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AHRQ sponsors first theme issue of Health Services Research with focus on improving efficiency and value in health care

The Agency for Healthcare Research and Quality (AHRQ) has sponsored the first in a new series of theme issues for the October 2008 Health Services Research 43 (5, Part 2). Seven new studies in this theme issue, "Improving Efficiency and Value in Health Care," seek to move beyond the measurement of efficiency toward implementing improvements in care efficiency and value.

The issue begins with an introduction to the topic by AHRQ researchers Irene Fraser, Ph.D., and William Encinosa, Ph.D., and Columbia University investigator Sherry Glied, Ph.D. The first four studies include examinations of 21 quality improvement (QI) programs in Minnesota hospitals; the impact of the Group Health Cooperative's Access Initiative on physician productivity; front-line staff perspectives on opportunities for improving safety and efficiency in hospital work systems; and the effect of a tiered hospital network on hospital admissions. The other three national-level studies explore the efficiency of specialty hospitals in the U.S.; analyze the efficient use of physician assistants across the country; and examine the efficiency of 1,377 U.S. hospitals. Brief summaries of the studies follow.

Olson, J.R., Belohlav, J.A., Cook, L.S., and Hays, J.M., "Examining quality improvement programs: The case of Minnesota hospitals," pp.1787-1806.

Hospitals vary widely in their ability to implement QI programs, depending in part on the difficulty of the programs, concludes this survey of 109 Minnesota hospital administrators. The administrators scored 21 QI programs based on difficulty of implementing them and then scored their hospital on how well they implemented the programs they attempted. The scoring provided a quantifiable prediction of success. For example, if a hospital with a lower ability tried to implement a very difficult program such as the Malcolm Baldridge Award program, its chance of success was less than 5 percent. However, its chance of implementing an easier improvement, such as an employee suggestion system, was 75 percent.

Tucker, A.L., Singer, S.J., Hayes, J.E., and Falwell, A., "Front-line staff perspectives on opportunities for improving the safety and efficiency of hospital work systems," pp. 1807-1829.

This study designed and implemented an intervention called "Leveraging Front-Line Expertise" in 20 hospitals to gather input from front-line workers about hospital patient safety system failures. According to the front-line workers, 36 percent of failures were equipment/supply failures or facility failures, which posed safety risks and diminished staff efficiency. Examples ranged from broken, missing, or inappropriate equipment or supplies to poor facility housekeeping and inadequate lighting. However, these types of failures have not been priorities of national patient safety initiatives and are not typically considered important to examine in QI programs. Campaigns to monitor and track equipment and facility failures may be a fruitful next step for major improvements in safety and efficiency of hospital systems, conclude the researchers.

Valdmanis, V.G., Rosko, M.D., and Mutter, R.L., "Hospital quality, efficiency, and input slack differentials," pp. 1830-1848.

By eliminating inefficiency, hospitals could increase outputs by 26 percent on average, found this study. The authors used a method to measure and quantify inefficiency in 1,377 hospitals across 34 States. They found that about 3 percent of the hospitals' inefficiency could be attributed to congestion (productivity loss due to the occurrence of patient safety problems). However, even among high-quality hospitals with low patient safety problems, there was still much inefficiency due principally to unused resources such as idle personnel. On the other hand, low-quality hospitals hired too few personnel, especially full-time licensed practical nurses. The high-quality hospitals tended to have higher overall efficiency than the other hospitals, suggesting that costs and quality do not necessarily need to be traded off. Reprints (AHRQ Publication No. 09-R005) are available from the AHRQ Publications Clearinghouse.

Scanlon, D.P., Lindrooth, R.C., and Christianson, J.B., "Steering patients to safer hospitals? The effect of a tiered hospital network on hospital admissions," (AHRQ grants HS13680 and HS10730), pp.1849-1868.

This study found that union workers whose company gave them financial incentives to choose hospitals that met the Leapfrog Group's three patient safety "leaps" were substantially more likely to choose high-quality hospitals for medical admissions. However, the incentive did not affect their hospital selection for surgical admissions. This result suggests potential "efficiencies" by appropriate use of financial incentives for patients. All patients were averse to travel time, but the union patients selecting an incentive hospital were less averse to travel time. Although financial incentives for surgery may need to be large enough so that patients are willing to travel further to a high-quality hospital, this may not be necessary for medical hospitalizations, conclude the researchers.

Carey, K., Burgess Jr., J.F., and Young, G.Y., "Specialty and full-service hospitals: A comparative cost analysis," pp. 1869-1887.

The number of specialty hospitals grew dramatically from 1998 to 2004. These specialty hospitals are no more efficient than the full-service hospitals with whom they compete, found this study. Indeed, surgical and orthopedic specialty hospitals had significantly higher levels of cost inefficiency than traditional full-service hospitals (inefficiency score of 47 vs. 27 percent). However, cardiac specialty hospitals were similar to traditional hospitals. Perhaps because many specialty hospitals are also physician-owned, efforts to be efficient may focus on setting operating room schedules for surgeons' convenience and workload rather than on minimizing hospital inefficiencies in resource use, suggest the authors. Their findings were based on analysis of Medicare cost data and hospital discharge data for three States.

Conrad, D., Fishman, P., Grembowski, D., and others, "Access intervention in an integrated, prepaid group practice: Effects on primary care physician productivity," pp. 1888-1905.

These researchers examined the impact of the Group Health Cooperative's (GHC's) Access Initiative on primary care physician productivity over an 8-year period. The initiative included seven system-wide incentives to improve patient access to care. Three of the seven incentives directly addressed productivity: primary care redesign to control costs, linking physician compensation to productivity, and financial incentives for physicians to use secure messaging with patients through a Web site. The incentives increased the number of enrollees for whom the physician was responsible. Moreover, service intensity per visit increased, while visits per full-time-equivalent (FTE) physician fell without reducing care quality. Overall, costs per patient declined. The findings were based on linking administrative records of physician characteristics, compensation, and FTE data to GHC enrollee care use and cost information.

Morgan, P.A., Shah, N.D., Kaufman, J.S., and Albanese, M.A., "Impact of physician assistant care on office visit resource use in the United States," pp. 1906-1922.

The number of employed physician assistants (PAs) grew from 20,000 in 1991 to over 68,000 in 2006. Patients whose care includes PAs have 16 percent fewer office-based visits than patients cared for by physicians only, according to this study. Moreover, this efficiency gain is not offset by increased office visit resource use in other settings, suggesting the potential for further productivity gains through use of PAs. These findings indicate that PAs serve more to extend physician services to patients than to play a complementary role that leads to increased health care resource use. If predicted physician shortages materialize, PAs will provide a larger share of U.S. patient care in the future at a reduced cost, thus increasing efficiency in health care delivery.

To access the complete articles in the HSR theme issue, "Improving Efficiency and Value in Health Care," go to

A limited supply of copies of "Improving Efficiency and Value in Health Care" (Publication No. OM 09-0006) are also available from the AHRQ Publications Clearinghouse.

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