Thomas P. Meehan

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.

National Trends in Patient Safety for Four Common Conditions, 2005–2011

BACKGROUND Changes in adverse-event rates among Medicare patients with common medical conditions and conditions requiring surgery remain largely unknown. METHODS We used Medicare Patient Safety Monitoring System data abstracted from medical records on 21 adverse events in patients hospitalized in the United States between 2005 and 2011 for acute myocardial infarction, congestive heart failure, pneumonia, or conditions requiring surgery. We estimated trends in the rate of occurrence of adverse events for which patients were at risk, the proportion of patients with one or more adverse events, and the number of adverse events per 1000 hospitalizations. RESULTS The study included 61,523 patients hospitalized for acute myocardial infarction (19%), congestive heart failure (25%), pneumonia (30%), and conditions requiring surgery (27%). From 2005 through 2011, among patients with acute myocardial infarction, the rate of occurrence of adverse events declined from 5.0% to 3.7% (difference, 1.3 percentage points; 95% confidence interval [CI], 0.7 to 1.9), the proportion of patients with one or more adverse events declined from 26.0% to 19.4% (difference, 6.6 percentage points; 95% CI, 3.3 to 10.2), and the number of adverse events per 1000 hospitalizations declined from 401.9 to 262.2 (difference, 139.7; 95% CI, 90.6 to 189.0). Among patients with congestive heart failure, the rate of occurrence of adverse events declined from 3.7% to 2.7% (difference, 1.0 percentage points; 95% CI, 0.5 to 1.4), the proportion of patients with one or more adverse events declined from 17.5% to 14.2% (difference, 3.3 percentage points; 95% CI, 1.0 to 5.5), and the number of adverse events per 1000 hospitalizations declined from 235.2 to 166.9 (difference, 68.3; 95% CI, 39.9 to 96.7). Patients with pneumonia and those with conditions requiring surgery had no significant declines in adverse-event rates. CONCLUSIONS From 2005 through 2011, adverse-event rates declined substantially among patients hospitalized for acute myocardial infarction or congestive heart failure but not among those hospitalized for pneumonia or conditions requiring surgery. (Funded by the Agency for Healthcare Research and Quality and others.).

Readmission and Death After Hospitalization for Acute Ischemic Stroke 5-Year Follow-Up in the Medicare Population

Background and Purpose— Stroke is a leading cause of hospital admission among the elderly. Although studies have examined subsequent vascular outcomes, limited data are available regarding the full burden of hospital readmission after stroke. We sought to determine the rates of hospital readmissions and mortality and the reasons for readmission over a 5-year period after stroke. Methods— This retrospective observational cohort study included Medicare beneficiaries aged >65 years who survived hospitalization for an acute ischemic stroke (International Classification of Diseases, Ninth Revision, Clinical Modification codes 434 and 436) and who were discharged from Connecticut acute care hospitals in 1995. This population was followed from discharge in 1995 through 2000 using part A Medicare claims and Social Security Administration mortality data. The primary outcome was hospital readmission and mortality and readmission diagnosis. Results— Among 2603 patients discharged alive, more than half had died or been readmitted at least once during the first year after discharge (1388/2603, 53.3%), and <15% survived admission-free for 5 years (372/2603, 14.3%). The reasons for hospital readmission varied over time, with stroke remaining a leading cause for readmission (3.9 to 6.1% of patients annually). Acute myocardial infarction accounted for a comparable number of readmissions (4.2 to 6.0% of patients annually). The most common diagnostic category associated with readmission, however, was pneumonia or respiratory illnesses, with an annual readmission rate between 8.2% and 9.0% throughout the first 5 years after stroke. Conclusions— Few stroke patients survive for 5 years without a hospital readmission. Between the acute care setting and readmission to the hospital, a window of opportunity may exist for interventions, beyond prevention of recurrent vascular events alone, to reduce the huge public health burden of poststroke morbidity.

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.

Long-Term Mortality in Cerebrovascular Disease

Background and Purpose— Stroke is the third leading cause of death in the United States, yet data are limited about the temporal pattern of mortality among patients with cerebrovascular disease. The objectives of this study were to identify predictors of 6-month mortality and to evaluate 5-year mortality in patients with cerebrovascular disease. Methods— Our population included fee-for-service Medicare beneficiaries aged ≥65 years who were discharged with an acute ischemic stroke, transient ischemic attack (TIA), or carotid stenosis (International Classification of Diseases, Ninth Revision, Clinical Modification codes 433 to 436) from Connecticut acute care hospitals in 1995. This cohort was followed through 2000 by means of part A Medicare claims and Social Security Administration mortality data. Results— Among 5123 patients, 4781 survived their hospitalization and were followed for an average of 3.4 years; 670 (14.0%) died within 6 months of discharge, and 2517 (52.6%) died within 5 years. Predictors of 6-month mortality included older age, male sex, increasing comorbidity, discharge not to home, and prior admission within a year of the index hospitalization. The annual mortality rates for year 1 after discharge differed depending on the discharge diagnosis of the index hospitalization: carotid stenosis, 10.6%; TIA, 14.8%; and acute ischemic stroke, 26.4%. The 5-year cumulative mortality rates were as follows: carotid stenosis, 38.3%; TIA, 49.6%; and acute ischemic stroke, 60.0%. Conclusions— Mortality after acute ischemic stroke, TIA, and carotid stenosis is substantial. Rates and patterns of mortality differ according to patients’ discharge diagnoses.

Promoting physicians' self‐assessment and quality improvement: The ABIM diabetes practice improvement module

Introduction: The American Board of Internal Medicine (ABIM) recognized that certification and recertification must be based on an assessment of performance in practice as well as an examination of medical knowledge. Physician self‐assessment of practice performance is proposed as one method that certification boards may use to evaluate competence in practice‐based learning and improvement and systems‐based practice. Methods: Sixteen practicing general internists and endocrinologists with 10‐year time‐limited certification participated in a beta test of the ABIMs diabetes practice improvement module (PIM) as part of their recertification program. A PIM consists of a self‐directed medical record audit, practice system survey, and patient survey. A quality improvement education specialist from the Connecticut Quality Improvement Organization provided on‐site and distance consultation on quality improvement methods and tools. An independent audit assessed the reliability of physician self‐audit. Qualitative interviews were conducted at 2 time points to assess for physician satisfaction and behavioral change in quality improvement. Results: Fourteen physicians completed the diabetes PIM. All but 1 physician found the medical record audit to provide important information about the practice. Of the 11 physicians who completed a follow‐up interview, 10 stated that the quality improvement education specialist helped improve their practice. Discussion: Self‐assessment using the ABIM diabetes PIM as part of recertification provides valuable practice information and can lead to meaningful behavioral change by physicians. Collaboration with an educator in quality improvement appears to facilitate the effects of the practice improvement module. Future work should investigate the effect on patient outcomes.

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

Use of critical pathways to improve the care of patients with acute myocardial infarction

PURPOSE While critical pathways have become a popular strategy to improve the quality of care, their effectiveness is not well defined. The objective of this study was to investigate the effect of a critical pathway on processes of care and outcomes for Medicare patients admitted with acute myocardial infarction. SUBJECTS AND METHODS A retrospective cross-sectional and longitudinal cohort study was made of Medicare patients aged 65 years and older hospitalized at 32 nonfederal Connecticut hospitals with a principal diagnosis of myocardial infarction during two periods: June 1, 1992, to February 28, 1993, and August 1, 1995, to November 30, 1995. The main endpoints of the cross-sectional analyses for the 1995 cohort were the proportion of patients without contraindications who received evidence-based medical therapies, length of stay, and 30-day mortality. Hospitals with specific critical pathways for patients with myocardial infarction were compared with hospitals without critical pathways. The main endpoints of the longitudinal analyses were change between 1992-93 and 1995 in the proportion of patients receiving evidence-based medical therapies, length of stay, and 30-day mortality. RESULTS Ten hospitals developed critical pathways between 1992-93 and 1995. Eighteen of 22 nonpathway hospitals employed some combination of standard orders, multidisciplinary teams, or physician champions. Patients admitted to hospitals with critical pathways did not have greater use of aspirin within the first day, during hospitalization, or at discharge; beta-blockers within the first day or at discharge; reperfusion therapy; or use of angiotensin-converting enzyme inhibitors at discharge in 1995. The mean (+/- SD) length of stay in 1995 was not significantly different between pathway (7.8 +/- 4.6 days) versus nonpathway hospitals (8.0 +/- 4.2 days), and the change in length of stay between 1992-93 and 1995 was 2.2 days for pathway hospitals and 2.3 days for nonpathway hospitals. Patients admitted to critical pathway hospitals had lower 30-day mortality in 1995 (8.6% versus 11.6% for nonpathway hospitals, P = 0.10) and in 1992-93 (12.6% versus 13.8%, P = 0.39), but the differences were not statistically significant. CONCLUSIONS Hospitals that instituted critical pathways did not have increased use of proven medical therapies, shorter lengths of stay, or reductions in mortality compared with other hospitals that commonly used alternative approaches to quality improvement among Medicare patients with myocardial infarction.

Factors Associated with the Hospitalization of Low-risk Patients with Community-acquired Pneumonia in a Cluster-Randomized Trial

AbstractBACKGROUND: Many low-risk patients with pneumonia are hospitalized despite recommendations to treat such patients in the outpatient setting. OBJECTIVE: To identify the factors associated with the hospitalization of low-risk patients with pneumonia. METHODS: We analyzed data collected by retrospective chart review for 1,889 low-risk patients (Pneumonia Severity Index [PSI] risk classes I to III without evidence of arterial oxygen desaturation) enrolled in a cluster-randomized trial conducted in 32 emergency departments. RESULTS: Overall, 845 (44.7%) of all low-risk patients were treated as inpatients. Factors independently associated with an increased odds of hospitalization included PSI risk classes II and III, the presence of medical or psychosocial contraindications to outpatient treatment, comorbid conditions that were not contained in the PSI (cognitive impairment, history of coronary artery disease, diabetes mellitus, or pulmonary disease), multilobar radiographic infiltrates, and home therapy with oxygen, corticosteroids, or antibiotics before presentation. While 32.8% of low-risk inpatients had a contraindication to out-patient treatment and 47.1% had one or more preexisting treatments, comorbid conditions, or radiographic abnormalities not contained in the PSI, 20.1% had no identifiable risk factors for hospitalization other than PSI risk class II or III. CONCLUSIONS: Hospital admission appears justified for one-third of low-risk inpatients based upon the presence of one or more contra-indications to outpatient treatment. At least one-fifth of low-risk inpatients did not have a contraindication to outpatient treatment or an identifiable risk factor for hospitalization, suggesting that treatment of a larger proportion of such low-risk patients in the outpatient setting could be achieved without adversely affecting patient outcomes.

The effects of patient volume on the quality of diabetic care for Medicare beneficiaries.

Background:The quality of care for Medicare beneficiaries with diabetes remains suboptimal. The contributing factors at the physician level are not well characterized, especially the relationship of patient volume and physician performance. Objective:We sought to determine associations between the number of Medicare diabetic patients cared for by a primary care physician and the receipt of important diabetic processes of care. Design:Physicians were grouped into quintiles based on the number of Medicare patients with diabetes. Hierarchical generalized linear models were used to examine associations between number of patients, frequency of visits, physician experience, patient factors and the receipt of diabetes processes of care using Part A and B Medicare claims data for 2001. Participants and Patients:All Connecticut primary care physicians who cared for Medicare fee-for-service beneficiaries with diabetes in 2001. Main Outcome Measures:The main outcome measures were associations of the receipt of diabetes process of care measures with the number of diabetic Medicare patients in a physician practice panel, adjusted for frequency of visits, patient comorbidity, age, ethnicity, and physician experience. Results:Patients in the highest volume physician quintile were significantly more likely to have received hemoglobin A1c measurements, lipid profiles, and retinal eye examinations than patients in the lowest physician quintile in 2001, even after adjustment for multiple factors. For each step up in quintile volume group among primary care physicians, the increased odds of receiving a hemoglobin A1c measurement was 1.16 (95% confidence interval [CI] 1.10–1.23), 1.12 (95% CI 1.07–1.18) for a lipid profile, 1.06 (95% CI 1.02–1.09) for a retinal eye examination, and 1.48 (95% CI 1.22–1.81) for receiving all 3 measures. Conclusions:This study suggests that Medicare fee-for-service patients with diabetes cared for by physicians with greater numbers of diabetic Medicare patients in their practice are more likely to receive important diabetes processes of care.