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Health Care Quality

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Four AHRQ-funded studies focus on health care quality

Four new articles, featured in the March/April 2003 issue of Health Affairs, focus on different aspects of health care quality. The articles are authored by researchers at the Agency for Healthcare Research and Quality. They examine a range of issues: hospital procedure volume used as a proxy for quality; patient safety indicators as a way to benchmark performance and target opportunities for improvement; the role of insurance coverage in explaining racial and ethnic disparities; and high-cost priority conditions identified as areas of focus for improving quality of care.

Reprints of articles are available from the AHRQ Publications Clearinghouse.

Staffing linked to different outcomes at low- and high-volume hospitals.

Death rates were significantly higher at hospitals that performed fewer of certain complex procedures, such as coronary artery bypass graft or esophageal cancer surgery, than at hospitals that performed a larger number of those procedures. AHRQ researchers Anne Elixhauser, Ph.D., Claudia Steiner, M.D., M.P.H., and Irene Fraser, Ph.D., examined data from 2000 on 10 procedures using the Nationwide Inpatient Sample, part of AHRQ's Healthcare Cost and Utilization Project, to provide a nationwide view of the link between death rates and how often a hospital performs a procedure.

Although the majority of U.S. patients received their procedures in high-volume hospitals, for 7 of 10 procedures examined, over 75 percent of hospitals would be considered low volume. The researchers also found that low-volume hospitals tended to have lower numbers of residents and registered nurses (RNs) than high-volume hospitals. However, for two procedures, heart transplants and pediatric heart surgery, death rates were the same at high- and low-volume hospitals, and low-volume hospitals had RN and resident staffing equal to or higher than high-volume hospitals.

The researchers found that low-volume hospitals tended to be small, urban non-teaching, or rural institutions that had for-profit ownership, or they were located in the southern region of the United States.

Details are in "Volume thresholds and hospital characteristics in the United States," by Drs. Elixhauser, Steiner, and Fraser, in the March/April 2003 Health Affairs, 22(2), pp. 167-177.

Reprints (AHRQ Publication No. 03-R026) are available from the AHRQ Publications Clearinghouse.

Patient safety indicators based on hospital data can identify potential safety-related problems.

A test of AHRQ's soon-to-be released Patient Safety Indicators (PSIs) demonstrates that, in general, the number of potential safety-related events measured by most non-obstetric PSIs decreased between 1995 and 2000. The PSIs, developed by AHRQ's Evidence-based Practice Center at the University of California-Stanford, use diagnosis codes to detect potential adverse events in patients who have undergone medical or surgical care. The test of the 20 PSIs, led by Patrick S. Romano, M.D., M.P.H., of the University of California at Davis, provides a national profile of patient safety. The PSIs were designed for use with hospital administrative data and were applied in this study to AHRQ's Nationwide Inpatient Sample, part of the Agency's Healthcare Cost and Utilization Project, to identify trends in potential patient safety problems.

The study found that most technical complications, such as postoperative hemorrhage or reopening of a wound, decreased between 1995 and 2000, except for a 7 percent rise in the number of accidental punctures and lacerations. Also during that time, obstetric trauma decreased about 3 percent, foreign bodies left during procedures decreased 7 percent, anesthesia complications decreased 18 percent, and transfusion reactions decreased 40 percent.

The PSIs will provide a portion of the analysis for AHRQ's National Healthcare Quality Report, which is due out later this year. They will be useful primarily as screening tools for hospitals and hospital systems, medical groups, health plans, and purchasers to identify potential patient safety problems that merit further investigation. Providers may use them to screen for preventable complications and to identify opportunities for quality improvement on the system level.

Details are in "A national profile of patient safety in U.S. hospitals," by Dr. Romano, Jeffrey J. Geppert, Sheryl Davies, and others, in the March/April 2003 Health Affairs 22(2), pp. 154-166.

Reprints (AHRQ Publication No. 03-R027) are available from the AHRQ Publications Clearinghouse.

Insurance coverage alone cannot explain racial and ethnic disparities in care.

Racial and ethnic minority groups continue to have poorer access to quality health care services and different patterns of health care use relative to whites, according to 1996-1999 data from AHRQ's Medical Expenditure Panel Survey (MEPS). To try to identify the reasons for these disparities, AHRQ researchers Samuel H. Zuvekas, Ph.D., and Gregg S. Taliaferro, Ph.D., examined the role that insurance coverage, the delivery system, and external factors play in explaining persistent disparities in access to health care among racial and ethnic groups of all ages. They found that variations in health insurance coverage are not the only source of disparities in access and actually may provide only a small part of the explanation.

Their findings indicate that while health insurance coverage is important, differences in coverage explained only about one-third of disparities between Hispanics and whites and two-fifths of disparities between blacks and whites. External factors, such as employment, job characteristics, marital status, income, and education are key reasons why minorities are less likely than whites to have private health insurance. However, disparities exist even among well-insured racial and ethnic minority groups, and large portions of disparities remain unexplained. The researchers conclude that health care policies that simply seek to increase insurance coverage may not be sufficient to eliminate racial and ethnic disparities in health care.

Details are in "Pathways to access: Health insurance, the health care delivery system, and racial/ethnic disparities, 1996-1999," by Drs. Zuvekas and Taliaferro, in the March/April 2003 Health Affairs 22(2), pp. 139-153.

Reprints (AHRQ Publication No. 03-R028) are available from the AHRQ Publications Clearinghouse.

High-cost conditions identify areas of focus to improve quality of care.

The most expensive conditions in the United States are primarily chronic diseases, such as heart disease ($58 billion per year), cancer ($46 billion per year), and mental illness ($30 billion per year), according to a new analysis of data from AHRQ' 1997 MEPS examining the 15 most expensive conditions in the United States. However, AHRQ analysts Joel W. Cohen, Ph.D., and Nancy Krauss, also found that several of the top 15 conditions were acute conditions, such as trauma, pneumonia, and infectious diseases.

Their findings indicate that most individuals with at least one of the top 15 conditions had more than one, with costs incurred by the affected individuals dramatically increasing as the number of coexisting conditions increased. In general, the people who used the most hospital inpatient services had the highest expenses. Private insurance and Medicare were the primary sources of payment for most of the top 15 conditions. The findings highlight factors, such as complex financing arrangements and coexisting conditions, that are likely to complicate efforts to reform the current health care system.

Details are in "Spending and service use among people with the fifteen most costly medical conditions, 1997," by Dr. Cohen and Ms. Krauss, in the March/April 2003 Health Affairs 22(2), pp. 129-138.

Reprints (AHRQ Publication No. 03-R029) are available from the AHRQ Publications Clearinghouse.

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