Statement by David Schulke

EMBARGOED FOR RELEASE Contact: Richard Deutsch Until 4PM ET June 14, 2005 202-261-7573 JAMA Study: Additional Assessment of QIO Work Needed Statement by AHQA Executive Vice President David Schulke The following comments are in response to an article, “Do Quality Improvement Organizations Improve the Quality of Hospital Care for Medicare Beneficiaries,” to be published in the Journal of the American Medical Association on Wednesday, June 15. The summary conclusion of the JAMA article implies that the research presented in the article is an evaluation of the QIO program as it exists today. That is clearly not true. Research for this article applies to QIO activities in five states during 1999-2001, well before the program was substantially revised. In 2002, the QIO program was refocused to take advantage of advances in quality improvement methodology developed by the Institute for Healthcare Improvement and other expert sources. We hope and expect that JAMA will correct the misimpression created by this article by publishing the results of QIO efforts during the most recent work cycle, 2002-2005. Those results will be available from CMS later this year. Preliminary data from the current cycle of QIO work, recently presented by CMS to the Institute of Medicine , shows QIOs are having a significant impact on hospital improvement. This data shows that hospitals working intensively with QIOs achieved greater improvement in 9 out of 10 quality measures than did hospitals that received little or no QIO assistance. Also encouraging are preliminary results from a three-year nationwide QIO effort to improve prevention of surgical infections, with specific attention to the administration of antibiotics within the recommended 60 minutes prior to incision. So far, QIOs in 32 states report that the hospitals they are working with have made strong gains. For example: 26 California hospitals working with their QIO increased the proportion of surgical patients receiving antibiotics within one hour of incision from 73.8% to 84.3%. In Colorado , 16 hospitals increased antibiotics delivered within one hour of incision from 62% to 88%. In Maryland , 16 hospitals went from 72% to 92% of patients. In New Mexico , 19 hospitals went from 48% to 68%. In Texas , 42 hospitals went from 61% to 84%. Another set of newly available data that strongly suggests QIO efforts are effective is the growing number of physicians and hospitals that report benefiting from QIO assistance. In December 2004, the research firm Westat conducted an independent survey of more than 4,000 hospitals, finding that 92% of them were either very satisfied or satisfied with the QIO's quality improvement assistance. It is critical that the QIO program be as effective as possible because its assignment is enormous. At the time covered by the JAMA article the QIO program had $150 million a year to improve the product of the trillion dollar health care industry -- the largest industry in America . Today, funding for the QIO program is larger, as is its mandate. QIOs are now working in the full range of clinical areas, including nursing homes and home health. It is unfortunate that the authors of the JAMA article do not note the fact that QIOs are continuously improving their techniques to be more effective. In the past few years, QIOs have adopted a number of new strategies, including: Helping hospitals to measure and publicly report their quality performance; Recruiting and engaging provider board members and executive leadership in culture change; and Hosting and facilitating breakthrough collaboratives, developed by the Institute for Healthcare Improvement, where providers learn best practices not only from QIOs but directly from each other. These changes since 2001 are motivating hospitals to examine their performance, improving the timeliness of quality measurement, and speeding up the pace of quality improvement. Over the next three years, QIOs work will expand to also include: Helping doctors and hospitals use information technology to provide better care. Ensuring and improving the quality of prescription drug therapy. Helping nursing homes focus on resident satisfaction. Reducing hospital admissions for home care patients. Supporting organizational culture change in all clinical settings. Reviewing expedited appeals for beneficiaries facing discharge or termination of service. The methodology used in the JAMA article to assess the impact of QIO hospital work would be a reasonable approach to take today, but was not feasible in 1999-2001. During that period , the design of the QIO work assignment made it extremely difficult to assess the contribution of QIOs to nationwide hospital quality improvement documented in an earlier JAMA article. The new study sheds little new light on this issue. The major challenge confronting the authors of this JAMA article and others is this: starting in 1999, Medicare officials gave QIOs new directions to improve hospital care across entire states. As a result, every QIO attempted to give some degree of information and support to all hospitals. The study therefore compares two different levels of QIO support for hospitals. That approach might have yielded useful information about which QIO strategies work best, but it was not possible to separate out the different strategies used at each hospital several years after the work was done. In addition, the data used to assess the QIOs’ impact in the JAMA study was gathered at the halfway point in the three year QIO contract. This means many hospitals in the study sample had been working with the QIO for only a short time, and some had not yet have started working with the QIO at all. We agree with the authors’ conclusion that “additional efforts to assess and improve the QIO’s effectiveness may be needed.” Some assessment was possible i n the 1996-99 QIO contract cycle, before the period studied by Snyder. At that time, before QIOs had to work with every hospital, it was possible for QIOs to work intensively with a small group of hospitals and compare the results with institutions they had not worked with. One study of QIO work in that earlier period (1996-1999), done with 36 small rural hospitals, found that pneumonia patients in hospitals working with the QIO were 10 times more likely to receive antibiotics within 4 hours of hospital arrival than patients who came into the control hospitals during the same time frame. Another study of QIO effectiveness in hospitals in four states by Marciniak (published in JAMA in1998) found that QIO strategies improved heart attack care and reduced mortality compared to hospitals in states that did not receive QIO assistance. For specific examples of QIO work in every state improving care in hospitals and other clinical settings, please visit our website at www.ahqa.org. The American Health Quality Association is dedicated to improving the safety and effectiveness of health care. AHQA represents the national network of Quality Improvement Organizations (QIOs) that work with hospitals, medical practices, health plans, long-term care facilities, home health agencies, and employers to encourage the spread of best clinical practices and improve systems of care delivery. Visit: www.ahqa.org.