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Health Care Quality

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AHCPR-supported studies suggest quality improvements

Five papers supported by the Agency for Health Care Policy and Research and published in the November 19 issue of the Journal of the American Medical Association (volume 19, number 278) present findings and suggestions that could be used to improve the quality of medical care. The papers are summarized here.

Schmittdiel, J., Selby J.V., Grumbach, K., and Quesenberry, C.P. "Choice of a personal physician and patient satisfaction in an HMO," pp. 1596-1599.

In this study, Julie Schmittdiel, M.A., of Kaiser Permanente's Division of Research, and colleagues found that patients of a large group model HMO who were allowed to chose their primary care physician were much more satisfied with their care than patients of the same HMO who were randomly assigned to a doctor. According to the authors, these results suggest that even in a setting of limited physician choice, the opportunity to select one's personal doctor may influence satisfaction.

Schriger, D.L., Baraff, L.J., Rogers, W.H., and Cretin, S. "Implementation of clinical guidelines via a computer charting system: Effect on the initial care of health care workers exposed to body fluids," pp. 1585-1590.

David L. Schriger, M.D., and fellow researchers found that integrating an experimental software program of guideline-based advice for emergency room physicians with the electronic patient record system of a large medical center increased quality of care and reduced costs. The software program offered guidelines on testing and treating health care workers exposed to potentially dangerous body fluids. According to the researchers, their program could be made available to doctors via the Internet at a cost the first year of just 33 cents per person for the approximately 300,000 exposures to potentially dangerous body fluids that occur each year in the United States.

Blumenthal, D. "The future of quality measurement and management in a transforming health system," pp. 1622-1625.

Author David Blumenthal, M.D., predicts that over the next 10 to 20 years, the Internet will be largely responsible for assuring and improving health care quality, while at the same time preserving and even enhancing the autonomy of health care providers.

Cleary, P.D. and Edgman-Levitan, S. "Health care quality: Consumer perspectives," pp. 1608-1612.

According to authors Paul D. Cleary, Ph.D., and Susan Edman-Levitan, P.A., there are two major challenges to improving the quality of health care from the consumer's perspective. They are collecting information from representative samples of diverse consumers about the value they place on different types of quality information and conducting research on how well different types of consumers understand and interpret quality indicators.

Iezzoni, L.I., "The risks of risk adjustment," pp. 1600-1607.

Harvard Medical School's Lisa I. Iezzoni, M.D., concludes, after studying severity measures used to produce comparisons of risk-adjusted hospital death rates, that severity of illness does not explain differences in death rates across hospitals. Dr. Iezzoni says that different severity measures frequently produce different impressions about relative hospital performance, and severity-adjusted mortality rates alone are unlikely to isolate quality differences across hospitals.

Drug errors occur twice as often in ICUs as in other hospital units, mostly because more drugs are prescribed there

The rate of preventable drug errors leading to injuries (adverse drug events or ADEs) in patients and potential ADEs (errors with potential for injury) is twice as high in intensive care units (ICUs)—where caregiver/patient interactions are more frequent and more intense—as in other areas of the hospital. However, when the greater number of drugs administered in ICUs is taken into account, the likelihood of ADEs or potential ADEs is not greater for ICUs than for other hospital units, according to a study supported in part by the Agency for Health Care Policy and Research (HS07107). Surprisingly, a stressed and overworked staff in an environment with many distractions was not the reason for ADEs in the ICU. Most individuals in this study who were involved in the ADEs perceived that they were working under reasonably normal circumstances, not at the extremes of workload, stress, or a difficult environment.

One way to reduce preventable and potential ADEs in the ICU is to reduce the overall number of drugs used in the ICU, suggests David J. Cullen, M.D., M.S., of Massachusetts General Hospital, and his colleagues from Brigham and Women's Hospital and Harvard University and School of Public Health. They studied 4,032 patients at 11 ICU and general care units at two tertiary care hospitals over a 6-month period in 1993. They evaluated the rates of preventable and potential ADEs, lengths of stay, charges, costs, and each medical unit's environment. The rate of preventable and potential ADEs in ICUs was nearly twice that of non-ICUs (19 events versus 10 events per 1,000 patient days). However, when adjustments were made for the number of drugs used in the previous 24 hours or ordered since admission, there were no differences in ADE rates between ICUs and non-ICUs.

There were almost no differences between ICUs and non-ICUs in patient characteristics, the patient care team, systems, and individual caregivers. Also, no particular group of drugs was involved in a disproportionate share of ADEs. Rather than targeting particular drugs, the researchers recommend use of a computerized order entry system that presents interactive information about the drug being ordered, the patient, relevant laboratory data, drug-drug interaction data, and prescribing guidelines. Such a system could potentially eliminate many errors due to insufficient information about the patient and the drug ordered. The researchers estimate that each preventable ADE avoided would save $5,857.

Details are in "Preventable adverse drug events in hospitalized patients: A comparative study of intensive care and general care units," by Dr. Cullen, Bobbie Jean Sweitzer, M.D., David W. Bates, M.D., and others, in Critical Care Medicine 25(8), pp. 1289-1297.

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Health Care for the Elderly

Family help and living arrangements, more than income and public programs, keep elderly disabled people in the community

Disabled elderly people who have a network of family helpers and live with a helper receive more in-home help than elderly individuals living alone or without available family helpers, according to a recent study supported by the Agency for Health Care Policy and Research (HS07861). The study found that after controlling for disabilities in physical and cognitive functioning, the most important coping resources are the combination of family helpers who join forces and coresidence with a helper.

The effect of helpers' networks is large and consistent across marital status and living arrangements. The networks are more extensive for married people than unmarried individuals. In the case of elderly people who rely only on non-relatives for help, a network of a spouse and children enables a married person to have 40 additional weekly hours of help. A network of children and others enables an unmarried person to have 29 additional hours of help per week if he or she coresides with other adults and 20 additional hours of help each week for those who do not. Cash income and third-party payments from public programs enable a disabled elderly person to obtain paid help, but their effects on the number of help hours are relatively small.

The issue for public policy is whether family networks can continue to provide as much help in the future, when due to demographic changes more elderly individuals will be divorced, unmarried, or without children. The concern will be how to obtain the funds for paid help to maintain disabled elderly people in the community, note Rachel F. Boaz, Ph.D., and Jianxun Hu, M.B.A., of the City University of New York. The findings of their study are based on a national sample of 4,563 community-dwelling elderly people who participated in the 1989 National Long-Term-Care Survey. The study was designed to quantify the effect of coping resources on the amount (hours) of help used by disabled elderly individuals in their homes, resources that enable them to continue living in the community and avoid or postpone nursing home residence.

Details are in "Determining the amount of help used by disabled elderly persons at home: The role of coping resources," by Dr. Boaz and Mr. Hu in the November 1997 Journal of Gerontology: Social Sciences 52B(6), pp. S317-S324.

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AHCPR News and Notes

From the Administrator

Editor's Note: This "From the Administrator" column summarizes Dr. Eisenberg's remarks at the recent conference "Outcomes Research: Engine for Quality Improvement," sponsored by the Agency for Health Care Policy and Research. The conference was held October 30 and 31 in Washington, DC.

This conference on outcomes research will educate all of us about the state of outcomes research. It also will help AHCPR set its agenda for stimulating, translating, and disseminating research related to outcomes. We will build on the foundation that has been laid and use the conference to provide guidance for the evolution and improvement of outcomes research.

AHCPR can claim success in many ways. Our research methods have set the standard for the discipline. They have been adopted and adapted by other Federal agencies and in the private sector. Another mark of our success is the fact that we are often approached to help fund outcomes research. Many of the researchers who are attending the conference can take credit for this recognition. In many ways, AHCPR has become "the outcomes agency"—and we are proud of that as well.

Although these achievements are remarkable, the need continues for current information on the relationship between the process and outcomes of care in order to enhance our ability to assess and improve quality. It is clear to all of us that the agenda in outcomes must go beyond what has been done previously—that is, principally examining and describing the outcomes of clinical trials. We need to move to a more experimental model. We need to ask what these outcomes mean. What do these differences that we are measuring mean to people?

As researchers, we can be pleased that outcomes research methods are being employed by those who do not consider themselves outcomes researchers. At the same time, that is also a challenge, especially when we consider the new kinds of methods that are needed. To meet this challenge, we can begin by asking how today's research will influence what will be done 5 or 10 years from now.

We need to go beyond identification of practice variations; we have to ask what that variation actually means. Should we be eliminating or celebrating variations? We know that there is more skin cancer in the South, so we would expect to see more surgery for skin cancer there than in the North.

There are geographic, cultural, and biological reasons for variation. As investigators, we ought to be looking at how those variations can be explained and justified. When they cannot be explained and reasonably justified, they ought to be eliminated; and, part of our challenge will be to determine how best to bring about this change. We also need to examine the relationship between those variations and quality of care.

We need to develop better disease-specific measures; at the same time, we must recognize that many Americans, especially the elderly, often have more than one disease, so generic measures are also essential. We have to do a better job of validating the measures we have. Another challenge will be dealing with issues of case mix. Whether you call this risk adjustment or severity adjustment, outcomes measures need to be controlled for these factors which are external to the care being provided. Most of the time today, when we consider case mix for risk and severity adjustment, we are trying to determine how we can pay differently according to case mix and risk adjustment.

But, at a time when measuring outcomes is increasingly important, risk adjustment will be used in measurements of quality. It is a difficult challenge, and there is very little literature to inform current policy discussions.

Another area in which we need progress is outcomes research studying how nonclinical health care influences outcomes. What are the outcomes of new ways of organizing and financing health care? For example, whether we are introducing a case-management system, a disease-management system, a gatekeeper, a new copayment mechanism, or any new organizational or financing arrangement, we should be asking the same tough research questions we ask for clinical interventions: What works? When and for whom? What are the benefits, the risks, and the costs? There are many strongly held beliefs about organizational change.

I recently reviewed the literature on case management and disease management and found that, although there were many articles in glossy magazines, few articles on these topics have made it into serious research publications. I challenge you to think about these nonclinical health interventions and the outcomes that result from them, as well as traditional clinical interventions.

We also need to take a step back and ask ourselves, "What are the outcomes of outcomes research? This is what we might call "outcomes squared." We need to consider what has been achieved with outcomes research, whether it has made a difference, and how we should measure its impact. As researchers, we should be able to answer the questions about outcomes of our work—just as we hold clinicians, other providers, patients, purchasers, and plans to demonstrate the outcomes of their work.

Whether we are providing information to inform individual patient choice about the care and services they will receive or informing purchasers about the plans they will select, outcomes research will be increasingly important to decisionmakers. I challenge you as researchers, when you report on your own research, to go back over what you have written to make sure it is understandable and useful to these decisionmakers.

To effectively communicate the results of our research, we must synthesize and explain them to "tell the story" of outcomes research.

I challenge you to meet two tests: first, the "mom test." In other words, could you get on the phone tonight and explain your research to your mother? If she understands it, great. If not, I maintain that you either do not understand it yourself or you are unable to communicate it. In addition to the "mom test," we have the "cafeteria line test." Can you explain your work to a colleague while standing in a cafeteria line? We should be able to explain AHCPR's research between the time we pick up a tray and the time we get to the cashier.

Peer-reviewed journals help translate the work we do to an audience on the front line. They validate and disseminate our research. But, as a researcher, when you get that letter from the journal editor letting you know that your article has been accepted for publication, and you think your job is done, think again. You are wrong; your job is only half done. You still need to disseminate what is in that article to reach beyond the journal audience so that results may be incorporated into clinical practice and policy decisions. We at AHCPR want to help you tell your story. You just need to let us know when you have been successful.

We need to share our research, and we need to shout about our research. We all deserve to be proud of what we have accomplished—but we cannot rest on those laurels.

AHCPR merges two components and creates a new Center to improve efficiency

The Agency for Health Care Policy and Research has consolidated two existing components to create the Center for Practice and Technology Assessment (CPTA), which will oversee the Agency's Evidence-based Practice Program. CPTA will house the existing Office of the Forum for Quality and Effectiveness in Health Care, and it also will include the functions of the former Center for Health Care Technology. The consolidation, designed to improve efficiency, was announced November 18 in the Federal Register.

According to John M. Eisenberg, M.D., AHCPR's Administrator, the Center for Practice and Technology Assessment will play a leadership role in improving the evidence base underpinning the practice of medicine. CPTA will produce state-of-the-science reports and technology assessments and will focus on closing the gap between what is known and what is done, to help improve the quality of health care.

CPTA's major activities will include: producing evidence reports and technology assessments, principally through AHCPR's 12 Evidence-based Practice Centers; facilitating the development and operation of an Internet-based National Guideline Clearinghouse™ in partnership with the American Medical Association (AMA) and the American Association of Health Plans (AAHP); and coordinating the work of the U.S. Preventive Services Task Force. CPTA also will conduct and support research on the implementation of evidence-based recommendations into the health care delivery system and on the methodologic aspects of this work.

CPTA will be directed by Douglas Kamerow, M.D., who has been serving as Director of AHCPR's Office of the Forum for Quality and Effectiveness in Health Care and as Acting Director of the Center for Health Care Technology. Dr. Kamerow is a family physician and an epidemiologist, and recently he was promoted to the rank of Assistant Surgeon General in the Public Health Service's Commissioned Corps. As Dr. Kamerow points out, CPTA will provide a single point of contact for organizations and individuals who are looking for comprehensive evidence reviews on health conditions, treatments, and technologies, particularly those that are most costly.

New members appointed to AHCPR's National Advisory Council

Four new members and two special advisors have been appointed to the National Advisory Council for Health Care Policy, Research, and Evaluation. Acting Chairman Harold S. Luft, Ph.D., has been named as Chairman of the Council. Select for Overview of the Council.

The Council is made up of representatives from academia, consumer groups, purchasers of health care, and major private health care foundations; health care providers; and Federal health officials. Its role is to provide advice to the Secretary of the Department of Health and Human Services and to the Administrator of the Agency for Health Care Policy and Research on matters related to AHCPR activities. The new members of the Council are:

  • Colleen Conway-Welch, Ph.D., Professor and Dean, Vanderbilt University School of Nursing, Nashville, TN.
  • Dennis G. Fryback, Ph.D., Professor, Department of Preventive Medicine, University of Wisconsin, Madison, WI.
  • Vanessa Northington Gamble, M.D., Ph.D., Associate Professor and Director, Center for the Study of Race and Ethnicity, University of Wisconsin School of Medicine, Madison, WI.
  • Ruby Takanishi, Ph.D., President, Foundation for Child Development, New York, NY.

The two special advisors are:

  • Elliott S. Fisher, M.D., M.P.H., Associate Professor of Medicine, Dartmouth Medical School, Hanover, NH.
  • Nelda P. Wray, M.D., M.P.H., Director, Houston Center for Quality of Care and Utilization Studies, Veterans Affairs Medical Center, Houston, TX.

They will join 10 existing council members (including Dr. Luft), some of whose terms will expire in May 1998. These returning members of the panel are:

  • Richard E. Behrman, M.D., J.D., Managing Director, Center for the Future of Children, The David and Lucile Packard Foundation, Los Altos, CA.
  • Nancy Wilson Dickey, M.D., President-Elect, American Medical Association; Program Director, Brazos Family Medical Center; and Associate Professor, Texas A&M University, College Station, TX.
  • Jose Julio Escarce, M.D., Ph.D., Senior Natural Scientist, RAND, Santa Monica, CA.
  • Ada Sue Hinshaw, Ph.D., R.N., Dean and Professor, University of Michigan School of Nursing, Ann Arbor, MI.
  • Sharon C. Kiely, M.D., Medical Director, Tri-State Health Systems, Pittsburgh, PA.
  • Jeffrey P. Koplan, M.D., M.P.H., President, The Prudential Center for Health Care Research, Atlanta, GA.
  • Harold S. Luft, Ph.D., Director, Institute for Policy Studies, University of California School of Medicine, San Francisco, CA.
  • Woodrow A. Myers, Jr., M.D., M.B.A., Director, Health Care Management, Ford Motor Company, Dearborn, MI.
  • Martin Paris, M.D., M.P.H., Vice President, Medical Affairs, Tenet Healthcare Corp., Los Angeles, CA.
  • Stephen M. Shortell, Ph.D., Professor, Health Services Management, Northwestern University, Evanston, IL.

In addition to the private-sector members, the following Federal officials serve as ex-officio members of the Council: Director, National Institutes of Health; Commissioner, Food and Drug Administration; Administrator, Substance Abuse and Mental Health Services Administration; Director, Centers for Disease Control and Prevention; Administrator, Health Care Financing Administration; Assistant Secretary for Defense (Health Affairs); and Chief Medical Officer, Department of Veterans Affairs.

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