Susan L. Lovejoy

Evaluation of Centers of Excellence Program for Knee and Hip Replacement

Background:Medicare and private plans are encouraging individuals to seek care at hospitals that are designated as centers of excellence. Few evaluations of such programs have been conducted. This study examines a large national initiative that designated hospitals as centers of excellence for knee and hip replacement. Objective:Comparison of outcomes and costs associated with knee and hip replacement at designated hospitals and other hospitals. Research Design:Retrospective claims analysis of approximately 54 million enrollees. Study Population:Individuals with insurance from one of the sponsors of this centers of excellence program who underwent a primary knee or hip replacement in 2007–2009. Outcomes:Primary outcomes were any complication within 30 days of discharge and costs within 90 days after the procedure. Results:A total of 80,931 patients had a knee replacement and 39,532 patients had a hip replacement of which 52.2% and 56.5%, respectively, were performed at a designated hospital. Designated hospitals had a larger number of beds and were more likely to be an academic center. Patients with a knee replacement at designated hospitals did not have a statistically significantly lower overall complication rate with an odds ratio of 0.90 (P=0.08). Patients with hip replacement treated at designated hospitals had a statistically significant lower risk of complications with an odds ratio of 0.80 (P=0.002). There was no significant difference in 90-day costs for either procedure. Conclusions:Hospitals designated as joint replacement centers of excellence had lower rates of complications for hip replacement, but there was no statistically significant difference for knee replacement. It is important to validate the criteria used to designate centers of excellence.

Evaluation of a center of excellence program for spine surgery.

Background:The Centers for Medicare and Medicaid Services and many private health plans are encouraging patients to seek orthopedic care at hospitals designated as centers of excellence. No evaluations have been conducted to compare patient outcomes and costs at centers of excellence versus other hospitals. The objective of our study was to assess whether hospitals designated as spine surgery centers of excellence by a group of over 25 health plans provided higher quality care. Methods:Claims representing approximately 54 million commercially insured individuals were used to identify individuals aged 18–64 years with 1 of 3 types of spine surgery in 2007–2009: 1-level or 2-level cervical fusion (referred to as cervical simple fusion), 1-level or 2-level lumbar fusion (referred to as lumbar simple fusion), or lumbar discectomy and/or decompression without fusion. The primary outcomes were any complication (7 complications were captured) and 30-day readmission. The multivariate models controlled for differences in age, sex, and comorbidities between the 2 sets of hospitals. Results:A total of 29,295 cervical simple fusions, 27,214 lumbar simple fusions, and 28,911 lumbar discectomy/decompressions were identified, of which 42%, 42%, and 47%, respectively, were performed at a hospital designated as a spine surgery center of excellence. Designated hospitals had a larger number of beds and were more likely to be an academic center. Across the 3 types of spine surgery (cervical fusions, lumbar fusions, or lumbar discectomies/decompressions), there was no difference in the composite complication rate [OR 0.90 (95% CI, 0.72–1.12); OR 0.98 (95% CI, 0.85–1.13); OR 0.95 (95% CI, 0.82–1.07), respectively] or readmission rate [OR 1.03 (95% CI, 0.87–1.21); OR 1.01 (95% CI, 0.89–1.13); OR 0.91 (95%, CI 0.79–1.04), respectively] at designated hospitals compared with other hospitals. Conclusions:On average, spine surgery centers of excellence had similar complication rates and readmission rates compared with other hospitals. These results highlight the importance of empirical evaluations of centers of excellence programs.

A Retrospective Evaluation of the Perfecting Patient Care University Training Program for Health Care Organizations

This study evaluated how the Perfecting Patient Care (PPC) University, a quality improvement (QI) training program for health care leaders and clinicians, affected the ability of organizations to improve the health care they provide. This training program teaches improvement methods based on Lean concepts and principles of the Toyota Production System and is offered in several formats. A retrospective evaluation was performed that gathered data on training, other process factors, and outcomes after staff completed the PPC training. A majority of respondents reported gaining QI competencies and cultural achievements from the training. Organizations had high average scores for the success measures of “outcomes improved” and “sustainable monitoring” but lower scores for diffusion of QI efforts. Total training dosage was significantly associated with the measures of QI success. This evaluation provides evidence that organizations gained the PPC competencies and cultural achievements and that training dosage is a driver of QI success.

Measuring success for health care quality improvement interventions.

Background:The lack of a standard measure of quality improvement (QI) success and the use of subjective or self-reported measures of QI success has constrained efforts to formally evaluate QI programs and to understand how the various contextual factors impact QI success. Objectives:The objective of this study was to assess how best to measure “QI success” by comparing self-reported and externally rated measures of QI success. Research Design:We performed a retrospective evaluation that analyzed data on different measures of QI success for organizations after their staff completed the QI training. Subjects:The sample included 30 organizations whose staff had received QI training during 2006–2008, and who had used this training to carry out at least some subsequent QI initiative in their organizations. Measures:We developed 2 measures of self-reported QI success based on survey responses and 4 externally rated measures of QI success based on outcome data provided by the participating organizations in addition to qualitative data generated from the interviews. Results:We found some variation in the mean scores of the different QI success measures and only moderate to small correlations between the self-report and externally rated QI measures. Conclusions:This study confirms that there are important differences between self-reported and externally rated measures of QI success and provides researchers with a methodology and criteria to externally rate measures of QI success.

Episode-Based Approaches to Measuring Health Care Quality

Most currently available quality measures reflect point-in-time provider tasks, providing a limited and fragmented assessment of care. The concept of episodes of care could be used to develop quality measurement approaches that reflect longer periods of care. With input from clinical experts, we constructed episode-of-care frameworks for six illustrative conditions and identified potential gaps and measure development priority areas. Episode-based measures could assess changes in health outcomes (“delta measures”), the amount of time during an episode in which a patient has suboptimal health status (“integral measures”), quality contingent upon events occurring previously (“contingent measures”), and composites of measures throughout the episode. This article identifies a number of challenges that will need to be addressed to advance operationalization of episode-based quality measurement.

Potential benefits of health information technology for integrating physical and behavioral health care: perinatal depression as a case-in-point

Depression among pregnant and postpartum women (i.e., perinatal depression) is the number one complication of childbirth. The Allegheny County Maternal Depression Initiative aimed to bridge gaps between physical and behavioral health care and improve the capacity of local systems of care for identifying and treating women at high risk for perinatal depression. To achieve these goals, the collaborative adopted a community-based model of systems change focused on women enrolled in the local Medicaid managed care system. Although the systems change protocol included a number of strategies for enhancing communication at all levels of care, variations in health information technology (HIT) capacities and/or capabilities across initiative partners frequently prevented optimal implementation of these strategies. Here, we present an overview of the results of the initiative, share insights from the collaborative regarding how HIT could have improved those results, and offer recommendations related to ways to effectively leverage HIT to integrate physical and behavioral health care.

Evaluation Design Recommendations for the Certified Community Behavioral Health Clinic Demonstration Program

This article provides information and recommendations regarding the evaluation design of the Certified Community Behavioral Health Clinic (CCBHC) demonstration. Mandated by Congress in Section 223 of the Protecting Access to Medicare Act of 2014, the CCBHC is a new model of specialty behavioral health clinic, designed to provide comprehensive and integrated care for adults with mental health or substance-use disorders and children with serious emotional distress. Certification criteria for the CCBHCs have been specified by Substance Abuse and Mental Health Services Administration covering six core areas: staffing; accessibility; care coordination; scope of services; quality and other reporting; and organizational authority, governance, and accreditation. In addition, services provided to Medicaid enrollees in CCBHCs will be reimbursed through one of two alternative prospective payment systems. At present, 24 states have been awarded grants to begin the planning process for implementing CCBHCs. Of these states, eight will be selected to participate in the demonstration project beginning in January 2017. Results from the evaluation will inform mandated reports to Congress over the two-year demonstration period and the three years following the end of the demonstration, providing information to policymakers on the programs impact and value. In addition, the results can inform the direction of future efforts at integration of behavioral health into the health care system at this critical time of transformation.

Minding the Gaps: Measuring Quality Based on Episodes of Care

The desire to improve care by holding clinicians accountable for the quality and costs of care delivered is a theme running through recent health policy proposals and changes. Providers report on a flurry of quality measures that tend to be based on discrete patient-provider encounters. But these snapshots measure fragments of care that cannot easily be pieced together to fully assess a patient’s health care experience. In a recent RAND study, researchers posit that it is time to focus health care quality measurement efforts on rendering a more complete picture of care. By measuring on the basis of an episode of care—management of a condition through diagnosis, treatment, and subsequent follow-up— data on patients’ care and experiences could be more comprehensive. RAND researchers worked with medical professionals to investigate how to construct episodebased care measurement. They started by mapping episodes of care for six conditions and identifying where quality metrics would be applied. Significant gaps existed; there were no quality measures for large portions of the care episodes. Most current metrics focus on specific events or items, such as recovery from a surgical procedure or blood work values, instead of on broader concepts, such as clinical improvement or degree of control over one’s disease progression.

Evaluation of the Arkansas Tobacco Settlement Program: Progress Through 2011

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