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Study: Most Physicians Not
Involved In QI Activities Commonwealth Study Gives Medicare Quality Mixed
Review ‘Starter Set’ of
Ambulatory Care Measures Published McClellan: Early Findings of P4P Project Show
Marked Improvement HHS Expands Efforts to Address Minority Health AHRQ Opens Draft HCAHPS Survey for Field Testing AHRQ, DOD Release Compendium of Patient Safety
Research New Form to Improve Care for Diabetic Patients;
Available on AHQA Website Free Service Provides Interoperable Health
Record for All Americans Bipartisan Bill Funds Regional Health Information
Networks, Provider Incentives Report: Hospital Infections Costly, Rising;
Gap between Top and Bottom Hospitals Widens Report Indicates Practice Improves Outcome
of Heart Surgery Glucose Control Crucial for Diabetic Patients
After Heart Attack A majority of physicians are not actively engaged in quality improvement
practices and are reluctant to share information about the quality of
the care they provide with the general public, a ccording to a study
published in the May/June edition of Health Affairs. The study
also finds that a majority of physicians observed instances where appropriate,
quality care for patients was compromised due to lack of coordination
and failure to transfer information. The findings stem from a survey of more than 1800 physicians conducted
by Commonwealth Fund researchers in 2003. Overall,
the authors found that physicians’ adoption of measures,
tools, and methods necessary to improve quality is moving slowly, and
is not where it should be to achieve a high performance health care system,
which depends on seamless transfer of information among clinicians, health
care managers, and patients, and on the capacity to engage in assessing
and improving care when it is needed. The study
notes that other than patient surveys from health care organizations,
physicians receive little data on their own quality of care. In fact,
85 percent of physicians find it difficult or impossible to generate
lists of their patients by lab results or current drugs prescribed,
making it more difficult to follow-up with high-risk patients. Only
eighteen percent of physicians have data on their patients’ outcomes.
Physicians note that the most common quality problem is a lack of care
coordination. Nearly three-quarters of physicians (72 percent) reported instances
when a patient's medical records, test results, or other relevant information
was not available at the time of the patient's visit. The top three strategies physicians cited as most effective in improving
quality of care include increased time with patients (52 percent), better
patient access to preventive care (41 percent), and improved teamwork
and communication among health care professionals (35 percent). One-third
of physicians said their patients are more likely to ask them about the
quality of their care than two years ago. The survey also revealed a deep divide in quality improvement efforts
between physicians in solo or small practices and those in large group
practices, who are more likely to have access to quality information
and be involved in quality improvement. Barriers to adopting quality
improvement methods and tools include cost, lack of time, and lack of
training. “Since nearly three-quarters of physicians in this country are
in solo or small group practice settings, it is critical that those designing
quality improvement tools and incentives take this fact into consideration,” says
lead author Anne-Marie Audet, MD, assistant vice president at the Commonwealth
Fund. The study finds that about half of physicians believe that providing
the best quality care often or sometimes leads to decreased revenue.
Those in small groups or solo practices are more likely to agree with
this statement. Other key findings of the survey: “The American public expects manufacturers of products such as
automobiles to know what the quality of their products is, to be providing
information about quality and safety to the public, either directly or
through the government, and to be continually engaged in improving their
products,” Commonwealth Fund Executive Vice President Stephen C.
Schoenbaum, M.D., a co-author of the article, said in a release. “In
that context it is shocking that doctors don't know what the quality
of their care is compared to their peers, are very reluctant to make
such information available to their patients and the public, and are
not continually engaged in major efforts to improve care,” he added. The Commonwealth
Fund last week published a study on quality of care that concludes
that Medicare is improving delivery of preventive care, but needs to
do far more to improve quality of care for beneficiaries. “Medicare
has achieved its major purpose of providing the elderly and disabled
with access to needed care. Once previously uninsured adults become eligible
for Medicare, their use of recommended preventive services increases
substantially,” the study said. But the study also calls on Medicare
to “intensify and focus its efforts” to improve quality of
care. Funded by
The Commonwealth Fund and authored by quality experts Sheila Leatherman,
a professor at the University of North Carolina and Douglas McCarthy,
president of Issues Research, Inc., the report illustrates in a set
of sixty charts both Medicare’s progress and deficiencies
in the quality of care, as well as disparities and variations in care. Leatherman
told a Washington press conference that the study “does
not recommend a change of direction” by the Centers for Medicare & Medicaid
Services in its efforts to improve quality of care. But she said CMS
needs to set national priorities with “explicit numerical targets” and “focus
on unjustified variation” in quality of care. Quality
of Health Care for Medicare Beneficiaries: A Chartbook Focusing on
the Elderly Living in the Community is the third in a series of
such publications that analyze data published since 2002 to shed light
on quality of care. The study draws on a review of more than 400 studies
and data sets. Despite progress, Medicare can do more to ensure patients are screened
for colorectal cancer, treated for depression, immunized against pneumonia,
and protected against falls and fractures, the report says. “This chartbook makes the case for a concerted effort towards
a national agenda for quality that sets out explicit targets to achieve
and by when,” says Commonwealth Fund President Karen Davis. "Medicare …needs
to be an innovative leader in improving the quality of American health
care by making information on quality and efficiency more widely available
and rewarding health care providers for high performance.” The study makes clear that the quality of care Medicare beneficiaries
receive is not related to higher spending, noting that states with higher
spending per Medicare beneficiary tended to rank lower on 22 quality
of care indicators. It also highlights continuing disparities in quality
of care experienced by minorities and ethnic groups, and it points out
that care for chronic conditions needs substantial improvement. The chartbook is available at: http://www.cmwf.org/newsroom/newsroom_show.htm?doc_id=275625 The Ambulatory
care Quality Alliance (AQA) recently published a “starter
set” of 26 clinical performance measures for the ambulatory care
setting intended to provide clinicians, consumers and purchasers with
a set of quality indicators that can be used for quality improvement,
public reporting and pay for performance programs. AQA represents
a collaboration of stakeholders organized in 2004 by the American Academy
of Family Physicians, the American College of Physicians, America’s
Health Insurance Plans and the Agency for Healthcare Research and Quality
with the aim of finding common ground on physician-level performance
metrics to improve quality of care and lay a foundation for pay-for-performance
programs. AQA’s mission is “to improve health care quality and patient
safety through a collaborative process in which key stakeholders agree
on a strategy for measuring, reporting and improving performance at the
physician level” and to promote uniformity in order to provide
consumers and purchasers with consistent information and to reduce the
burden on providers. The uniform starter set of clinical performance measures for the ambulatory
care setting includes prevention measures for cancer screening and vaccinations;
measures for chronic conditions including coronary artery disease, heart
failure, diabetes, asthma, depression, and prenatal care; and, two efficiency
measures that address overuse and misuse. Except for the two efficiency metrics, the AQA limited its measures
to those that are currently under review by the National Quality Forum.
Recognizing the urgency to develop standardized measures, the AQA designed
a starter set to give physicians a uniform set of measures they can begin
using now to collect the data and report their performance while waiting
for the NQF to finalize its measures. The starter set of measures may
be incorporated into performance-based payments as early as next year. AQA’s
approach is similar to the Hospital Quality Alliance effort that has
involved a broad array of stakeholders with the goal of producing a
standardized set of measures for inpatient care. Mark B.
McClellan, MD, PhD, Administrator, Centers for Medicare & Medicaid
Services issued a statement on the “starter set” AQA measures
saying, “ This initial set of measures selected by the AQA is a
milestone for all those who wish to have a valid, reliable set of performance
measures for physicians’ offices, group practices, and other ambulatory
care settings. CMS supports the AQA's continued efforts to implement
valid, reliable measures that benefit consumers and clinicians by enhancing
the quality of the nation’s health care.” To obtain a copy of the start set measures, visit: http://www.ahrq.gov/qual/aqastart.htm The demonstration
project, which started in October of 2003, tracks hospital performance
on a set of 34 widely-accepted measures of processes and outcomes of
care for five common clinical conditions. The 17
measures included in the national Hospital Quality Alliance reporting
program are a subset of these measures. Hospitals can receive bonuses in Medicare payments based on how well
they perform on the quality measures. The preliminary
analysis was conducted by Premier Inc., a nonprofit health care alliance
collectively owned by independent hospitals and health care systems,
whose member hospitals are also participants in the demonstration.
Premier has conducted site visits with top-performing hospitals to
document best practices. Under
the demonstration, the results of the site visits will be shared with
other participants and the rest of the health care industry to help
achieve further significant improvements. CMS administrator
Mark B. McClellan, MD, PhD, says “These early
returns demonstrate that using financial incentives to reward better
quality patient care works to deliver better care and avoid costly complications
for our patients,” Dr. McClellan said. “We are seeing
improvements across the board, regardless of a hospital’s initial
performance on the quality measures.” During the
life of the three-year demonstration project, Medicare will reward
high performers with bonuses totaling $7 million per year for a total
of $21 million. Poorly
performing hospitals may face financial penalties in the third year. The first year scores are important because they set a baseline for
the bottom 20 and 10 percent in quality performance, CMS said. Those
hospitals performing in the lowest 20 percent could receive a 1 to 2
percent reduction in their Medicare payments in the program's final year.
However, CMS expects that all participating hospitals will be above the
baseline levels by that time. In the last month, Department of Health and Human Services (HHS) Secretary Mike Leavitt has announced two new efforts aimed at reducing
or eliminating disparities and improving the health of minorities. Leavitt announced the availability of $95 million in grants to help
reduce the number of cancer deaths in minority and poor populations.
This new initiative, called the Community Networks Program (CNP), was
developed by the Center to Reduce Cancer Health Disparities, part of
the National Cancer Institute (NCI). As many as 25 grants will be awarded
over five years to help CNPs develop programs to reduce cancer disparities
through community participation in education, interventions, research
and training. Interventions will include proven approaches including
smoking cessation, encouraging healthy eating and physical activity,
and early detection and treatment of breast, cervical and colorectal
cancers. Programs will be designed to reach communities and populations experiencing
a disproportionate share of the cancer burden, and will address African
Americans, American Indians/Alaska natives, Hawaiian natives and other
Pacific Islanders, Asians, Hispanics/Latinos, and rural underserved populations. Each CNP
will put together an advisory group that will serve as the “voice
of the community.” These advisory groups will work with local community
members to gather information and report results. A steering committee
of community-based leaders, researchers, clinicians and public health
professionals will provide additional support. To sustain successful efforts in their communities, CNP grantees also
will work closely with policymakers and non-governmental funding sources.
Together, CNP grantees and NCI will train investigators, identify potential
research opportunities, and work to ensure that best practice models
are widely disseminated. For additional information about the Community Networks Program, go
to: http://crchd.nci.nih.gov/CNP/index.htm Also, Secretary Leavitt announced the appointment of eight members
to serve on the Advisory Committee on Minority Health that will help
HHS improve the health of racial and ethnic minority groups and develop
goals and program activities for the department's Office of Minority
Health. The committee
includes: L eo MacKay, Ph.D., Chief Operating Officer, ACS State Healthcare,
Atlanta, GA, as chairperson and Joseph Kevin Villagomez, M.A., Counseling
Psychologist, Department of Public Health, Saipan, Commonwealth of
the Northern Mariana Islands; Cheryl Killion, B.S., M.S., M.A., Ph.D.,
Research Associate Professor, Center for Minority Family Health, Hampton,
VA; Edna M. Berastain, M.B.A., Executive Director of Latinos/as, Contra
SIDA, Hartford, CT; Inam Ur Rahman, M.D., President and Founder of the
Diabetic Clinic, Honolulu, HI; RADM Kermit C. Smith, D.O., M.P.H. (Ret),
Former Chief Medical Officer, Indian Health Service (IHS), Tucson, AZ;
Adrienne Laverdure, M.D., Medical Director of Family Health, Peter Christensen
Health Center, Lac Du Flambeau, WI; and Valerie Romero-Leggott, M.D.,
Assistant Professor/Director of Cultural & Ethnic Programs, University
of New Mexico, Albuquerque, NM as committee members. The Agency for Healthcare Research and Quality (AHRQ) published a request
for hospitals to field test a revised draft of the Hospital Consumer
Assessment of Health Plans Study (HCAHPS) survey. Hospitals wishing to
take part in this field test should submit an application to AHRQ by
June 8. AHRQ is
developing HCAHPS as a standardized, reliable and valid instrument
to measure patients’ hospital experiences along with reporting
strategies to maximize the utility of the survey results, making them
widely available. There are many survey tools available to hospitals,
but there is currently no nationally used or universally accepted survey
instrument that allows comparisons across all hospitals. The survey
was developed at the request of the Centers for Medicare & Medicaid
Services (CMS) with input from various stakeholders in the industry.
The initial draft of the HCAHPS instrument was tested as part of a CMS
three-state pilot by hospitals in Arizona , Maryland and New York . Last
December, CMS submitted the revised HCAHPS instrument to the National
Quality Forum (NQF) to undergo the formal consensus process required
for endorsement. The survey then went out for comment by the NQF membership
and the public. The membership and board vote on HCAHPS endorsement is
currently proceeding. Testing the draft survey allows hospitals to evaluate the 27 question
assessment and suggest additional questions. It will also allow the institutions
to consider the impact of integrating the survey with other patient questionnaires
and data collection methods. Institutions
interested in field testing the survey must seek permission to use
the instrument from AHRQ. Field testing will continue until the start
of the “dry run,” expected later this summer or fall.
During the “dry run,” hospitals and vendors will begin collecting
HCAHPS data and transmitting it to CMS, but it will not be publicly reported. After consensus is reached and the survey is finalized, it will be
posted on the AHRQ and CMS website for free use by individuals, hospitals,
and other organizations interested in reporting on consumer perceptions
of hospital quality. For more information about this project or to download an application
for authorization, please visit the CAHPS User Network Web site at http://www.cahps-sun.org. The Agency for Healthcare Research and Quality (AHRQ) and the Department
of Defense released a compendium of 140 peer-reviewed articles in four
volumes that represents an overview of patient safety studies by AHRQ-funded
researchers and other government-sponsored research. The four volumes contain information on virtually every dimension of
patient safety, including new research findings on medication safety,
technology, investigative approaches to better treatment, process analyses,
human factors, and practical tools for preventing medical errors and
harm. The compendium features lessons from clinical studies, presents
cutting-edge technologies such as simulation tools for surgery training,
the effects of change on dynamic systems of care, and national and regulatory
issues. “Our hope is that the information and knowledge contained in
these volumes will fuel the momentum of efforts to improve patient safety,” said
AHRQ Director Carolyn M. Clancy, M.D. “This new resource should
give researchers and practitioners a sense of what has been accomplished
and what still needs attention.” Advances in Patient Safety: From Research to Implementation is
available as a searchable CD-ROM. A limited number of four-volume printed
sets also are available. To order free single copies of the CD-ROM or
a printed set, contact the AHRQ Publications Clearinghouse at 1-800-358-9295,
or at ahrqpubs@ahrq.gov. Individual
articles that comprise the four volumes are also available at www.ahrq.gov/qual/advances. The Department of Health and Human Services and the Administration
on Aging are urging seniors to become more physically active during May
when Older Americans Month is celebrated across the nation. This year’s theme for Older Americans Month is “Celebrate
Long-Term Living!” HHS Secretary Mike Leavitt says, “Just
by walking or swimming or lifting weights, seniors can see a significant
improvement in their overall health.” For more
information on Older Americans Month or to sponsor a local physical
fitness event in your local area, visit the Administration on Aging’s
Web site at http://www.aoa.gov. In cooperation with AHQA, the American Association of Diabetes Educators
(AADE) and the American Dietetic Association (ADA) have developed a Diabetes
Services Order Form. The form is now available to providers
and QIOs on the AHQA website. The form
is designed as a simple, convenient way for a physician to refer Medicare
patients with diabetes to a Medicare-certified diabetes educator for
diabetes self-management training (DSMT) and to a registered dietitian
for medical nutrition therapy (MNT). Diabetes service benefits in the Medicare population are underutilized
despite the fact that one fifth of people over age 60 have diabetes.
Data from QIOs indicate that the root cause of this dilemma has been
confusion or limited awareness of benefits available from providers.
To alleviate this problem, AHQA approached the ADA and AADE with a request
to develop a standardized referral form that could be used by any facility
or health care professional. The resulting form, called the Diabetes
Services Order Form, includes
key information required to meet Medicare regulatory requirements for
MNT and/or DSMT referrals. It is streamlined on one page for physician
and/or qualified non-physician practitioners’ ease in initiating
the diabetes referral. Physician or qualified non-physician practitioner
referral is a prerequisite for Medicare coverage of self management education
services. The form has been reviewed by the Centers for Medicare and Medicaid
(CMS) and field tested with diabetes educators, registered dietitians,
physicians and several QIOs. The field test results were positive, with
the most frequent comments acknowledging the concise one-page format
allowed sufficient space for adding written physician instructions or
comments. “It is hoped that by providing one consistent order form for two
diabetes-related services, and providing education about the services
at the time this order form is released will result in an increase in
orders and consequently enhanced access to diabetes services,” said
AADE President Mary M. Austin, RD, MA, CDE. “While the Medicare Diabetes Services Order Form is important
in helping increase access to diabetes services, the form is but a tool
that practitioners use, said Kessey Kieselhorst, MPA, RD, CDE, chair
of ADA’s Quality Management Committee. “An equally, if not
more important element to increasing access to Medicare diabetes services
is communication and education about Medicare MNT and DSMT services.” Medem, Inc.
a for-profit company affiliated with the American Medical Association
and a coalition of national health care leaders have made public a
free online personal health record, iHealthRecord, which is available
to anyone in the U.S. According to Medem, more than 10,000 Americans
have already used iHealthRecord to create a personal health records
since it was offered to the public on a limited basis within the last
several weeks. The iHealthRecord
includes personal health data for use by physicians or emergency departments – including
current medical conditions, medications, past surgeries and allergies
as well as end of life directives. The service also provides a suite
of services to increase medication adherence, enhance continuity of
care and improve patient-physician communication. Patient
safety features include education programs developed in conjunction
with leading U.S. medical societies, the American Heart Association,
American Cancer Society, CDC, FDA and other national experts. The iHealthRecord
provides education specific to patients’ medical conditions,
automated reminders regarding their medications and conditions, as
well as FDA-related safety warnings and recalls. Information
in the iHealthRecord is updated by patients themselves, by their physician’s
electronic medical records systems or by their health plan. Data is
encrypted much like online financial information and users can control
who can view their records. The service provides a history of each
use so users can see who has accessed their information. The system is free at iHealthRecord.org or through 90,000 physician
websites affiliated with Medem, facilitating information exchange between
health care providers -- a key goal of the national health care IT infrastructure
and regional health information organizations (RHIOs). Based in
San Francisco, Medem incorporated in 1999 and was founded by a group
of the nation's leading medical societies, including: the American
Academy of Ophthalmology; the American Academy of Pediatrics; the American
College of Allergy, Asthma and Immunology; the American College of
Obstetricians and Gynecologists; the American Medical Association;
the American Psychiatric Association; and the American Society of Plastic
Surgeons. There are currently 47 societies partnering with Medem whose
combined membership represents more than two-thirds of physicians currently
practicing in the United States. James Rohack,
M.D., Chairman of the American Medical Association says, “We
believe that electronic personal health records are an important service
for physicians and patients, and a key element of the national IT infrastructure." For more information, visit: www.iHealthRecord.org Representatives Patrick Kennedy, D-RI and Tim Murphy, R-PA, recently
introduced the 21 st Century Health Information Act (H.R. 2234) authorizing
financial and other support for regional health information networks.
The proposal is the first bipartisan bill to address systemic obstacles
and misaligned incentives that have hindered the adoption of health information
technology. H. R. 2234 would provide $50 million in grants in fiscal year 2006
to regional organizations to instigate and support widespread adoption
of health information technology designed to facilitate the transfer
of health data quickly between doctors, hospitals and nurses, and to
ensure interoperability between different hospitals. The grants will
run for three years. The measure would authorize loans for accredited regional networks
and matching grants to states that use Medicaid funds to develop and
implement an approved regional plan. Several provider incentives for health IT adoption and participation
in an accredited regional health information network are also included.
Chief among them are adjustments to Medicare payments to help cover IT
costs and exemption of appropriate network equipment and services from
federal self-referral and anti-kickback laws. The proposal also requires
that health IT purchased with federal dollars be certified by the Certification
Commission for Health Information Technology. Senator
Hillary Clinton, D-NY, and former House Speaker Newt Gingrich supported
the bipartisan measure. "Harnessing the potential of information
technology will help reduce errors and improve quality in our health
system. The legislation being introduced in the House today takes an
important step forward in making our health care system more effective
and efficient," says Senator Clinton. A report by HealthGrades, Inc. finds that hospital-acquired infections
have increased by 20 percent in the last three years and might be a good
indication of overall hospital patient safety. The study, which looked
at 5000 hospitals, finds a growing safety gap between the top tier of
hospitals and lower tiers. HealthGrades
conducted the analysis by applying AHRQ’s Patient
Safety Indicator (PSI) methodology to three years of Medicare data (2001-2003)
to identify the best-performing hospitals and establish a best-practice
benchmark against which other hospitals can be evaluated. Among other
things, the study looked at the failure to adequately respond to medical
problems, infections, post-operative respiratory failures, wounds, and
treatments of certain problems such as hip fracture, pulmonary embolism
and hemorrhage. Key findings include: Read the full report at: http://www.healthgrades.com/media/DMS/pdf/PatientSafetyInAmericanHospitalsReportFINAL42905Post.pdf The state of California recently published results from hospitals in
the state that voluntarily reported outcomes of coronary artery bypass
graft surgery (CABG). Based on risk-adjusted data from 2000 to 2002,
the report concludes that hospitals with a higher volume of the CABG
procedures had better outcomes. The report
is the third and final submission resulting from a collaboration between
the Office of Statewide Health, Planning & Development, a
state agency that plans for and supports the development of a health
care delivery system that meets the current and future needs of Californians,
the Pacific Business Group on Health and 77 statewide hospitals that
voluntarily reported their results. Seventy-three
percent of coronary artery bypass surgeries performed in California’s
hospitals were tracked in the report, which confirms findings from
previous reports - volunteer hospitals are the better performing hospitals
and hospitals with a higher volume of surgeries (greater than 200 per
year) tend to have better outcomes. The results indicate that although
not all low volume hospitals have poor performance, there is a clear
relationship between high volume and lower mortality. The report also indicated an overall in-hospital death rate of 2.61
percent among participating hospitals compared to a death rate of 3.35
percent among hospitals not participating in the study during the same
period. To compile
the report, analysts used a risk adjustment model that allows for fair
comparison across different hospitals and assures that hospitals are
not punished for taking on more serious cases. After adjusting for
the clinical severity of their patients, 60 hospitals performed “as
expected,” eight performed “better than expected,” and
nine performed “worse than expected.” The reports helped catalyze the enactment of California Senate Bill
680 (2001), which now mandates that all hospitals report their heart
bypass surgery performance. Taking quality accountability one step further,
SB 680 calls for the measurement and public reporting of surgeon-specific
mortality rates beginning in 2006. Copies of the report can be downloaded at: www.oshpd.ca.gov Researchers report in the April edition of the European Heart Journal
that keeping blood sugar levels tightly controlled significantly impacts
outcome for patients with type 2 diabetes who have a heart attack. In a multi-center study, investigators compared three glucose-control
strategies in 1200 diabetic patients suspected of having a heart attack.
They found no long-term difference in effectiveness of the three treatment
approaches or significant difference in death rate of the patients. However,
high glucose levels were identified as one of the most important prognostic
predictors of a patient dying. An abstract of the article is available at: http://eurheartj.oupjournals.org/cgi/content/abstract/26/7/650  Home :: Inside AHQA :: For The Media :: Public Policy :: Advancing Quality :: Quality Connections :: SiteMap
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