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Dartmouth
Study Shows Links High Quality Care to Lower Costs Cutting
Spending Not The Answer To Improving Care for Medicare Beneficiaries McClellan
Calls for EMRs, E-Prescriptions Before 2009 Deadline AHRQ
To Solicit IT Grant Proposals For State, Local Demos Limited
NHII Could Be Available in 2-3 Years, HHS Advisor Says HIMSS
Survey: $100 Million May Not Be Enough for IT Increasing
Diabetes Awareness Improves Outcomes, Report Says New
NCQA Quality Diabetes Measures Endorsed IOM
Report: Health Literacy Problem Limits Quality of Care Dartmouth
Study Shows Links High Quality Care to Lower Costs States with
higher Medicare spending often provide lower quality, less effective care
to Medicare beneficiaries, according to a study released April 7 by Dartmouth
College economists Katherine Baicker and Amitabh Chandra. The study, published
in the current issue of Health Affairs, shows that spending more money
does not necessarily translate into better care for the elderly. States spending
more money per Medicare beneficiary are likely spending those dollars
on intensive, expensive care instead of more effective care, the study's
authors said. High-spending states also are likely to have a greater concentration
of specialists. The study
examined state-level differences in spending per Medicare beneficiary
and the quality of care provided. Higher spending did not reflect higher
quality care for patients. For example, New Hampshire, which spent about
$5,000 per Medicare beneficiary, had the highest overall quality ranking,
while Louisiana, which spent the most per Medicare beneficiary at $8,000
per person, had the lowest overall quality ranking. "Health
care leaders should not make the mistake of thinking that we can only
improve the quality of health care delivered to elderly Americans by spending
more money," said Baicker, an assistant professor in Dartmouth's
economics department. "Instead, we could simply use existing dollars
much more effectively." Baicker and
colleague Amitabh Chandra, also an assistant professor of economics, said
that higher spending is unlikely to cause lower quality care, but is an
indicator of a particular style of health care provision and resources.
In fact, the composition of the physician workforce - the mix of specialists
and general practice physicians in a given area - play a critical role
in determining the use of highly effective care. States with
relatively more general practitioners showed greater use of high-quality
care and lower spending per beneficiary. Increasing the presence of general
practitioners in a state by 1 per 10,000 people was associated with a
rise in the state's quality ranking and a reduction in overall spending
of $684 per beneficiary. Conversely, increasing the presence of specialists
by 1 per 10,000 people led to a drop in overall quality and an increase
in spending of $526 per beneficiary. Among the
study's other findings: States with
lower spending often had better quality care - higher use of interventions
and screening methods such as prescribing beta-blockers at hospital discharge
for patients treated for a heart attack, ordering mammograms every two
years for women aged 65-69 and conducting regular hemoglobin tests and
biennial eye exams for people with diabetes. States with
higher spending and lower quality care had more frequent hospitalizations
and use of Intensive Care Units (ICUs) for patients in the last six months
of life. Medicare
patients in states that spent $1,000 more per beneficiary spent an average
of 1.3 more days in the hospital and were 3.9 percent more likely to be
admitted to an ICU. The researchers
based their analysis on 24 quality measures developed by the Medicare
Quality Improvement Organization (QIO), as well as data from the Dartmouth
Atlas of Health Care on the number of days Medicare beneficiaries in their
last six months of life spend in a hospital and what fraction of them
are admitted to the ICU. Cutting
Spending Not The Answer To Improving Care for Medicare Beneficiaries Despite the
link between higher spending and lower quality care, the researchers emphasize
that cutting Medicare spending to improve quality could have the undesirable
effect of reducing the quality of medical care in high-spending states
even more. Instead the authors suggest concentrating on policies that
improve the quality of care for beneficiaries, such as establishing national
practice benchmarks for basic quality measures, and encouraging greater
access to general practitioners. "Improving
quality of care has everything to do with how the money is spent,"
said Chandra. "And there is good evidence that, in many cases, we
are not spending it wisely now. We need to determine how to make better
use of health care dollars, especially with the baby boom generation about
to enter the Medicare system in the next few years." For more
info, http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.184. McClellan
Calls for EMRs, E-Prescriptions Before 2009 Deadline Dr. Mark
B. McClellan, MD, PhD named electronic medical records and electronic
prescribing as two of his top priorities as the new administrator of the
Centers for Medicare and Medicaid Services, calling for electronic prescribing
in place well before the 2009 deadline. In one of
his first speeches as the new administrator, McClellan told an audience
April 5 at Massachusetts Institute of Technology’s Sloan School
of Management that removing barriers to electronic prescribing in physician
offices is key to implementing the Medicare reforms mandated by Congress. “Under
the law, we will have electronic prescribing by 2009. I would like to
see it way before that,” Dr. McClellan said, according to Medscape
Medical News. Dr. McClellan
said the agency plans to pilot programs to help physicians implement systems
in their offices, with possible funding through the Agency for Healthcare
Research and Quality (AHRQ), Medscape reported. “This
is coming, it’s just a question of how we can accelerate it,”
McClellan said, according to Information Week. McClellan
also told the MIT audience that he expected that the Food and Drug Administration’s
requirement for mandatory bar coding would accelerate computerized physician
order entry. Medscape
also reported that another step involves revisions, already proposed,
to rules applying the Stark Law, a set of rules that prohibit many transactions
from which physicians could reap a financial gain. The changes
would remove a barrier to electronic sharing of patient records, by permitting
health care organizations to adopt information technology “for community
benefit,” Dr. McClellan said. “We’re
going to see a lot more things like that,” he said, adding that
promoting interchangeability of patient records will also be a priority
in the ongoing implementation of the Health Insurance Portability and
Accountability Act (HIPAA). McClellan
predicted that individual physicians would invest in information technology
systems once changes are in place and they can see a pay-off, adding that
pharmacies are already well connected with electronic systems. In about
a month, Dr. McClellan said “Medicare Compare” would allow
subscribers to compare drug prices at pharmacies in their neighborhood,
Medscape reported. AHRQ
To Solicit IT Grant Proposals For State, Local Demos The Agency
for Healthcare Research and Quality is soliciting grant proposals for
state or regional demonstrations of health information technology projects
that improve health care quality and efficiency. The demonstrations
should identify and support statewide data sharing and interoperability
activities aimed at improving the quality, safety, efficiency and effectiveness
of health care for patients and populations on a state or regional level.
Participants
in the project should cover a broad geographic area within an entire state
and involve a variety of stakeholders including purchasers, payers, hospitals
and other providers. If the responding
facility is not part of state government, there must be demonstrated involvement
of state entities such as the state department of public health or health
policy commission AHRQ plans to release application details April 13.
For more
info, www1.eps.gov/spg/HHS/AHRQ/DCM/AHRQ%2D04%2D0015/SynopsisP.html. Among the
many provisions of the Medicare reform legislation are demonstration projects
designed to test potential future improvements in Medicare coverage, expenditures,
and quality of care. The mandated projects address coverage of certain
prescription drugs, rural community hospitals, quality of care, chronic
care improvement, and more. Descriptions
of all MMA-mandated demonstrations are at www.cms.hhs.gov/researchers/demos/MMAdemolist.asp. NJ
Passes Medical Error Bill The legislation
requires hospitals to report any injury attributable to an error or system
failure if it results in death, loss of a body part or disability that
lasts more than a week, said NJHA spokesman Ron Czajkowski. Information
provided to state regulators would not be made public and would be shielded
from discovery in any court proceedings, Czajkowski said, a protection
intended to foster open discussion, dialogue and self-critical analysis
on matters of patient safety. Limited
NHII Could Be Available in 2-3 Years, HHS Advisor Says A limited
form of the National Health Information Infrastructure project could be
operating in two or three years, said William Yasnoff, HHS’ senior
advisor to the NHII, according to Health-IT World News. Yasnoff,
who described the NHII as an “anytime, anywhere health care information
and decision-support system,” said it could be 10 years before a
more comprehensive version of the system is available. Yasnoff spoke
this week at the Health-IT World Conference and Expo. HIMSS
Survey: $100 Million May Not Be Enough for IT A survey
conducted by a publication from the Healthcare Information and Management
Systems Society on federal funding of health information technology found
that more than half of health IT professionals do not think the $100 million
proposed for allocation by President George W. Bush in his State of the
Union address will be sufficient to achieve electronic records to improve
patient care. The survey also found that the majority of health care IT
professionals feel the greatest impact will be achieved if appropriate
financial resources are allocated to this effort. The survey
addressed federal support for technology in health care, and had 246 responses
from health IT professionals in February and March 2004. According
to survey results, 60% felt that the $100 million proposal from President
Bush in the 2005 budget would not be enough; 22% felt it would have a
significant impact; 14% felt it would have little impact, and 4% said
they did not know. In terms
of spending the money, 42% felt funds should go toward grants to subsidize
the purchase of technology, and 36% felt funding should concentrate on
standards development initiatives. For more
info, www.himss.org/content/files/vantagepoint/vantagepoint_042004f.htm. Increasing
Diabetes Awareness Improves Outcomes, Report Says Increasing
diabetes awareness and integrating a multi-faceted approach to improve
patient care and education results in significantly improved patient outcomes,
according to a report in the April issue of Clinical Diabetes, a publication
of the American Diabetes Association. The article
reports the results of the first two years of an initiative to increase
diabetes awareness among the University of Pittsburgh Medical Center’s
(UPMC) 220 primary care physician practices, called UPMC Community Medicine,
Inc. (CMI), and the implementation of a structured program to improve
care and outcomes. “This
is a rather extraordinary accomplishment,” said Francis X. Solano
Jr., M.D., vice president, physician services division and chief medical
officer of CMI. “Our physicians have provided interventions on more
than 15,000 patients that have exceeded outcome measures reported in The
New England Journal of Medicine last year. The dramatic accomplishments
in such a large population of patients is remarkable and demonstrates
the UPMC physician service division’s commitment to leading edge
quality care in diabetes mellitus.” “At
the beginning of the initiative, we found that primary care physicians
were not uniformly delivering diabetes care based on evidence-based guidelines.
Since over 90% of patient visits were to primary care providers (PCPs),
it became critical to determine if PCPs could adopt a process delivery
system that included use of evidence-based guidelines,” said Linda
Siminerio, Ph.D., executive director of the University of Pittsburgh Diabetes
Institute and assistant professor of medicine and nursing at the University
of Pittsburgh. “After two years, we found that physicians made major
strides in the improvement of health care practices and patient outcomes,”
Dr. Siminerio continued. A review
of 15,687 laboratory test results found that at the end of the two-year
period, the patients’ average HbA1c (which indicate a person’s
blood sugar control over the past 2 to 3 months) was reduced to 6.97%,
which is better than the national average HbA1c of 7.8%. There were
4,598 patients tracked with respect to blood pressure and cholesterol
management. Some 51% of these patients lowered their blood pressure below
130/80 mm and 78% lowered their blood pressure below 140/90 mm. A total
of 71% of patients were placed on an ACE inhibitor or beta-blocker for
heart disease. More than 42.8% of patients lowered their LDL cholesterol
level below 100 mg and 76.4% lowered LDL to less than 130 mg. A total
of 77% of patients were put on a lipid-lowering drug. Physician compliance
with a prospective tracking form that focused on lipid and blood pressure
management was over 95%. According
to a 2002 study in the Annals of Internal Medicine, national figures show
that 65.7% of people with diabetes have blood pressure lower than 140/90,
only 11% have LDL less than 100 mg and only 42% have LDL less than 130
mg. The Focus
on Diabetes initiative began by laying the foundation for improved diabetes
care practices through implementation of the American Diabetes Association
(ADA) Standards of Care, supporting education efforts and creating community
awareness. ADA Standards with companion flow sheets were disseminated
to the practices. Presentations to physicians on diabetes care focused
on ADA guidelines, rationale and strategies for treatment and diabetes
self-management education. Coordinators of the initiative said this was
a major challenge since the UPMC physician network extends across a radius
of 250 miles. Physician education was delivered through a variety of venues,
including telecommunicated programs for outlying rural practices, regional
physician meetings and lectures from the academic endocrine faculty. Officials
said one of the major factors for success has been getting physicians
involved in the quality improvement process and making them responsible
for collecting their data in a prospective manner. By asking them to track
their patient interventions, physicians were not only assessing their
results but also responding to them at the time of encounter. It was also
critical to give physicians data on their population of patients and tools
to facilitate patient management, according to Drs. Solano and Siminerio.
Physicians
received quarterly reports on the laboratory data pertinent to the care
of their diabetes patients. Laboratory results along with patient demographics,
visits and charges were captured into a large UPMC clinical data repository
called Medical Archival Retrieval System (MARS). The initiative
began as a voluntary participation project; but physician participation
eventually was mandated. At the start of the initiative approximately
120-130 physicians (50 to 60%) participated in tracking and reporting
data based on the project guidelines, by the end of the study period 95%
participated. In addition,
diabetes educators were hired to provide diabetes education at physician
practices on “diabetes days,” in order to maximize efficiency
with the added benefit of the focused visits for the practice. Education
was promoted through the practices and public awareness campaigns. “Diabetes
care is becoming a priority for health systems as costs and health outcomes
are being closely scrutinized. Because the traditional health care system
is designed to provide a symptom-driven response to acute illnesses, it
is poorly configured to meet the needs of the chronically ill,”
said Dr. Siminerio. “Although it may take years to see significant
impacts on micro- and macro-vascular disease, our results would lead us
to believe our patients have been best served by these ongoing quality
efforts.” New
NCQA Quality Diabetes Measures Endorsed A group of
experts representing public health and medical organizations announced
April 7 that they strongly supported new diabetes quality of care measures
that include a measure of A1C<7% for people with diabetes in line with
the clinical guidelines established by the American Diabetes Association.
The previous measurement was A1C<8%. The new measures are scheduled
to take effect this month. The guidelines
by the National Committee for Quality Assurance (NCQA) and the American
Diabetes Association for the Diabetes Physician Recognition Program (DPRP)
will adopt the new measure as part of performance standards and criteria.
The program is a voluntary program for individual physicians or physician
groups that provide care to people with diabetes. “An
A1C<7% is an important and achievable goal, and can help prevent or
reduce the risk of severe health complications related to diabetes, saving
lives and healthcare dollars,” said James R. Gavin III, M.D., Ph.D.,
chair of the National Diabetes Education Program and President of Morehouse
School of Medicine in Atlanta. “Throughout the United States, there
are inconsistencies among guidelines, which may be contributing to confusion
among physicians and to the epidemic of uncontrolled diabetes.”
“We
are hopeful that further changes will be reflected in other national quality
measurement standards such as HEDIS, the Health Plan Employer and Data
Information Set, that currently does not define an optimal A1C control
level but only reports the percentage of patients in poor control defined
as an A1C [greater than or equal to] 9.5%,” added Dr. Gavin. A1C, also
referred to as glycosylated hemoglobin (HbA1c), is a measure of blood
glucose (sugar) levels over a two- to three-month period. In people without
diabetes, the normal range for A1C is 4-6%. People with diabetes who have
elevated blood glucose levels have higher A1C levels. “These
changes are very significant, as we have now included as ‘measures’
both the current diabetes measures of the National Diabetes Quality Improvement
Alliance and the current ADA Clinical Practice Recommendations for A1C,
BP (blood pressure) and LDL (low-density lipoprotein),” said Dr.
Nathaniel Clark, M.D., vice president of clinical affairs of American
Diabetes Association. “This
will allow better tracking of the extent to which Recognized Providers
are meeting current treatment goals, including the treatment goal of A1C
<7%,” he said. “We
applaud NCQA for taking the important step of setting the A1C performance
measure at a level that will benefit the most people with diabetes,”
said Dr. Richard M. Bergenstal, M.D, a member of the coalition and executive
director of the International Diabetes Center part of Park Nicollet Health
Services, a multispeciality clinic in Minneapolis. The International
Diabetes Center obtained NCQA recognition for its entire health care system
with over 200 primary care physicians. “If
more physicians who care for individuals with diabetes are recognized
through NCQA, then treatment standards will automatically be strengthened,”
Bergenstal said. He added
that at the same time, more managed care plans and employers should be
encouraged to do everything in their power to recognize and reward high
performing physicians who are a part of the DPRP. “A
treatment standard of A1C<7% would benefit everyone,” he said. The government-funded
study NHANES 1999-2000 showed that only 37% of people with diabetes had
achieved an A1C<7%, demonstrating that the number of people with uncontrolled
diabetes has increased over the last decade. “We
can and should be doing a better job at controlling this epidemic,”
said Dr. Bergenstal. Last November,
the coalition, called Aim.Believe.Achieve.: The Diabetes A1C Initiative(TM),
developed a blueprint for all people with diabetes, their physicians,
and their caregivers in the U.S. to achieve a blood sugar goal of A1C<7%.
The coalition represents more than 40 public and private groups focused
on helping people with diabetes achieve this important goal. There are
18.2 million people in the United States, or 6.3% of the population, who
have diabetes. While an estimated 13 million have been diagnosed with
diabetes, 5.2 million people (or nearly one-third) are unaware that they
have the disease . If untreated
or not managed well — can lead to a number of devastating complications,
such as blindness, stroke, heart disease, amputation, and kidney disease.
The Diabetes
Initiative(TM), and A1C<7% by 2007(TM), visit www.aimbelieveachieve.com
Aim. Believe. Achieve.: The Diabetes A1C Initiative(TM) and A1C<7%
By 2007(TM) are supported by Aventis Pharmaceuticals. For more
info, www.aimbelieveachieve.com.
IOM
Report: Health Literacy Problem Limits Quality of Care Nearly half
of all American adults-- 90 million people-- have difficulty understanding
and using health information, and there is a higher rate of hospitalization
and use of emergency services among patients with limited health literacy,
says a report from the Institute of Medicine titled Health Literacy: A
Prescription to End Confusion. Limited health literacy may lead to billions
of dollars in avoidable health care costs. More than
a measurement of reading skills, health literacy also includes writing,
listening, speaking, arithmetic, and conceptual knowledge. Health literacy
is defined as the degree to which individuals have the capacity to obtain,
process, and understand basic information and services needed to make
appropriate decisions regarding their health. At some point, most individuals
will encounter health information they cannot understand. Even well educated
people with strong reading and writing skills may have trouble comprehending
a medical form or doctor's instructions regarding a drug or procedure. A concerted
effort by the public health and health care systems, the education system,
the media, and health care consumers is needed to improve the nation's
health literacy, the report says. If patients cannot comprehend needed
health information, attempts to improve the quality of care and reduce
health care costs and disparities may fail. The report
recommends that health care systems should develop and support programs
to reduce the negative effects of limited health literacy and that health
knowledge and skills be incorporated into the existing curricula of kindergarten
through 12th grade classes, as well as into adult education and community
programs. Furthermore, programs to promote health literacy, health education,
and health promotion programs should be developed with involvement from
the people who will use them. And all such efforts must be sensitive to
cultural and language preferences. For more
info, www.iom.edu/report.asp?id=19723.  Home :: Inside AHQA :: For The Media :: Public Policy :: Advancing Quality :: Quality Connections :: SiteMap
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