MAIN OUTCOME MEASURES Changes in hospital performance between 2004 and 2006, estimating whether disparities in hospital quality between hospitals with high and low percentages of Medicaid patients have changed. RESULTS Of the 4464 participating hospitals, 3665 (82%) were included in the final analysis. Hospitals with high percentages of Medicaid patients had worse performance in 2004 and had significantly smaller improvement over time than those with low percentages of Medicaid patients. Hospitals with low percentages of Medicaid patients improved composite acute myocardial infarction performance by 3.8 percentage points vs 2.3 percentage points for those with high percentages, an absolute difference of 1.5 (P = .03). This resulted in a relative difference in performance gains of 39%. Larger performance gains at hospitals with low percentages of Medicaid patients were also seen for heart failure (difference of 1.4 percentage points, P = 0.04) and pneumonia (difference of 1.3 percentage points, P <.001). Over time, hospitals with high percentages of Medicaid patients had a lower probability of achieving high-performance status. In a simulation model, these hospitals were more likely to incur financial penalties due to low performance and were less likely to receive bonuses. CONCLUSIONS Safety-net hospitals tended to have smaller gains in quality performance measures over 3 years and were less likely to be high-performing over time than non-safety-net hospitals. An incentive system based on these measures has the potential to increase disparities among hospitals.

Effect of pay-for-performance incentives on quality of care in small practices with electronic health records: A randomized trial

IMPORTANCE Most evaluations of pay-for-performance (P4P) incentives have focused on large-group practices. Thus, the effect of P4P in small practices, where many US residents receive care, is largely unknown. Furthermore, whether electronic health records (EHRs) with chronic disease management capabilities support small-practice response to P4P has not been studied. OBJECTIVE To assess the effect of P4P incentives on quality in EHR-enabled small practices in the context of an established quality improvement initiative. DESIGN, SETTING, AND PARTICIPANTS A cluster-randomized trial of small (<10 clinicians) primary care clinics in New York City from April 2009 through March 2010. A city program provided all participating clinics with the same EHR software with decision support and patient registry functionalities and quality improvement specialists offering technical assistance. INTERVENTIONS Incentivized clinics were paid for each patient whose care met the performance criteria, but they received higher payments for patients with comorbidities, who had Medicaid insurance, or who were uninsured (maximum payments:

Incidence, predictors, and outcomes associated with postoperative atrial fibrillation after major noncardiac surgery.

200/patient;

Federally Qualified Health Centers and Private Practice Performance on Ambulatory Care Measures

100,000/clinic). Quality reports were given quarterly to both the intervention and control groups. MAIN OUTCOMES AND MEASURES Comparison of differences in performance improvement, from the beginning to the end of the study, between control and intervention clinics for aspirin or antithrombotic prescription, blood pressure control, cholesterol control, and smoking cessation interventions. Mixed-effects logistic regression was used to account for clustering of patients within clinics, with a treatment by time interaction term assessing the statistical significance of the effect of the intervention. RESULTS Participating clinics (n = 42 for each group) had similar baseline characteristics, with a mean of 4592 (median, 2500) patients at the intervention group clinics and 3042 (median, 2000) at the control group clinics. Intervention clinics had greater adjusted absolute improvement in rates of appropriate antithrombotic prescription (12.0% vs 6.1%, difference: 6.0% [95% CI, 2.2% to 9.7%], P = .001 for interaction term), blood pressure control (no comorbidities: 9.7% vs 4.3%, difference: 5.5% [95% CI, 1.6% to 9.3%], P = .01 for interaction term; with diabetes mellitus: 9.0% vs 1.2%, difference: 7.8% [95% CI, 3.2% to 12.4%], P = .007 for interaction term; with diabetes mellitus or ischemic vascular disease: 9.5% vs 1.7%, difference: 7.8% [95% CI, 3.0% to 12.6%], P = .01 for interaction term), and in smoking cessation interventions (12.4% vs 7.7%, difference: 4.7% [95% CI, -0.3% to 9.6%], P = .02 for interaction term). Intervention clinics performed better on all measures for Medicaid and uninsured patients except cholesterol control, but no differences were statistically significant. CONCLUSIONS AND RELEVANCE Among small EHR-enabled clinics, a P4P incentive program compared with usual care resulted in modest improvements in cardiovascular care processes and outcomes. Because most proposed P4P programs are intended to remain in place more than a year, further research is needed to determine whether this effect increases or decreases over time. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00884013.

The Accuracy of Present-on-Admission Reporting in Administrative Data

BACKGROUND Although major noncardiac surgery is common, few large-scale studies have examined the incidence and consequences of post-operative atrial fibrillation (POAF) in this population. We sought to define the incidence of POAF and its impact on outcomes after major noncardiac surgery. METHODS Using administrative data, we retrospectively reviewed the hospital course of adults who underwent major noncardiac surgery at 375 US hospitals over a 1-year period. Clinically significant POAF was defined as atrial fibrillation occurring during hospitalization that necessitated therapy. RESULTS Of 370,447 patients, 10,957 (3.0%) developed clinically significant POAF while hospitalized. Of patients with POAF, 7,355 (67%) appeared to have pre-existing atrial fibrillation and 3,602 (33%) had newly diagnosed atrial fibrillation. Black patients had a lower risk of POAF (adjusted odds ratio, 0.53; 95% CI, 0.48-0.59; P < .001). Patients with POAF had higher mortality (adjusted odds ratio, 1.72; 95% CI, 1.59-1.86; P < .001), markedly longer length of stay (adjusted relative difference, +24.0%; 95% CI, +21.5% to +26.5%; P < .001), and higher costs (adjusted difference, +

Support From Hospital to Home for Elders: A Randomized Trial

4,177; 95% CI, +

Public Reporting and Pay-for-Performance: Safety-Net Hospital Executives' Concerns and Policy Suggestions

3,764 to +

United States rural hospital quality in the Hospital Compare database-accounting for hospital characteristics.

4,590; P < .001). These findings did not differ by whether POAF was a recurrence of pre-existing atrial fibrillation, or a new diagnosis. CONCLUSION POAF following noncardiac surgery is not uncommon and is associated with increased mortality and cost. Our study identifies risk factors for POAF, which appear to include race. Strategies are needed to not only prevent new POAF, but also improve management of patients with pre-existing atrial fibrillation.

Timeliness of abnormal screening and diagnostic mammography follow-up at facilities serving vulnerable women.

BACKGROUND The 2010 Affordable Care Act relies on Federally Qualified Health Centers (FQHCs) and FQHC look-alikes (look-alikes) to provide care for newly insured patients, but ties increased funding to demonstrated quality and efficiency. PURPOSE To compare FQHC and look-alike physician performance with private practice primary care physicians (PCPs) on ambulatory care quality measures. METHODS The study was a cross-sectional analysis of visits in the 2006-2008 National Ambulatory Medical Care Survey. Performance of FQHCs and look-alikes on 18 quality measures was compared with private practice PCPs. Data analysis was completed in 2011. RESULTS Compared to private practice PCPs, FQHCs and look-alikes performed better on six measures (p<0.05); worse on diet counseling in at-risk adolescents (26% vs 36%, p=0.05); and no differently on 11 measures. Higher performance occurred in ACE inhibitors use for congestive heart failure (51% vs 37%, p=0.004); aspirin use in coronary artery disease (CAD; 57% vs 44%, p=0.004); β-blocker use for CAD (59% vs 47%, p=0.01); no use of benzodiazepines in depression (91% vs 84%, p=0.008); blood pressure screening (90% vs 86%, p<0.001); and screening electrocardiogram (EKG) avoidance in low-risk patients (99% vs 93%, p<0.001). Adjusting for patient characteristics yielded similar results, except that private practice PCPs no longer performed better on any measures. CONCLUSIONS FQHCs and look-alikes demonstrated equal or better performance than private practice PCPs on select quality measures despite serving patients who have more chronic disease and socioeconomic complexity. These findings can provide policymakers with some reassurance as to the quality of chronic disease and preventive care at Federally Qualified Health Centers and look-alikes, as they plan to use these health centers to serve 20 million newly insured individuals.

An Assessment of the Quality of Mammography Care at Facilities Treating Medically Vulnerable Populations

OBJECTIVE To test the accuracy of reporting present-on-admission (POA) and to assess whether POA reporting accuracy differs by hospital characteristics. DATA SOURCES We performed an audit of POA reporting of secondary diagnoses in 1,059 medical records from 48 California hospitals. STUDY DESIGN We used patient discharge data (PDD) to select records with secondary diagnoses that are powerful predictors of mortality and could potentially represent comorbidities or complications among patients who either had a primary procedure of a percutaneous transluminal coronary angioplasty or a primary diagnosis of acute myocardial infarction, community-acquired pneumonia, or congestive heart failure. We modeled the relationship between secondary diagnoses POA reporting accuracy (over-reporting and under-reporting) and hospital characteristics. DATA COLLECTION We created a gold standard from blind reabstraction of the medical records and compared the accuracy of the PDD against the gold standard. PRINCIPAL FINDINGS The PDD and gold standard agreed on POA reporting in 74.3 percent of records, with 13.7 percent over-reporting and 11.9 percent under-reporting. For-profit hospitals tended to overcode secondary diagnoses as present on admission (odds ratios [OR] 1.96; 95 percent confidence interval [CI] 1.11, 3.44), whereas teaching hospitals tended to undercode secondary diagnoses as present on admission (OR 2.61; 95 percent CI 1.36, 5.03). CONCLUSIONS POA reporting of secondary diagnoses is moderately accurate but varies by hospitals. Steps should be taken to improve POA reporting accuracy before using POA in hospital assessments tied to payments.