Marcia K. Petrillo

Aspirin in the Treatment of Acute Myocardial Infarction in Elderly Medicare Beneficiaries Patterns of Use and Outcomes

BACKGROUND Although aspirin is an effective, inexpensive, and safe treatment of acute myocardial infarction, the frequency of use of aspirin in actual medical practice is not known. Elderly patients, a group with low rates of utilization of effective therapies such as thrombolytic therapy, also may be at risk of not receiving aspirin for acute myocardial infarction. To address this issue, we sought to determine the current pattern of aspirin use and to assess its effectiveness in a large, population-based sample of elderly patients hospitalized with acute myocardial infarction. METHODS AND RESULTS As part of the Cooperative Cardiovascular Project Pilot, a Health Care Financing Administration initiative to improve quality of care for Medicare beneficiaries, we abstracted hospital medical records of Medicare beneficiaries who were hospitalized in Alabama, Connecticut, Iowa, or Wisconsin from June 1992 through February 1993. Among the 10,018 patients > or = 65 years old who had no absolute contraindications to aspirin, 6140 patients (61%) received aspirin within the first 2 days of hospitalization. Patients who were older, had more comorbidity, presented without chest pain, and had high-risk characteristics such as heart failure and shock were less likely to receive aspirin. The use of aspirin was significantly associated with a lower mortality (OR, 0.78; 95% CI, 0.70 to 0.89) after adjustment for potential confounders. CONCLUSIONS About one third of elderly patients with acute myocardial infarction who had no contraindications to aspirin therapy did not receive it within the first 2 days of hospitalization. The elderly patients with the highest risk of death were the least likely to receive aspirin. After adjustment for differences between the treatment groups, the use of aspirin was associated with 22% lower odds of 30-day mortality. The increased use of aspirin for patients with acute myocardial infarction is an excellent opportunity to improve the delivery of care to elderly patients.

A statewide initiative to improve the care of hospitalized pneumonia patients: The Connecticut Pneumonia Pathway Project.

PURPOSE A statewide quality improvement initiative was conducted in Connecticut to improve process-of-care performance and to decrease length of stay for patients hospitalized with community-acquired pneumonia. SETTING AND METHODS Data were collected on 1,242 elderly (> or =65 years) pneumonia patients hospitalized at 31 of 32 acute care hospitals between January 16, 1995, and March 15, 1996, and on 1,146 patients hospitalized between January 1, 1997, and June 30, 1997. Interventions included feedback of performance data (Qualidigm, the Connecticut Peer Review Organization), dissemination of an evidence-based pneumonia critical pathway (Connecticut Thoracic Society), and sharing of pathway implementation experiences (hospitals). Process and outcome measures included early antibiotic administration, blood culture collection, oxygenation assessment, length of stay, 30-day mortality, and 30-day readmission rates. Analyses were adjusted for severity of illness and hospital-specific practice patterns. RESULTS After the statewide initiative, improvements were noted in antibiotic administration within 8 hours of hospital arrival (improvement from 83.4% to 88.8%, relative risk [RR] = 1.21; 95% confidence interval [CI]: 1.10 to 1.32), oxygenation assessment within 24 hours of hospital arrival (93.6% to 95.4%; RR = 1.23, 95% CI: 1.11 to 1.38), and length of stay (7 days to 5 days, P <0.001). There were no significant changes in blood culture collection within 24 hours of hospital arrival, blood culture collection before antibiotic administration, 30-day mortality, or 30-day readmission rates. CONCLUSIONS Statewide improvements were demonstrated in the care of hospitalized pneumonia patients concurrent with a multifaceted quality improvement intervention. Further research is needed to separate the effects of the quality improvement interventions from secular trends.

Correlation of the agency for health care policy and research congestive heart failure admission guideline with mortality: Peer review organization voluntary hospital association initiative to decrease events (PROVIDE) for congestive heart failure

STUDY OBJECTIVE We quantify patient risk as related to the presence or absence of the Agency for Health Care Policy and Research (AHCPR) congestive heart failure (CHF) hospital admission criteria. METHODS This was a retrospective observational cohort study at 12 acute care hospitals examining consecutive patients with the final primary diagnosis of CHF. Trained record abstractors blinded to outcome extracted 386 data elements, including 6 AHCPR admission criteria: (1) pulmonary edema (determined by radiograph) or severe respiratory distress (respiration >40 breaths/min), (2) hypoxia (oxygen saturation <90%) not caused by pulmonary disease, (3) significant edema (>/=+2) or anasarca, (4) symptomatic hypotension (<90 mm Hg systolic blood pressure) or syncope, (5) CHF of recent onset, and (6) clinical evidence (chest pain) of myocardial ischemia. The association between admission criteria and mortality rate (30 days, 6 months, and 1 year) was quantified and risk adjusted by stepwise logistic regression analysis. RESULTS Of the 1,674 patients with CHF, 1,340 (80%) were admitted to the hospital. Patients not admitted had a lower mortality rate than admitted patients (30-day mortality rate, 2.1% [95% confidence interval [CI] 0.6 to 3.6] versus 11.5% [95% CI 9.8 to 13.2]; odds ratio 0.20 [95% CI 0.09 to 0.45]). Two of the admission criteria did not correlate with a higher mortality rate: CHF of recent onset and myocardial ischemia. Excluding those 2 criteria, the number of admission criteria present correlated with the patients probability of hospital admission (P <.001), length of hospital stay (P =.014), and 30-day mortality rate (P <.0001). When zero or 1 admission criteria was present, physician clinical judgment did distinguish patients less likely to die in the subsequent 30 days (1.5% [95% CI 0.2 to 2.8] sent home versus 10.2% [95% CI 8.5 to 11.9] admitted). When 2 or more admission criteria were present, physician clinical judgment did not distinguish patients less likely to die in the subsequent 30 days (18.2% [95% CI 0 to 42.0] sent home versus 19.4% [95% CI 13.6 to 25.2] admitted). CONCLUSION Selected criteria of the AHCPR CHF admission guideline correlate with mortality rate. Combined with physician clinical judgment, they may be useful in the risk stratification of patients with CHF. Selected low-risk patients with CHF identified by the admission criteria who are presently managed in the acute care hospital may be candidates for outpatient management. [Graff L, Orledge J, Radford MJ, Wang Y, Petrillo M, Maag R: Correlation of the Agency for Health Care Policy and Research congestive heart failure admission guideline with mortality: Peer Review Organization Voluntary Hospital Association Initiative to Decrease Events (PROVIDE) for congestive heart failure.

Process and Outcome of Care for Acute Myocardial Infarction among Medicare Beneficiaries in Connecticut: A Quality Improvement Demonstration Project

In August 1992, Jencks and Wilensky [1] described the new approach of the Health Care Financing Administration (HCFA) for improving the quality of health care provided to Medicare beneficiaries. This new philosophy, titled the Health Care Quality Improvement Program, stresses analysis of patterns of care rather than case-by-case review. It also emphasizes educational feedback rather than punitive interactions between peer review organizations and providers [2]. In an editorial accompanying the initial description of this program, Nash [3] pointed out several potential barriers to successful implementation and suggested an alternative strategy emphasizing additional planning and more staged implementation. The Medicare Hospital Information Project is the first project to use HCFAs new philosophy for quality improvement. This project is designed to determine whether the Peer Review Organization and the provider communities can collaborate effectively on quality improvement initiatives through analysis of Medicare claims data and, with the commitment of limited additional resources, through medical record review. The Medicare Hospital Information Project was piloted by Peer Review Organizations from Connecticut and Wisconsin between May 1992 and March 1993. We describe the experience of the Peer Review Organization from Connecticut in the pilot phase of the project and highlight some of the scientific challenges confronting Peer Review Organizations in implementation of the Health Care Quality Improvement Program [2]. Our pilot project specifically involves analysis of the Medicare mortality data issued by HCFA from 1989 to 1991 [4]. Since their initial release, these reports have been a source of substantial controversy. The reports are derived primarily from claims submitted by hospitals to HCFA for payment of services rendered to Medicare beneficiaries and from mortality data from the Social Security Administration. Hospital representatives and the health services research community have criticized the reports as inaccurate, inadequately adjusted for risk [5], and easily misunderstood by the lay public [6]. Nevertheless, the reports contain potentially useful data for Peer Review Organization and hospital-sponsored quality improvement efforts. In Connecticut, a three-member team consisting of the Peer Review Organizations physician clinical coordinator, statistician, and project coordinator spearheaded the pilot activities of the Medicare Hospital Information Project. This team worked closely with the Interhospital Study Committee, which incorporated physicians, nurses, hospital administrators, health services researchers, and medical records personnel from the Connecticut Hospital Association, the Connecticut State Medical Society, the Yale University and University of Connecticut Schools of Medicine and Public Health, the carrier fiscal intermediary (Travelers Insurance Company) for the Connecticut HCFA, and Connecticut hospitals. After several preliminary meetings and review of the initial claims analysis done by the Peer Review Organization team, the Interhospital Study Committee suggested that a limited chart abstraction study be developed to evaluate potential sources of variation across hospitals in risk-adjusted mortality. Acute myocardial infarction was chosen as the focus condition because it is a high-volume, high-mortality diagnosis. Methods Use of the Medicare Mortality Data To Select the Study Hospitals Six hospitals were selected for evaluation on the basis of observed/expected 30-day mortality rates (standardized mortality ratios) for acute myocardial infarction (principal diagnosis 410) during federal fiscal years 1989 to 1991 (1 October 1988 to 30 September 1991). The claims-based regression model for mortality used by HFCAreferred to as the Bailey-Makeham model [7]forecasts the probability of death after admission to the hospital on the basis of several explanatory factors. These include patient age, sex, admission source (for example, elective or emergency), comorbid conditions (for example, cancer, cardiovascular disease, cerebrovascular disease, diabetes, liver disease, pulmonary disease, and renal disease), and previous hospitalizations (number and type, by risk level). The explanatory factors are combined in an exponential risk function. The model is constructed separately within numerous relatively homogenous diagnostic and procedure analytic categories, using all Medicare discharges nationwide. For each discharged patient, the model generates an estimate of the probability of survival to a specified number of days after admission. The estimates are then summarized at designated times (30 days, 90 days, and 180 days after admission). By aggregation over a given hospitals set of discharged patients (for all causes or within given diagnostic or procedure categories), these estimates yield average predicted mortality estimates. The predicted mortality estimates may then be compared with observed death rates to generate a set of standardized mortality ratios for that hospital. Using this method, we randomly selected two hospitals from each of the three terciles of the standardized mortality ratio distribution for all the patients admitted with acute myocardial infarction from 1989 to 1991. Throughout our report, we refer to these six hospitals as Low Mortality1, Low Mortality2, Average Mortality1, Average Mortality2, High Mortality1, and High Mortality2. Development of the Expert Panel An expert panel for acute myocardial infarction determined which elements to abstract from the charts in order to examine differences across the six hospitals in the following areas: 1) coding accuracy for the principal diagnosis of acute myocardial infarction; 2) severity of illness for acute myocardial infarction; and 3) quality of care for acute myocardial infarction assessed by several process measures. The expert panel for acute myocardial infarction convened with representatives from the study hospitals (although the hospitals were not informed that they were part of a special study) and from the Connecticut chapter of the American College of Cardiology. Final membership of the expert panel included the three members of the Peer Review Organization team, four cardiologists, three internists, and one nurse. On the basis of discussions among the panel members, a data collection instrument was then constructed, tested on a sample of charts available at the Peer Review Organization, and revised accordingly. Patients Fifty patients who were at least 65 years of age and had been reported on the hospital claims as having a primary diagnosis of acute myocardial infarction during federal fiscal years 1989 to 1991 were selected from the subset of admissions of Medicare beneficiaries at each of the six study hospitals that had been included in the mortality modeling project for HCFA. The hospitals participating in this demonstration project included teaching and nonteaching hospitals, community hospitals, and tertiary care centers. Case Sampling For each hospital, 50 consecutive patients with myocardial infarction were selected (patients with a principal diagnosis code of 410), starting with the discharges at the end of federal fiscal year 1991 (30 September 1991) and working backward in time until 50 patients were assembled. This sampling was done without regard to outcomes and without regard to whether the patients had catheterization or invasive surgery (coronary artery bypass graft surgery or percutaneous transluminal coronary angioplasty) during that admission or any later admission. For the smallest hospital among the six, it was necessary to go back 2 years to assemble a sample of 50 patients. Data Collection Procedures A copy of the medical record of each patient was requested from the hospitals; on receipt at the Connecticut Peer Review Organization, a single nurse-reviewer abstracted the data. This nurse-reviewer had 14 years of intensive care unit experience and 7 years of data abstraction experience. As questions arose during data abstraction, the reviewer met with the principal clinical coordinator to clarify and validate the data. Confirmation of the principal diagnosis of acute myocardial infarction was based on the method of Iezzoni and colleagues [8]. The diagnosis was confirmed if two of the following three criteria were met: 1) typical symptoms [for example, chest pain, discomfort, pressure, or heaviness; arm, back, or jaw pain; nausea or vomiting; diaphoresis; sense of impending doom; dyspnea]; 2) electrocardiographic changes [for example, new Q waves; progressive ST-segment elevation or depression; progressive inversion of T waves]; and 3) abnormal levels of cardiac enzymes (for example, peak creatine kinase levels greater than twice the normal level; increased peak creatine kinase levels and an increase in the creatine kinase cardiac muscle fraction above 5%; peak lactate dehydrogenase [LDH] levels greater than 1.5 times the normal level and LDH1 levels greater than LDH2 levels). Symptoms were assessed from the admission history, progress notes, or cardiology consultation notes [if present]. Electrocardiographic evidence of myocardial infarction was abstracted from 1) the official interpretation of the electrocardiogram or the physicians interpretation as documented in the progress notes or 2) the hospital discharge summary. Abnormal levels of cardiac enzymes were determined using each hospitals reference range. Killip Classification System The medical record was also reviewed to determine the Killip class [9] as a measure of severity of acute myocardial infarction. The Killip classification system stratifies patients with acute myocardial infarction into four mutually exclusive levels according to the following criteria. 1. Class 1: no sign of congestive heart failure (no rales or crackles). 2. Class 2: rales (crackles) in one half or less of both lung fields. 3. Class 3: rales (crack

The Effect of a Multifaceted Physician Office‐Based Intervention on Older Women's Mammography Use

BACKGROUND: In response to identified low mammography use among older women in three geographic areas in Connecticut, a physician office‐based mammography intervention was initiated under the Health Care Financing Administrations Health Care Quality Improvement Program.

Assessing the quality of asthma care provided to Medicaid patients enrolled in managed care organizations in Connecticut

BACKGROUND Many states have enrolled Medicaid beneficiaries in managed care organizations (MCOs). Few assessments of the quality of asthma care provided by these new programs are available. OBJECTIVE To describe the quality of care provided to asthmatic Medicaid children enrolled in MCOs. METHODS For this cross-sectional survey, a chart abstraction tool was developed to evaluate fulfillment of key performance measures chosen from a national guideline for asthma diagnosis and management. These measures were prescription of an inhaled anti-inflammatory medication, accomplishment of patient education, evaluation of exposure to environmental triggers of asthma, and administration of influenza vaccination. From State of Connecticut administrative databases, a random sampling of Medicaid children, ages 5 to 18 years, enrolled in four MCOs was selected. Chart entries from July 1, 1996 to June 30, 1997 were reviewed using the abstraction tool. Accomplishment of performance measures was evaluated for the total sample and for children who were high utilizers of medical services (at least one ED visit or hospitalization during the study period). RESULTS For 80 high utilizers among 315 children, completion of performance measures was suboptimal: 46% were prescribed inhaled steroids; an action plan was outlined for 43%; evaluation of patient or family tobacco use was documented for 56%; evaluation of the presence of a pet for 43% or mite exposure for 19%; and allergy skin testing or RAST was accomplished for 15%. CONCLUSIONS This information suggests that opportunities exist to improve the quality of care for these children.

Mammography underutilization among older women in Connecticut

OBJECTIVES: The primary goals were to examine mammography use rates among older women in Connecticut and to determine if there was significant variation among different areas and racial groups in the state. The secondary goal was to examine what impact the initiation of Medicare reimbursement for mammography screening has had on mammography use.

Preventing Pressure Ulcers in Connecticut Hospitals by Using the Plan-Do-Study-Act Model of Quality Improvement

BACKGROUND Seventeen hospitals and the Peer Review Organization of Connecticut (Qualidigm) attempted to increase early identification of high-risk patients and utilization of pressure ulcer preventive measures. METHODS A multihospital retrospective cohort study with medical record abstraction was used to obtain a total of 1,955 (baseline) and 891 (follow-up) patients aged 65 years and older discharged after treatment for pneumonia, cerebrovascular disease, or congestive heart failure with a length of stay > or = five days. During a nine-month period, the hospitals conducted four plan-do-study-act improvement cycles and shared their results in conference calls and group meetings. RESULTS Statistically significant increases were noted from baseline (1/1/96-12/31/96) to follow-up (10/1/97-3/31/98) in identification of high-risk patients, repositioning of bed-bound or chair-bound patients, nutritional consults in malnourished patients, and staging of acquired Stage II pressure ulcers. Daily skin assessments occurred at a high rate in both periods. There were no statistically significant changes in other processes of care, pressure ulcer incidence, or mortality. DISCUSSION Performance of four pressure ulcer prevention processes of care increased concurrently with a multifaceted improvement intervention.

Lack of effect of a pneumonia clinical pathway on hospital-based pneumococcal vaccination rates

Although the pneumococcal polysaccharide vaccine is effective in preventing morbidity and mortality from pneumococcal disease among the elderly (1), it remains underutilized. In 1997, national data revealed that only 45% of seniors 65 years of age and older reported ever receiving the vaccine (2). Efforts to increase the use of the pneumococcal vaccine among patients admitted to acute care hospitals have been advocated (1,3), as a high percentage of hospitalized patients are elderly or have an underlying condition that makes them a candidate for vaccination. Hospital-based vaccination also allows access to patients who otherwise have limited contacts with physicians (3). However, a 1995 study in 12 states showed that only 0.4% of 4,548 Medicare patients admitted to the hospital were vaccinated before discharge (4). Recently, there has been increased interest in clinical pathways, which are designed to improve patient outcomes by standardizing care based on best practices (5,6). We undertook a multihospital pneumonia quality improvement project in Connecticut, in which a template for a pneumonia pathway was adapted by participating hospitals (7), and we measured the effect of this pathway on hospital-based pneumococcal vaccination rates.

A Collaborative Project in Connecticut to Improve the Care of Patients with Acute Myocardial Infarction

BACKGROUND State-based peer review organizations (PROs) and individual hospitals are challenged to achieve their quality improvement (QI) goals with shrinking resources. In 1993-1994 the Connecticut PRO and 15 local hospitals generated a comparative QI database on acute myocardial infarction (AMI) care for 1,202 Medicare and non-Medicare patients discharged in 1992 and 1993. METHODS A steering committee composed of hospital and PRO representatives was assembled to provide oversight. PRO staff developed a chart abstraction tool and trained hospital abstractors who collected and submitted data to the PRO for comparative analyses. Written feedback was provided to all hospitals and supplemented with onsite presentations when requested. Each hospital prepared a written QI plan based on its unique data profile. RESULTS Opportunities for improvement were identified at all hospitals. The most commonly targeted areas for improvement included the use of thrombolytics at presentation, aspirin at presentation and at discharge, and beta blockers at discharge. Improvement interventions included staff education sessions, development of AMI critical paths and standing orders, and storage of appropriate medications in emergency departments. Self-report data from the hospitals indicate improvements in care. DISCUSSION PROs and hospitals can augment their individual QI activities by working together to share data, resources, and lessons learned. Twenty-three hospitals are now collaborating with the Connecticut PRO on a similarly designed QI project aimed at improving the care of patients hospitalized with atrial fibrillation. This project includes a more formal means of communicating QI interventions.