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A Measure of Quality: Improving Performance in American Health Care
Executive Summary
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A
Measure of Quality: Improving Performance in American Health Care
October
2000
Just as there is no question that the American health care system offers some
of the best and most sophisticated care in the world, there is no question that
we can improve the quality of care in this country. But casting blame and pointing
fingers won't spur better performance. Instead we - quality improvement experts,
doctors, hospitals, consumers and policymakers - must all acknowledge that we
can do better and work together to improve the quality of care in a systematic
and measurable way for all Americans. Gathering information to guide our efforts
is essential to improving the performance of our health care system. Once we gather
the information needed to know where we stand, we can improve care and measure
our progress.
While there has been significant attention recently about the need to improve
care, there has been far less fanfare about ongoing quality improvement successes.
For example, few people know about the existing national network of quality improvement
organizations working with doctors and hospitals in local communities every day
to help ensure Medicare beneficiaries receive high-quality care.
Moving
Science from the Bookshelf to the Bedside
The main goal of Medicare's private quality improvement contractors, known as
Peer Review Organizations, or PROs, is to move the findings of science and evidence
from the "bookshelf" to the bedside. As community resources, PROs help doctors
and hospitals make good care better. In our world of exploding technology and
rapid changes, the delivery of health care is complicated. Many physicians, pharmacists,
nurses and aides must all interact to provide care for a single patient. PROs
analyze care delivery systems to identify opportunities to improve the way care
is delivered. In fiscal years 1996-99, PROs in all 50 states, the District of
Columbia, Puerto Rico and the Virgin Islands worked on countless small, local
projects to help physicians and hospitals improve the quality of care for Medicare
beneficiaries in a measurable way.
This report, A Measure of Quality: Improving Performance in American Health
Care, summarizes the results of 325 of these local quality improvement projects
that fostered improved care for an estimated 16 million Medicare beneficiaries.
The report demonstrates the positive, measurable impact PROs have on health care
quality throughout America. A Measure of Quality was compiled by the Washington,
D.C.- based American Health Quality Association, the national, not-for-profit
membership association of independent, community-based quality improvement organizations
holding Medicare PRO contracts.
While leaders of national groups or the federal government can set agendas or
list priorities or highlight a problem, it is the work of men and women in communities
across America - often working together in projects convened by the PROs - that
will make a measurable difference in the quality of care. The successes reported
are truly theirs, and the American Health Quality Association is pleased to share
their progress with you.
Knowing
Where We Stand
About a year ago, the Health Care Financing Administration (HCFA), which administers
Medicare, decided to focus the collective power of the PROs and the nation's hospitals
and physicians on a national campaign to improve care for beneficiaries in six
critical disease areas - heart attack, breast cancer, diabetes, heart failure,
pneumonia and stroke. Taken together, these diseases pose the greatest risk to
seniors' lives and health. Yet, there are many treatments and preventive steps
- like quickly getting aspirin after a heart attack or an eye exam at least every
two years if you are diabetic - that can manage these diseases and help seniors
live longer, happier and more productive lives.
To guide quality improvement efforts, HCFA collected information about the care
Medicare beneficiaries received in 1997-99 based on 24 clinical indicators in
the six targeted disease areas - heart attack, breast cancer, diabetes, heart
failure, pneumonia and stroke. The results of this first-ever national snapshot
of the quality of care in fee-for-service Medicare were published recently in
the Journal of the American Medical Association and clearly show that tremendous
opportunities remain to improve care for older Americans.
When former President Gerald Ford recently had a stroke, his physicians gave him
an oral blood-thinning medicine, known generically as warfarin, to prevent a second
stroke. According to the HCFA data, however, almost half of all Medicare beneficiaries
whose hearts beat irregularly due to a condition called atrial fibrillation, and
who are, therefore, at risk of having a stroke, don't receive warfarin. Likewise,
studies have shown that screening mammograms can prevent roughly one in four breast
cancer deaths. But the HCFA data show that almost half of all women Medicare beneficiaries
between the age of 52 and 69 don't get a mammogram at least every two years.
In these and too many other instances, Medicare beneficiaries simply aren't getting
the right care at the right time. What's different today is that we now have a
measure of the quality of care provided to older Americans. Physicians and hospitals
aided by PRO quality improvement experts know how to improve care and are already
hard at work in local communities. In 2002, HCFA will remeasure the 24 indicators
to gauge our progress.
Continuous
Quality Improvement
PROs
are awarded three-year contracts known as scopes of work. A Measure of Quality:
Improving Performance in American Health Care is based on reports filed by
PROs with Medicare officials from the last (fifth) contract cycle, which covered
fiscal years 1996-99. During the fifth contract cycle, PROs developed and tested
tools to improve the quality of health care. Based on the promising early results
of the fifth contract cycle, Medicare chose to focus nationally on the six critical
disease areas in the current contract cycle, which runs through 2002. An additional
priority area for the PROs during the current contract is to improve care for
underserved populations.
PROs work with Medicare to develop clinical indicators reflecting the quality
of health care services, and then Medicare takes baseline measurements to determine
how often care is delivered in accordance with the clinical indicators. When there
is a gap between the ideal standard of care and the actual care provided, PROs
work to persuade doctors, hospital personnel and other health professionals to
examine their practices and change how they provide care. PROs provide suggestions
based on successful improvement projects in other hospitals and clinics. The last
step is to remeasure and find out if the quality improvement intervention succeeded.
Along with their quality improvement activities, PROs also respond to individual
beneficiary complaints and work with hospitals to reduce payment errors. Total
Medicare spending for nearly 40 million beneficiaries in 1999 was about $213 billion,
or just under $5,500 per beneficiary. Total annual direct payments to PROs are
about $250 million, or about $6.25 per beneficiary per year. Looked at another
way, Medicare pays the PROs 52 cents a month for each beneficiary - less than
the cost of a cup of coffee. This money pays for skilled doctors knowledgeable
about quality improvement techniques, expert statisticians and epidemiologists,
dedicated nurses, and other health care professionals who serve as community resources
for local physicians, hospitals and other caregivers.
Simple
Gifts
Florence,
a Pennsylvania Medicare beneficiary, works at her local neighborhood senior center.
One summer day, she was helping local seniors get to a stroke-screening program
sponsored by the local PRO. Helping the elderly in her community get the care
they need is just part of her job. But on that day, someone would help Florence
get the care that she most needed. When Florence was examined that day at the
stroke screening, a PRO physician suspected she might have a blocked artery to
her brain.
Alerted to a possible problem, Florence immediately went to her personal physician
and soon had an operation to open the clogged artery, which was 98 percent blocked.
Because the blockage was detected and removed successfully, Florence made a complete
recovery and continues to live a full life. That simple screening program may
have saved her life. Medicare PROs give these simple but precious gifts each day
in communities throughout America.
The
Right Care at the Right Time
PROs
help hospitals and doctors organize care delivery systems to make sure patients
get the right care at the right time. Hospitals, doctors and PROs collaborating
to improve the quality of care works. For example, according to HCFA:
- PRO/provider
projects to improve care for heart attack patients save an estimated 3,000 lives
a year.
- PRO/provider
projects to increase the rapid first administration of antibiotics help prevent
an estimated 700 deaths annually of Medicare beneficiaries with pneumonia.
- PRO/provider
projects to increase the appropriate use of blood thinners for people at risk
of having a stroke prevent an estimated 1,285 strokes annually.
Scope
of Selected Projects from the 1996-99 Contract Cycle Project
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Project
Topic
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Number
of Projects
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Number
of Organizations/Providers
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Number
of Medicare Beneficiaries
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Heart
Attack Prevention and Treatment
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53
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4,121
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407,600
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Breast
Cancer Screening
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11
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N/A
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672,932
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Diabetes
Treatment
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43
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3,591
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977,783
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Heart
Failure Treatment
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28
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1,157
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141,598
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Influenza
and Pneumococcal Disease Prevention and Treatment
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110
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N/A
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13.656,996
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Stroke
Prevention and Treatment
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36
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860
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171,709
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Total
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281
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9,729
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16,028,618
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Results
of Selected Local Quality Improvement Projects by Clinical Indicator, 1996-99
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Disease
Topic
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Clinical
Indicator
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Number
of Projects
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Number
of Beneficiaries*
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Increase**
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Heart
Attack
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Percentage
of eligible patients discharged on beta-blockers to prevent a second heart attack
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31
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N/A
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34%
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Breast
Cancer
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Percentage
of older women receiving a mammogram at least every two years
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11
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672,932
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25%
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Diabetes
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Percentage
of people with diabetes who received an annual foot exam to prevent amputation
|
18
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143,059
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41%
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Heart
Failure
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Percentage
of patients who received ACE inhibitors to reduce blood vessel constriction
|
15
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69,568
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12%
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Pneumococcal
Disease
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Percentage
of patients who received antibiotics within four hours of arrival at the hospital
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40
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124,893
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20%
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Stroke
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Percentage
of eligible patients who received warfarin
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26
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162,881
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23%
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*These
estimates are conservative because not all projects reported the number of beneficiaries.
**Represents relative median improvement for projects.
Catalysts
for Change
The success of the PRO program in recent years is a result of the partnership
and cooperation of physicians, hospitals, other caregivers, health plans, beneficiaries
and employers. PROs work with these partners to identify and fix systemic problems,
leading to improved quality of care and reductions in individual mistakes. The
experiences of the PROs teach us that an open dialogue among trusted partners
is a powerful way to discover what practices in disease treatment and prevention
work and which need to be improved. In every state in the union, local PROs have
the solid relationships with doctors, nurses, hospitals, health plans, and consumers
needed to make meaningful changes in how care is delivered. It makes good sense
that cooperation, good faith and proven strategies, exchanged between people who
know each other and share a community, should be the basis for improving performance
in American health care.
Sometimes improvement can occur through education - by giving patients and doctors
the latest facts about the best treatments available for a heart attack or stroke,
for instance. Or PROs may work with providers to help design system changes to
remind - or prompt - patients, doctors and others to ask about basic health services
such as screenings, vaccinations or how to take medicines properly.
Turning
Best Practices into Daily Practices
PROs know that improving health care quality in the United States' decentralized
health care system requires translating nationally recognized best practices into
local solutions. Put another way, the PRO approach to improving performance and
quality is to share globally and act locally.
Medical professionals are bombarded every day with new information, making it
difficult for them to stay on top of which new procedures and treatments are saving
lives. The types of procedures and treatments that are accepted by the medical
community but not always delivered to every patient who needs them range from
cutting edge to common sense. Following are some of the clinical practices that
PROs are working to encourage:
- Periodic
eye exams, foot exams, glucose screenings, cholesterol screenings and blood pressure
measurements for people with diabetes.
- Prescribing
and administering medicines such as aspirin or beta-blockers to prevent a second
heart attack and minimize the damage resulting from a heart attack.
- Rapidly
administering antibiotics to patients admitted to a hospital with pneumonia.
- Timely
pre-surgical antibiotics to prevent infection.
- Breast
cancer screening for at-risk women.
- Influenza
and pneumococcal vaccinations for seniors.
- Prescribing
the anti-clotting drug warfarin for patients whose hearts beat irregularly.
PROs use a variety of activities to promote improvement in each of the clinical
areas. Some interventions are focused on assisting providers with quality improvement
projects, while others are geared toward educating seniors about the appropriate
use of services such as immunizations. PRO projects to improve care include the
following:
Providing
hospitals and physicians with "clinical pathways," or detailed procedures, for
the care of patients with particular conditions.
Suggesting
proven methods to reorganize care, such as making sure certain medications are
kept in the emergency department for prompt use with heart attack patients.
Producing
and distributing tool-kits that include clinical guidelines, checklists and reminder
stickers that go in patient charts and prompt follow-up actions by caregivers.
Convening
coalitions of disease-specific interest groups to focus on a particular disease
and collaborating with community organizations, churches, senior centers and pharmacies
to give seniors information about how to improve their health.
Launching
media campaigns to encourage Medicare beneficiaries to take responsibility for
maintaining and improving their own health.
Establishing
registries to receive adverse event reports, analyzing the incidents for patterns
and then advising hospitals about how to prevent such events.
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