Quality Update for August 20, 2004

Miscommunication Important Cause of Treatment Errors ACE Inhibitor Drugs Underused, Study Finds NEJM Study Finds Disparities in Treatment for Black Medicare Patients NCQA Releases Draft Program for Comment Provider Tracking May Help Disparities in Care, AHRQ Study Says AcademyHealth Outcomes Resources Now Online Miscommunication Important Cause of Treatment Errors A study published in the July-August issue of the Annals of Family Medicine found that miscommunication appears to play an important role in propagating diagnostic and treatment mistakes. In “A String of Mistakes: The Importance of Cascade Analysis in Describing, Counting, and Preventing Medical Errors,” researchers examined 18 US family physicians participating in a six-country international study, who filed 75 anonymous error reports. The narratives were examined to identify the chain of events and the predominant proximal errors. We tabulated the consequences to patients, both reported by physicians and inferred by investigators. Although 83% of the errors that ultimately occurred were mistakes in treatment or diagnosis, two of three were set in motion by errors in communication. Fully 80% of the errors that initiated cascades involved informational or personal miscommunication. Examples of informational miscommunication included communication breakdowns among colleagues and with patients (44%), misinformation in the medical record (21%), mishandling of patients’ requests and messages (18%), inaccessible medical records (12%), and inadequate reminder systems (5%). When asked whether the patient was harmed, physicians answered affirmatively in 43% of cases in which their narratives described harms. Psychological and emotional effects accounted for 17% of physician-reported consequences but 69% of investigator-inferred consequences. Cascade analysis of physicians’ error reports is helpful in understanding the precipitant chain of events, but physicians provide incomplete information about how patients are affected, researchers concluded. For more info, www.annfammed.org Back to top ACE Inhibitor Drugs Underused, Study Finds Almost a third of heart failure patients face an increased risk of death because they do not receive an angiotensin-converting enzyme (ACE) inhibitor, according to a report in the Aug. 3 rapid access issue of Circulation: Journal of the American Heart Association. A review of data from the Centers from Medicare & Medicaid Services’ National Heart Care Project showed that 32% of elderly heart failure patients were discharged from hospitals without prescriptions for ACE inhibitors. Patients discharged without anti-angiotensin therapy had a 14% greater risk of dying within a year compared to patients treated with ACE inhibitors. The use of angiotensin receptor blockers (ARBs), an alternative to ACE-inhibitors in some patients with heart failure, did not explain the low rates of appropriate therapy. The study adds to previous evidence that ACE inhibitors are widely underused in patients who are eligible to receive the drugs. In particular, prescription rates for ACE inhibitors have not increased for hospitalized Medicare patients who should be receiving the drugs to treat heart failure, researchers reported Overall, 68% of the patients had prescriptions for ACE inhibitors upon hospital discharge. The proportion of patients treated with ACE inhibitors was 69% during 1998–1999 and 67 percent between 2000 and 2001. When ACE inhibitors and ARBs were considered together, 78 percent of patients had prescriptions at hospital discharge. http://circ.ahajournals.org. Back to top NEJM Study Finds Disparities in Treatment for Black Medicare Patients To a large extent, different groups of physicians treat elderly black and white Medicare patients, providing insights into possible explanations for the pervasive health disparities between blacks and whites, according to a study by researchers at Memorial Sloan-Kettering Cancer Center and the Center for Studying Health System Change in the Aug. 5 New England Journal of Medicine. Eighty percent of the primary care visits by elderly black Medicare patients were to 22% of physicians, and those physicians treating black patients were more likely to report difficulty getting hospital admissions, specialty referrals and other care for their patients, the study found. Physicians treating black patients provided more charity care; derived a higher percentage of their practice revenue from Medicaid, the state-federal health care program for the poor; were less likely to be board certified in their primary specialty; and more often practiced in low-income neighborhoods than physicians treating white patients, the study found. “The findings paint a picture of two health systems, where physicians treating black patients appear to have less access to important clinical resources and be less well trained clinically than physicians treating white patients,” said Peter B. Bach, MD, the study’s lead author and a researcher in the Department of Epidemiology and Biostatistics at Memorial Sloan-Kettering Cancer Center in New York City. Bach’s earlier studies of racial disparity in cancer outcomes demonstrated that the poor quality health care received prior to a black patient’s cancer diagnosis contributed, in part, to their lower rates of cancer survival. On average, a higher proportion of physicians practicing in communities where visits by white patients occurred reported they could access important health services for their patients than physicians who practice in communities where black patients receive care, the study found. The study is based on information from HSC’s nationally representative Community Tracking Study Physician Survey, which collects information from 12,000 practicing physicians, and Medicare claims information from a representative sample of 5 percent of Medicare beneficiaries. Data on physicians and patient visits were linked with the use of the physicians’ unique provider identification number, and a total of 4,355 primary care physicians, 43,032 elderly Medicare patients and 150,391 patient visits were included in the study. The study was coauthored by Deborah Schrag, MD, MPH., and Ramsey C. Tate, Memorial Sloan-Kettering Cancer Center, and J. Lee Hargraves, PhD, Center for Studying Health System Change, and was supported by grants from the National Cancer Institute, The Robert Wood Johnson Foundation, the American Cancer Society, and the American Lung Association of New York City. For more info, www.hschange.org. Back to top NCQA Releases Draft Program for Comment The National Committee for Quality Assurance (NCQA) has released for public comment draft standards for “Quality Plus,” a supplemental accreditation program that is designed to highlight health plans whose innovative approaches to member communications, care management, physician compensation and other activities are models for the industry. The voluntary program also seeks to engage newer health plan types such as consumer-directed health plans that represent a growing sector of the health care. The initial set of draft standards focus on how well a plan uses technology to provide members with interactive health tools and information about pharmacy benefits, claims and health improvement. The Quality Plus program is part of NCQA’s multi-year effort to transition to a more flexible generation of measurement and accreditation programs aimed at a wider range of organizations. Through Quality Plus, NCQA will introduce new standards that will give employers insight into whether or not a plan represents a good value, as well as standards designed to encourage more focused care management. Quality Plus standards fall broadly into three areas. They are: member connections, physician and hospital quality and health improvement. Comments on the draft Member Connections standards are due by Sept. 15. Relevant sections of the draft standards can be downloaded from NCQA’s Web site at www.ncqa.org/Programs/Accreditation/MCO2005PubComment.htm. Comments should be submitted online to ME2005@ncqa.org. Back to top Provider Tracking May Help Disparities in Care, AHRQ Study Says An AHRQ report, “Strategies for Improving Minority Healthcare Quality,” shows that there is excellent evidence that suggests provider tracking and reminder systems are effective in improving the quality of care for racial and ethnic minority patients. The study also suggests that cultural competence training can increase the knowledge and improve the attitudes and skills of health care providers. However, the researchers found it difficult to conclude which specific types of training interventions are effective in improving particular outcomes. Even within an outcome category, there is no uniformity in outcome measurement, making it difficult to determine which specific types of knowledge, attitudes, or skills are affected by cultural competence training. For more info, www.ahrq.gov/clinic/epcsums/minqusum.htm. Back to top AcademyHealth Outcomes Resources Now Online AcademyHealth, a health services research group, has developed a core list of books, journals, Web sites, and bibliographic databases in the field of health outcomes. Developed under contract with the National Library of Medicine Health Outcomes Core Library. This project serves as a guide for individuals new to the field or those interested in developing a collection of resources in health outcomes. For more info, www.academyhealth.org/publications/healthoutcomes.htm. Back to top

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