Quality Update for September 27, 2006

Symposium Celebrates Champions of Change and RAM Premiere First National Scorecard Gives US Health Care 66 Out of 100 IOM Calls for Active Learning System to Support P4P New Guidelines for Dementia Care During Disasters AHQA President Testifies at Congressional Hearing 41st ASHP Midyear Clinical Meeting and Exhibition HHS Names Interim Coordinator for HIT ‘Own Your Future’ Campaign Promotes Long-Term Care Planning in Six States Study: Pneumonia Guidelines Save 20 Lives Each Year Symposium Celebrates Champions of Change and RAM Premiere Health care quality leaders, policy makers, and patient advocates recently gathered at the “Champions of Change: A National Symposium on Improving Health Care” at the Kaiser Family Foundation in Washington to celebrate the coming premiere of the national PBS documentary series Remaking American Medicine (RAM) and the launch of a national outreach campaign to transform American health care. The RAM series airs every Thursday in October at 10 p.m. on local PBS stations. (Check local listings for details www.pbs.org/remakingamericanmedicine ) Keynote speakers included Donald Berwick, MD, MPP, FRCP, President and CEO of the Institute for Healthcare Improvement; Carolyn Clancy, MD, Director of the Agency for Healthcare Research and Quality; and Mark McClellan, MD, PhD, Centers for Medicare & Medicaid Administrator. Back to top McClellan highlights QIO role In his opening remarks, Dr. McClellan called the event a turning point, suggesting that the RAM outreach campaign would “raise national consciousness about what we want from health care.” Medicare, which controls one third of all health care spending, is working to support health care transformation through public reporting mechanisms, initiatives to align payment with quality care, and restructuring of benefits to focus more on preventive care, he said. Dr. McClellan also explained that the QIOs, which work on behalf of CMS at local levels to help providers improve care in every state, are leading many local outreach efforts in support of RAM. Dr. McClellan stressed that he was “very pleased” that QIOs are such important partners in RAM. What we need is outrage Dr. Berwick reminded the audience that transforming the health care system is a challenging but achievable task, using the success of IHI’s 100,000 Lives Campaign as an example. “What we need is outrage. We all need to say, ‘No, we don’t want to work in or depend on a health care system at any price, let along one that costs close to two trillion dollars, which is going to hurt patients when it tries to help them,” he said. RAM - a quiet revolution The themes of the RAM series are closely aligned to AHRQ’s mission to improve the quality, safety, efficiency, and effectiveness of health care said Dr. Clancy. She described the nationwide network that has developed from RAM’s efforts as a “quiet revolution” driving change. As an example of how those efforts are slowly permeating the American consciousness, Dr. Clancy cited findings of a survey by Kaiser Family Foundation and AHRQ on public views and knowledge of health care. The survey, which was completed in August, is an update of similar 2002 and 2004 surveys. It was released Wednesday. The findings show that: 51 percent of Americans are dissatisfied with the quality of health care 55 percent of Americans now understand the term “medical error” versus 43 percent in 2004 and 31 percent in 2002. 54 percent bring a list of medications to a doctor’s appointment – up from 48 percent in 2004. The findings show that “our efforts to help consumers and patients become more informed and empowered seem to be paying off,” said Dr. Clancy. But empowered patients are not enough – patients and clinicians need to be equal team players. In her interview on the fourth segment of RAM, “Hand in Hand,” Dr. Clancy discusses how changing the important relationship between patients and clinicians by giving patients and families a active role in their health care is contributing to better quality care. Back to top Panel discussions Among the day’s highlights were three panel discussions moderated by health reporters, Susan Dentzer, health correspondent, The NewsHour with Jim Lehrer; John Hockenberry, an award-winning journalist; and Avery Comarow, senior writer at U. S. News & World Report and director of the “America’s Best Hospitals” annual rankings. Panelists included: Patient advocates such as Sorrel King whose 18–month old daughter Josie died of medical error and representatives of the Johns Hopkins Hospital where she died who have since worked together to improve care practices. Physician and self-described zealot Anne Peters whose efforts in a diabetes clinic in impoverished Los Angeles are keeping patients healthier and the administrator who went out on a limb to support her efforts. Hospital administrator Patricia Sodomka and patient advocate Julie Moretz who worked together to create a new model of family and patient-centered care at the Medical College of Georgia. National partnership As a national partner in the RAM campaign, AHQA Executive Vice President David Schulke issued a public statement on September 27th urging readers to watch the groundbreaking series. RAM is unique in two ways, Schulke said. “First, it provides in-depth coverage of the hard work of clinical quality improvement that committed and innovative health professionals, consumers and purchasers are undertaking—sometimes together—in a number of communities around the United States. The program producers secured permission to give the public an inside view of people working together to get control of unreliable clinical processes that too often just don’t work. The program examines the problem of good people producing bad outcomes, and looks for more effective solutions than the common ‘shame and blame’ response to quality problems.” “Second, the RAM initiative is much more than a compelling documentary. From the beginning, the organizers made a conscious effort to promote local awareness of the program to help people in communities understand the depth of our quality problems and encourage them to continue to push hard for progress long after the last episode airs.” QIOs working with PBS stations and others in RAM coalitions across the country are to be commended for their contributions to this “quiet revolution,” said Schulke. First National Scorecard Gives US Health Care 66 Out of 100 In September 20 web exclusive, Health Affairs published “U.S. Health System Performance: A National Scorecard,” the first results of an annual national scorecard developed by the Commonwealth Fund. The United States’ total average score across all categories was 66 out of a possible 100. The article by Cathy Schoen, senior vice president for research and evaluation at the Commonwealth Fund and others uses a scorecard system developed by the Commonwealth Fund Commission on a High Performance Health System, led by James Mongan, MD, president and CEO of Partners Healthcare System in Boston. The scorecard, “which was designed to assess and monitor all key dimensions of performance in relationship to benchmarks and over time, provides a unique whole-system view,” the authors explain. “The overall picture that emerges from the scorecard is one of missed opportunities and room for improvement,” the authors summarize. Calling the study a “starting point for national discussion,” the authors said that policies should “address the interaction of access, quality, and cost and take a coherent whole-system view rather than a fragmented approach to change.” “There is evidence that quality and efficiency can be improved together. Savings can be generated from more efficient use of costly resources, producing the same or better quality at lower resource cost. The challenge is finding systematic ways to achieve net gains and rechannel the savings into investments to improve coverage and the capacity to innovate,” the authors observed. “Policies that facilitate and promote more-connected care, linking medical care providers and information in more integrated care systems, will be essential for productivity, efficiency, and quality gains” The Commonwealth scorecard contains thirty-seven scored indicators, many of them composites. The indicators, a mix of existing and new measures, are grouped into five broad “domains”: health outcomes, quality, access, efficiency, and equity. A score of 100 on a given indicator represents benchmarks set by top-performing countries or the top 10 percent of U.S. states, hospitals, health plans, or other providers. Some notable results for the adult population from the scorecard include: Health Outcomes. (Total U.S. score: 69) On a measure of “deaths before age seventy-five from conditions that are at least partially preventable or modifiable with timely and effective health care,” the United States ranked fifteenth out of nineteen countries in 1998. Quality. (Total U.S. score: 71) Barely half of adults receive all recommended clinical screening tests and preventive care according to guidelines; almost one-third of adults do not have a primary care “medical home.” Access. (Total U.S. score: 67) Four out of ten U.S. adults reported that they went without care because of costs during 2004 -- a rate four times higher than in the United Kingdom, the benchmark country. Efficiency. (Total U.S. score: 51) Rates of hospital readmission vary widely across geographic areas: Rates in the highest hospital regions were more than 50 percent higher than in the lowest 10 percent of regions. Equity. (Total U.S. score: 71) “The scorecard documents major inequities in health, quality, access, and efficiency dimensions. . . . Disparities are widest in the paired contrasts by income or insurance, with an average 34 percent gap between uninsured and insured populations and a 38 percent gap between low-income and high-income populations.” Read the article by Schoen and coauthors at: http://content.healthaffairs.org/cgi/content/abstract/hlthaff.25.w457 Back to top IOM Calls for Active Learning System to Support P4P In its third report in the Pathways to Quality Health Care series, “Rewarding Provider Performance: Aligning Incentives in Medicare,” the Institute of Medicine (IOM) recommended a phased-in approach for a national plan to give incentives to providers who provide care that is safe, effective, timely, patient-centered, efficient, and equitable. The report also called on Congress to form an “active learning system” to facilitate dynamic feedback to federal agencies on consumer, employer, and provider perceptions regarding federal transparency initiatives. The pay for performance report builds on the IOM’s two previous reports in the Pathways to Quality Health Care series said Robert Reischauer, PhD, co-chair of the committee that prepared the report. The first report on quality measurement was published last December; the second report, on the Quality Improvement Organization program, was published in March. Dr. Reischauer noted five key messages from this report: The Medicare payment system is broken and requires fundamental change. Paying for better care is only one part of the overall fix for Medicare. There are not proven methods for pay for performance but the idea is promising enough to warrant immediate action Payments should reward efficiency, across care settings and in chronic disease management. A learning system should be implemented to assess early experiences, adjust for unintended consequences and evaluate impact. Throughout their presentation, committee members Dr. Reischauer, Gail Wilensky, PhD (co-chair), and Robert S. Galvin, MD, agreed that pay for performance alone would not be enough to transform America’s health care system. It’s very difficult to have a pay for performance program without a measurement system in place, said Dr. Wilensky. It is also important to help providers build the capacity to report meaningful and appropriate data – technical assistance that IOM has suggested QIOs provide. But because there are so many unanswered questions about the effectiveness of different pay for performance models, having a mechanism for feedback, such as an active learning system, is also critically important the IOM said. Active learning system Congress should consider directing QIOs to serve as the active learning system proposed by the IOM, suggested AHQA Executive Vice President David Schulke. “Feedback from stakeholders is essential in developing a sustainable program to meet the needs of the public and providers. QIOs are a uniquely qualified national infrastructure with both the strong local relationships and the expertise needed to help Secretary Leavitt continuously improve this program,” said Schulke. The QIOs could report back to federal agencies on consumer, employer, and provider perceptions regarding federal transparency initiatives. QIOs could also alert these agencies to measurement problems and unintended consequences of pay for performance efforts – such as decreased patient access, explained Schulke. Report recommendations In addition to the implementation of an active learning system, the report includes nine recommendations to support the development of a national pay for performance program: Pay for performance should be implemented using a multi-phase approach. Existing resources should be used to fund the program – at least in the initial three to five year phase. This could be done by reducing base Medicare payments for each class of providers and using that savings to fund rewards in each provider class. Eventually, the provider classes should be combined into one aggregate pool to reward all providers for shared accountability and coordinated care. Initially rewards should be given only for health care that is of high clinical quality, patient-centered, and efficient. Rewards should be given to providers who improve performance significantly and those who achieve high performance. Providers should receive incentives for the submission of performance data that is transparent and made public in ways that are both meaningful and understandable to consumers. Virtually all Medicare providers should report and participate in pay for performance, voluntarily at first with the possibility of mandated reporting if needed; institutions should start immediately. A pay for performance program should include components that promote, recognize, and reward improved coordination of care across providers and through entire episodes of illness. Beneficiaries should identify a primary provider and Medicare should reward that provider for coordination of care. Providers should be assisted with health IT implementation to support data collection and reporting systems to strengthen the use of consistent performance measures. These recommendations along with those of the two earlier reports will inform Congress’ deliberations on reforming the American health care system. Gail Wilensky, co-chair of the IOM committee that crafted this report suggested that Congress “move as quickly and thoughtfully as they can” to implement the report’s recommendations. Read the report at: http://www.iom.edu/CMS/3809/19805/37232.aspx Back to top New Guidelines for Dementia Care During Disasters A coalition of long term care and consumer organizations released new guidelines for non-clinical staff caring for nursing home residents with dementia during a disaster situation. In addition to AHQA, the coalition includes the Alzheimer’s Association, American Association of Homes and Services for the Aging (AAHSA), American Medical Directors Association (AMDA), National Association of Directors of Nursing Administration (NADONA), American Health Care Association (AHCA) and the National Center for Assisted Living (NCAL). “In stressful times, when change is occurring, it is especially important that people with Alzheimer’s and dementia receive consistent, effective care,” said Peter Reed, Ph.D., director of Care Services for the Alzheimer’s Association. In events such as flu epidemic, fire, or hurricane, non-licensed staff of nursing facilities, assisted living residences, or other residential care settings where an average of 50 percent of residents have some form of dementia may assume more direct care responsibilities. Lay people, such as volunteers or family caregivers, may also become involved more directly in care during such events. Using strategies outlined in the guidelines, “Dementia Care Training Guide,” non-clinical and lay caregivers can improve the care they provide to dementia patients during stressful times. “Nursing home residents with dementia are particularly vulnerable during a crisis situation. AHQA is proud to have partnered with these groups to develop guidelines that will help care for this often-overlooked population,” said Dave Adler, AHQA Director of Government Affairs. The Dementia Care Training Guide is available at: www.ahqa.org It’s a companion to “Long-Term Care and Other Residential Facilities Pandemic Influenza Planning Checklist” http://pandemicflu.gov/plan/LongTermCareChecklist.html, which was completed by the coalition prior to AHQA’s involvement at the behest of the Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC) as part of resources available on pandemic flu. Dementia Care Practice Guidelines The Alzheimer’s Association also recently released Phase 2 of its Dementia Care Practice Guidelines. Developed from the latest evidence and experience of professional care experts, the guidelines now include a total six subject areas. Phase 1 advises caregivers on dementia care fundamentals, food and fluid consumption, pain management, and social engagement. Phase 2 adds recommendations on addressing resident wandering, falls, and restraint-free care. The guidelines are available at: http://www.alz.org/qualitycare/dementia_care_pract.asp AHQA supported the development of the Dementia Care Practice Guidelines and has again been invited to participate in developing the next set of guidelines related to end of life care. Back to top AHQA President Testifies at Congressional Hearing AHQA’s president Sallie Cook, MD, recently testified at the U. S. House Energy and Commerce Committee, Subcommittee on Health hearing “Medicare Physician Payments: 2007 and Beyond.” Dr. Cook joined nine other witnesses including: Dr. William Golden, Chair, Board of Regents, American College of Physicians and former AHQA president; Dr. Dirk M. Elston, Department of Dermatology, Geisinger Medical Center in Pennsylvania; Dr. Paul A. Martin, President and CEO of Providence Medical Group in Dayton Ohio on behalf of the American Osteopathic Association; Dr. Albert W. Morris Jr., President, National Medical Association; Dr. Thomas Russell, Executive Director, American College of Surgeons; Dr. Thomas J. Weida, Speaker, American Academy of Family Physicians; Dr. Cecil B. Wilson, Chair, Board of Trustees, American Medical Association; Dr. Nicholas Wolter, Chief Executive Officer, Billings Clinic and Director, American Medical Group Association; and Dr. Byron Thames, Board Member, AARP. Setting the stage for witness testimony, full Committee chairman Nathan Deal (R-GA) opened the hearing by saying that he was prepared to repeal the current physician payment system, “It doesn’t work. We can’t fix it,” he said. “It’s time, in my opinion, for real reform and real change.” Chairman Deal said he supports a multi-year approach with will hold physicians harmless and include incentives for voluntary quality improvement efforts. A better system, he said, “provides the correct incentives for proper care instead of the wrong ones, and one that recognizes there are savings accrued when chronic care is managed effectively. Let’s provide some incentives for better quality care and more efficient use, and then we’ll go from there.” “I want to assure everyone in this room that I am 100 percent committed to enacting legislation this year,” said Chairman Deal. Witnesses presented their views on several Medicare physician payment reform options currently being considered by the Subcommittee including HR 5916, sponsored by ranking Subcommittee member John Dingell (D-MI) and HR 5866, sponsored by Representative Michael Burgess (R-TX), which includes QIO provisions that are supported by AHQA. Cook testimony In her testimony, Dr. Cook urged lawmakers to support HR 5866, which follows recommendations of a March 9, 2006 Institute of Medicine (IOM) report to strengthen the QIO program and lay the foundation for better health care quality. The IOM’s pay for performance report, which was released September 21, 2006, characterized the QIO program as an “important national resource in building the necessary infrastructure” for the improvement assistance that providers need to qualify for payment incentives, Dr. Cook told the Subcommittee. “We hope you will strengthen this invaluable program by passing Dr. Burgess’ visionary legislation and making the program a central fixture in our collective drive to provide the right care to every patient, every time,” she told the Subcommittee. “Health care quality does not improve by itself,” Dr. Cook said. “It takes hard work. Physicians, nurses, and other professionals benefit from our expert help identifying quality gaps, and learning how to close those gaps. QIOs offer the only coordinated nationwide field force of experts dedicated to understanding the latest strategies in quality improvement and working with health professionals at the local level to make good care better.” Dr. Cook also asked the subcommittee to consider utilizing the QIOs to help improve the efficiency of health care. “QIOs already share quality data with providers and work with them to improve,” Dr. Cook told legislators. “The same could be done with efficiency data, especially if coupled with data on clinical quality.” Q&A Subcommittee members asked witnesses for their views on several issues, including: the utility of a medical home, physician involvement in the development of quality measures, care coordination, and the affects of physician payment issues on patient access. During his allotted question time, Rep. Burgess immediately noted Dr. Cook’s attendance and thanked her and AHQA for providing comments to the Subcommittee. When he later asked Dr. Cook about the QIO role in health IT, she responded that QIOs are helping more than 4,000 physician practices across the country adopt health IT, but the program remains severely under-funded. “For instance, in Virginia we are working with 200 physician practices but there are 16,000 physicians in the state. So really, we are making a very small dent in terms of technical assistance” compared to the need. Back to top 41st ASHP Midyear Clinical Meeting and Exhibition Anaheim, California December 3-7, 2006 Imagine the collective power of 20,000 professionals gathered in one place, focused on one critically important goal. For five days in December, at the world’s largest pharmacy meeting dedicated to continuing education, health-system pharmacists from all over the world will learn how to enhance patient care and safety. Whether you’re a new pharmacist or seasoned professional, pharmacy student or educator, this year’s ASHP Midyear Clinical Meeting and Exhibition will help increase your knowledge and develop your abilities--all with the objective of achieving optimum patient care. You can earn a full year’s worth of CE credit in less than a week--while you network with colleagues, connect with career possibilities, shop at the ASHP bookstore, party with celebrities and friends, and enjoy the delights of Anaheim. For the most up to date meeting information and to register, visit www.ashp.org/meetings/midyear or call1-866-279-0681. HHS Names Interim Coordinator for HIT Michael Leavitt, Secretary of Health and Human Services has announced that Robert Kolodner, MD would serve as Interim National Coordinator for Health Information Technology. Dr. Kolodner assumes the position vacated by David Brailer, MD, PhD, who resigned in May. Dr. Kolodner previously served as Chief Health Informatics Officer at the Veterans Health Administration where he was involved with the oversight and development of My HealtheVet and VistA. In a statement about the selection, Secretary Leavitt said that Dr. Kolodner “joins us at a time when we are making steady progress in advancing the President’s Health IT initiative, and his experience in patient care, health IT, and government will be invaluable to those efforts.” ‘Own Your Future’ Campaign Promotes Long-Term Care Planning in Six States As part of the “Own Your Own Future” campaign, the Department of Health and Human Services announced a partnership with Georgia, Massachusetts, Michigan, Nebraska, South Dakota, and Texas that allow will residents of those states take an active role in planning ahead for their future long-term care needs. Governors of the six participating states will send letters to all households containing residents who are between the ages of 45-70, promoting awareness of aging needs and encouraging them to order a free Long-Term Care Planning Kit. This kit features information about Medicare and Medicaid benefit packages, outlines ways to plan ahead and legal issues to consider, and provides guidance on how to assess private financing options. The letters from the governors are expected to reach a total of approximately 5.8 million households during the coming year. “There’s strong evidence that personal control leads to much better consumer satisfaction, better health outcomes, and lower costs per person served,” HHS Secretary Mike Leavitt said. The program is coordinated by three HHS components -- the Centers for Medicare & Medicaid Services (CMS), the Assistant Secretary for Planning and Evaluation (ASPE) and the Administration on Aging (AoA). CMS will contribute $3 million to fund the National Clearinghouse for Long-Term Care Information, which supports the expansion of the core awareness campaign activities in additional states and development of a Web site to enhance consumer access to long-term care information. The “Own Your Own Future” campaign is a joint effort between HHS and the National Governors Association. Back to top Study: Pneumonia Guidelines Save 20 Lives Each Year A new 10-year study of nearly 18,000 elderly Utah pneumonia patients shows that the use of pneumonia guidelines by health care providers saves about 20 lives each year and reduces the number of patients readmitted to the hospital after initial treatment. The study, “Improved Clinical Outcomes with Utilization of a Community-Acquired Pneumonia Guideline,” was conducted by Intermountain Healthcare with the support of Medicare data analysis by HealthInsight, the Utah QIO. Intermountain implemented the pneumonia guidelines in all of its hospitals and compared data from its facilities with that of all other Utah hospitals. The guidelines were developed by combining local practices with American Thoracic Society and Infectious Disease Society of America recommendations for treating community-acquired pneumonia. Patients hospitalized at Intermountain hospitals after guideline implementation had a 30-day mortality rate averaging 14.5 percent, compared with 15.8 percent at other Utah hospitals – an eight percent relative reduction in mortality. The percent of pneumonia patients who required readmission to the hospital within 30 days was 10.2 percent versus 11.7 percent at other Utah hospitals, about a 13 percent relative reduction. Community-acquired pneumonia is the sixth-leading cause of death and treatment consumes more than $10 billion in health care dollars. If the lower readmission rate found in the study is extrapolated to all Utah elderly pneumonia patients, about 25 hospital re-admissions could be avoided annually resulting in a savings of more than $125,000 dollars a year, said Nathan Dean, MD, lead author of the study. “A key part of this process was reporting outcome data back to the health care providers who are providing the care so that they could actually see the quality improvements being made with the use of this guideline,” said Dr. Kim Bateman, Vice President of Medical Affairs at HealthInsight. The study was funded by a grant from the Deseret Foundation and HealthInsight. Members of the research team include: Dr. Dean; Greg L. Snow; and David Hale from Intermountain and Dr. Bateman, Michael P. Silver, and Steven M. Donnelly from HealthInsight. The study is published in the September 2006 issue of Chest. Read an abstract of the article at: http://www.chestjournal.org/cgi/content/abstract/130/3/794 Back to top

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