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Blackstone EH. Commentary: A tale of two cities surgeons. JTCVS OPEN 2021; 7:272-273. [PMID: 36003752 PMCID: PMC9390341 DOI: 10.1016/j.xjon.2021.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 06/25/2021] [Accepted: 06/29/2021] [Indexed: 10/26/2022]
Affiliation(s)
- Eugene H. Blackstone
- Department of Thoracic and Cardiovascular Surgery, Sydell and Arnold Miller Family Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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Haeder SF, Weimer DL, Mukamel DB. Going the Extra Mile? How Provider Network Design Increases Consumer Travel Distance, Particularly for Rural Consumers. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2020; 45:1107-1136. [PMID: 32464649 DOI: 10.1215/03616878-8641591] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
CONTEXT The practical accessibility to medical care facilitated by health insurance plans depends not just on the number of providers within their networks but also on distances consumers must travel to reach the providers. Long travel distances inconvenience almost all consumers and may substantially reduce choice and access to providers for some. METHODS The authors assess mean and median travel distances to cardiac surgeons and pediatricians for participants in (1) plans offered through Covered California, (2) comparable commercial plans, and (3) unrestricted open-network plans. The authors repeat the analysis for higher-quality providers. FINDINGS The authors find that in all areas, but especially in rural areas, Covered California plan subscribers must travel longer than subscribers in the comparable commercial plan; subscribers to either plan must travel substantially longer than consumers in open networks. Analysis of access to higher-quality providers show somewhat larger travel distances. Differences between ACA and commercial plans are generally substantively small. CONCLUSIONS While network design adds travel distance for all consumers, this may be particularly challenging for transportation-disadvantaged populations. As distance is relevant to both health outcomes and the cost of obtaining care, this analysis provides the basis for more appropriate measures of network adequacy than those currently in use.
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The 30-Year Influence of a Regional Consortium on Quality Improvement in Cardiac Surgery. Ann Thorac Surg 2020; 110:63-69. [DOI: 10.1016/j.athoracsur.2019.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 09/10/2019] [Accepted: 10/01/2019] [Indexed: 11/22/2022]
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4
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Haeder SF, Weimer DL, Mukamel DB. A Knotty Problem: Consumer Access and the Regulation of Provider Networks. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2019; 44:937-954. [PMID: 31408883 DOI: 10.1215/03616878-7785835] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
In order to increase access to medical services, expanding coverage has long been the preferred solution of policy makers and advocates alike. The calculus appeared straightforward: provide individuals with insurance, and they will be able to see a provider when needed. However, this line of thinking overlooks a crucial intermediary step: provider networks. As provider networks offered by health insurers link available medical services to insurance coverage, their breadth mediates access to health care. Yet the regulation of provider networks is technically, logistically, and normatively complex. What does network regulation currently look like and what should it look like in the future? We take inventory of the ways private and public entities regulate provider networks. Variation across insurance programs and products is truly remarkable, not grounded in empirical justification, and at times inherently absurd. We argue that regulators should be pragmatic and focus on plausible policy levers. These include assuring network accuracy, transparency for consumers, and consumer protections from grievous inadequacies. Ultimately, government regulation provides an important foundation for ensuring minimum levels of access and providing consumers with meaningful information. Yet, information is only truly empowering if consumers can exercise at least some choice in balancing costs, access, and quality.
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Sandhu AT, Kohsaka S, Bhattacharya J, Fearon WF, Harrington RA, Heidenreich PA. Association Between Current and Future Annual Hospital Percutaneous Coronary Intervention Mortality Rates. JAMA Cardiol 2019; 4:1077-1083. [PMID: 31532454 DOI: 10.1001/jamacardio.2019.3221] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Multiple states publicly report a hospital's risk-adjusted mortality rate for percutaneous coronary intervention (PCI) as a quality measure. However, whether reported annual PCI mortality is associated with a hospital's future performance is unclear. Objective To evaluate the association between reported risk-adjusted hospital PCI-related mortality and a hospital's future PCI-related mortality. Design, Setting, and Participants This study used data from the New York Percutaneous Intervention Reporting System from January 1, 1998, to December 31, 2016, to assess hospitals that perform PCI. Exposures Public-reported, risk-adjusted, 30-day mortality after PCI. Main Outcomes and Measures The primary analysis evaluated the association between a hospital's reported risk-adjusted PCI-related mortality and future PCI-related mortality. The correlation between a hospital's observed to expected (O/E) PCI-related mortality rates each year and future O/E mortality ratios was assessed. Multivariable linear regression was used to examine the association between index year O/E mortality and O/E mortality in subsequent years while adjusting for PCI volume and patient severity. Results This study included 67 New York hospitals and 960 hospital-years. Hospitals with low PCI-related mortality (O/E mortality ratio, ≤1) and high mortality (O/E mortality ratio, >1) had inverse associations between their O/E mortality ratio in the index year and the subsequent change in the ratio (hospitals with low mortality, r = -0.45; hospitals with high mortality, r = -0.60). Little of the variation in risk-adjusted mortality was explained by prior performance. An increase in the O/E mortality ratio from 1.0 to 2.0 in the index year was associated with a higher O/E mortality ratio of only 0.15 (95% CI, 0.02-0.27) in the following year. Conclusions and Relevance At hospitals with high or low PCI-related mortality rates, the rates largely regressed to the mean the following year. A hospital's risk-adjusted mortality rate was poorly associated with its future mortality. The annual hospital PCI-related mortality may not be a reliable factor associated with hospital quality to consider in a practice change or when helping patients select high-quality hospitals.
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Affiliation(s)
- Alexander T Sandhu
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Shun Kohsaka
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California.,Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Jay Bhattacharya
- Center for Health Policy, Department of Medicine, Stanford University, Stanford, California.,Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University, Stanford, California
| | - William F Fearon
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Robert A Harrington
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California.,Veterans Affairs Palo Alto Health Care System, Palo Alto, California
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The Impact of Public Performance Reporting on Market Share, Mortality, and Patient Mix Outcomes Associated With Coronary Artery Bypass Grafts and Percutaneous Coronary Interventions (2000-2016): A Systematic Review and Meta-Analysis. Med Care 2019; 56:956-966. [PMID: 30234769 PMCID: PMC6226216 DOI: 10.1097/mlr.0000000000000990] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Supplemental Digital Content is available in the text. Objective: Public performance reporting (PPR) of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) outcomes aim to improve the quality of care in hospitals, surgeons and to inform consumer choice. Past CABG and PCI studies have showed mixed effects of PPR on quality and selection. The aim of this study was to undertake a systematic review and meta-analysis of the impact of PPR on market share, mortality, and patient mix outcomes associated with CABG and PCI. Methods: Six online databases and 8 previous reviews were searched for the period 2000–2016. Data extraction, quality assessment, systematic critical synthesis, and meta-analysis (where possible) were carried out on included studies. Results: In total, 22 relevant articles covering mortality (n=19), patient mix (n=14), and market share (n=6) outcomes were identified. Meta-analyses showed that PPR led to a near but not significant reduction in short-term mortality for both CABG and PCI. PPR on CABG showed a positive effect on market share for hospitals (3 of 6 studies) and low-performing surgeons (2 of 2 studies). Five of 6 PCI studies found that high-risk patients were less likely to be treated in States with PPR. Conclusions: There is some evidence that PPR reduces mortality rates in CABG/PCI-treated patients. The significance of there being no strong evidence, in the period 2000–2016, should be considered. There is need for both further development of PPR practice and further research into the intended and unintended consequences of PPR.
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Badwe RA. Public reporting of healthcare data - Need of the hour in India. Indian J Cancer 2018; 54:592-593. [PMID: 30082540 DOI: 10.4103/ijc.ijc_358_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- R A Badwe
- Director, Tata Memorial Centre, Dr E Borges Road, Parel, Mumbai, Maharashtra, India
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Yamana H, Kodan M, Ono S, Morita K, Matsui H, Fushimi K, Imamura T, Yasunaga H. Hospital quality reporting and improvement in quality of care for patients with acute myocardial infarction. BMC Health Serv Res 2018; 18:523. [PMID: 29973281 PMCID: PMC6033287 DOI: 10.1186/s12913-018-3330-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 06/26/2018] [Indexed: 11/10/2022] Open
Abstract
Background Although public reporting of hospital performance is becoming common, it remains uncertain whether public reporting leads to improvement in clinical outcomes. This study was conducted to evaluate whether enrollment in a quality reporting project is associated with improvement in quality of care for patients with acute myocardial infarction. Methods We conducted a quasi-experimental study using hospital census survey and national inpatient database in Japan. Hospitals enrolled in a ministry-led quality reporting project were matched with non-reporting control hospitals by one-to-one propensity score matching using hospital characteristics. Using the inpatient data of acute myocardial infarction patients hospitalized in the matched hospitals during 2011–2013, difference-in-differences analyses were conducted to evaluate the changes in unadjusted and risk-adjusted in-hospital mortality rates over time that are attributable to intervention. Results Matching between hospitals created a cohort of 30,220 patients with characteristics similar between the 135 reporting and 135 non-reporting hospitals. Overall in-hospital mortality rates were 13.2% in both the reporting and non-reporting hospitals. There was no significant association between hospital enrollment in the quality reporting project and change over time in unadjusted mortality (OR, 0.98; 95% CI, 0.80–1.22). In 28,168 patients eligible for evaluation of risk-adjusted mortality, enrollment was also not associated with change in risk-adjusted mortality (OR, 0.98; 95% CI, 0.81–1.17). Conclusions Enrollment in the quality reporting project was not associated with short-term improvement in quality of care for patients with acute myocardial infarction. Additional efforts may be necessary to improve quality of care. Electronic supplementary material The online version of this article (10.1186/s12913-018-3330-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hayato Yamana
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan. .,Department of Clinical Data Management and Research, Clinical Research Center, National Hospital Organization Headquarters, 2-5-21 Higashigaoka, Meguro-ku, Tokyo, 152-8621, Japan.
| | - Mariko Kodan
- Department of Clinical Data Management and Research, Clinical Research Center, National Hospital Organization Headquarters, 2-5-21 Higashigaoka, Meguro-ku, Tokyo, 152-8621, Japan.,Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Sachiko Ono
- Department of Biostatistics & Bioinformatics, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kojiro Morita
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kiyohide Fushimi
- Department of Clinical Data Management and Research, Clinical Research Center, National Hospital Organization Headquarters, 2-5-21 Higashigaoka, Meguro-ku, Tokyo, 152-8621, Japan.,Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Tomoaki Imamura
- Department of Public Health, Health Management and Policy, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-0813, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
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Williams MP, Modgil V, Drake MJ, Keeley F. The effect of consultant outcome publication on surgeon behaviour: a systematic review and narrative synthesis. Ann R Coll Surg Engl 2018; 100:428-435. [PMID: 29962298 PMCID: PMC6111901 DOI: 10.1308/rcsann.2018.0052] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2018] [Indexed: 02/02/2023] Open
Abstract
Introduction Surgeon-specific outcome data, or consultant outcome publication, refers to public access to named surgeon procedural outcomes. Consultant outcome publication originates from cardiothoracic surgery, having been introduced to US and UK surgery in 1991 and 2005, respectively. It has been associated with an improvement in patient outcomes. However, there is concern that it may also have led to changes in surgeon behaviour. This review assesses the literature for evidence of risk-averse behaviour, upgrading of patient risk factors and cessation of low-volume or poorly performing surgeons. Materials and methods A systematic literature review of Embase and Medline databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Original studies including data on consultant outcome publication and its potential effect on surgeon behaviour were included. Results Twenty-five studies were identified from the literature search. Studies suggesting the presence of risk-averse behaviour and upgrading of risk factors tended to be survey based, with studies contrary to these findings using recognised regional and national databases. Discussion and conclusion Our review includes instances of consultant outcome publication leading to risk-averse behaviour, upgrading of risk factors and cessation of low-volume or poorly performing surgeons. As UK data on consultant outcome publication matures, further research is essential to ensure that high-risk patients are not inappropriately turned down for surgery.
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Affiliation(s)
- MP Williams
- University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - V Modgil
- Heart of England NHS Foundation Trust, Birmingham, UK
| | - MJ Drake
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
- Translational Health Sciences, University of Bristol, Bristol, UK
| | - F Keeley
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
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Risk Aversion and Public Reporting. Part 1: Observations From Cardiac Surgery and Interventional Cardiology. Ann Thorac Surg 2017; 104:2093-2101. [DOI: 10.1016/j.athoracsur.2017.06.077] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 06/25/2017] [Indexed: 11/17/2022]
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11
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Tweddell JS, Jacobs JP, Austin EH. Are there negative consequences of public reporting? The hype and the reality. J Thorac Cardiovasc Surg 2017; 153:908-911. [PMID: 28359373 DOI: 10.1016/j.jtcvs.2017.01.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Revised: 01/14/2017] [Accepted: 01/31/2017] [Indexed: 11/19/2022]
Affiliation(s)
- James S Tweddell
- The Heart Center, Cincinnati Children's Hospital Medical Center and the University of Cincinnati, Cincinnati, Ohio.
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children's Heart Institute, All Children's Hospital and Florida Hospital for Children, Saint Petersburg, Tampa, and Orlando, Fla; Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Erle H Austin
- Norton Children's Hospital and University of Louisville, Louisville, Ky
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Greenhalgh J, Dalkin S, Gooding K, Gibbons E, Wright J, Meads D, Black N, Valderas JM, Pawson R. Functionality and feedback: a realist synthesis of the collation, interpretation and utilisation of patient-reported outcome measures data to improve patient care. HEALTH SERVICES AND DELIVERY RESEARCH 2017. [DOI: 10.3310/hsdr05020] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BackgroundThe feedback of patient-reported outcome measures (PROMs) data is intended to support the care of individual patients and to act as a quality improvement (QI) strategy.ObjectivesTo (1) identify the ideas and assumptions underlying how individual and aggregated PROMs data are intended to improve patient care, and (2) review the evidence to examine the circumstances in which and processes through which PROMs feedback improves patient care.DesignTwo separate but related realist syntheses: (1) feedback of aggregate PROMs and performance data to improve patient care, and (2) feedback of individual PROMs data to improve patient care.InterventionsAggregate – feedback and public reporting of PROMs, patient experience data and performance data to hospital providers and primary care organisations. Individual – feedback of PROMs in oncology, palliative care and the care of people with mental health problems in primary and secondary care settings.Main outcome measuresAggregate – providers’ responses, attitudes and experiences of using PROMs and performance data to improve patient care. Individual – providers’ and patients’ experiences of using PROMs data to raise issues with clinicians, change clinicians’ communication practices, change patient management and improve patient well-being.Data sourcesSearches of electronic databases and forwards and backwards citation tracking.Review methodsRealist synthesis to identify, test and refine programme theories about when, how and why PROMs feedback leads to improvements in patient care.ResultsProviders were more likely to take steps to improve patient care in response to the feedback and public reporting of aggregate PROMs and performance data if they perceived that these data were credible, were aimed at improving patient care, and were timely and provided a clear indication of the source of the problem. However, implementing substantial and sustainable improvement to patient care required system-wide approaches. In the care of individual patients, PROMs function more as a tool to support patients in raising issues with clinicians than they do in substantially changing clinicians’ communication practices with patients. Patients valued both standardised and individualised PROMs as a tool to raise issues, but thought is required as to which patients may benefit and which may not. In settings such as palliative care and psychotherapy, clinicians viewed individualised PROMs as useful to build rapport and support the therapeutic process. PROMs feedback did not substantially shift clinicians’ communication practices or focus discussion on psychosocial issues; this required a shift in clinicians’ perceptions of their remit.Strengths and limitationsThere was a paucity of research examining the feedback of aggregate PROMs data to providers, and we drew on evidence from interventions with similar programme theories (other forms of performance data) to test our theories.ConclusionsPROMs data act as ‘tin openers’ rather than ‘dials’. Providers need more support and guidance on how to collect their own internal data, how to rule out alternative explanations for their outlier status and how to explore the possible causes of their outlier status. There is also tension between PROMs as a QI strategy versus their use in the care of individual patients; PROMs that clinicians find useful in assessing patients, such as individualised measures, are not useful as indicators of service quality.Future workFuture research should (1) explore how differently performing providers have responded to aggregate PROMs feedback, and how organisations have collected PROMs data both for individual patient care and to improve service quality; and (2) explore whether or not and how incorporating PROMs into patients’ electronic records allows multiple different clinicians to receive PROMs feedback, discuss it with patients and act on the data to improve patient care.Study registrationThis study is registered as PROSPERO CRD42013005938.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Joanne Greenhalgh
- School of Sociology and Social Policy, University of Leeds, Leeds, UK
| | - Sonia Dalkin
- Department of Public Health, Northumbria University, Newcastle upon Tyne, UK
| | - Kate Gooding
- School of Sociology and Social Policy, University of Leeds, Leeds, UK
| | - Elizabeth Gibbons
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Judy Wright
- School of Sociology and Social Policy, University of Leeds, Leeds, UK
| | - David Meads
- School of Sociology and Social Policy, University of Leeds, Leeds, UK
| | - Nick Black
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Ray Pawson
- School of Sociology and Social Policy, University of Leeds, Leeds, UK
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Mukamel DB, Weimer DL, Zwanziger J, Gorthy SFH, Mushlin AI. Quality Report Cards, Selection of Cardiac Surgeons, and Racial Disparities: A Study of the Publication of the New York State Cardiac Surgery Reports. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2016; 41:435-46. [PMID: 15835601 DOI: 10.5034/inquiryjrnl_41.4.435] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Quality report cards have become common in many health care markets. This study evaluates their effectiveness by examining the impact of the New York State (NYS) Cardiac Surgery Reports on selection of cardiac surgeons. The analyses compares selection of surgeons in 1991 (pre-report publication) and 1992 (post-report publication). We find that the information about a surgeon's quality published in the reports influences selection directly and diminishes the importance of surgeon experience and price as signals for quality. Furthermore, selection of surgeons for black patients is as sensitive to the published information as is the selection for white patients.
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Affiliation(s)
- Dana B Mukamel
- Department of Medicine, Division of General Internal Medicine and Primary Care, Center for Health Policy Research, University of California, Irvine, 111 Academy Way, Suite 220, Irvine, CA 92697-5800 , USA.
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Mechanisms and effects of public reporting of surgeon outcomes: A systematic review of the literature. Health Policy 2016; 120:1151-1161. [DOI: 10.1016/j.healthpol.2016.08.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 08/03/2016] [Accepted: 08/04/2016] [Indexed: 11/21/2022]
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Abstract
Provider report cards feature prominently in ongoing efforts to improve patient quality. A well-known example is the cardiac surgery report-card program started in New York, which publicly compares hospital and surgeon performance. Public report cards have been associated with decreases in cardiac surgery mortality, but there is substantial disagreement over the source(s) of the improvement. This article develops a conceptual framework to explain how report-card-related responses could result in lower mortality and reviews the evidence. Existing research shows that report cards have not greatly changed referral patterns. How much providers increased their quality of care and altered their selection of patients remains unresolved, and alternative explanations have not been well studied. Future research should expand the number of states and years covered and exploit the variation in institutional features to improve our understanding of the relationship between report cards and outcomes.
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Joynt KE, Orav EJ, Zheng J, Jha AK. Public Reporting of Mortality Rates for Hospitalized Medicare Patients and Trends in Mortality for Reported Conditions. Ann Intern Med 2016; 165:153-60. [PMID: 27239794 PMCID: PMC6935351 DOI: 10.7326/m15-1462] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Public reporting is seen as a powerful quality improvement tool, but data to support its efficacy are limited. The Centers for Medicare & Medicaid Services' Hospital Compare program initially reported process metrics only but started reporting mortality rates for acute myocardial infarction, heart failure, and pneumonia in 2008. OBJECTIVE To determine whether public reporting of mortality rates was associated with lower mortality rates for these conditions among Medicare beneficiaries. DESIGN For 2005 to 2007, process-only reporting was considered; for 2008 to 2012, process and mortality reporting was considered. Changes in mortality trends before and during reporting periods were estimated by using patient-level hierarchical modeling. Nonreported medical conditions were used as a secular control. SETTING U.S. acute care hospitals. PARTICIPANTS 20 707 266 fee-for-service Medicare beneficiaries hospitalized from January 2005 through November 2012. MEASUREMENTS 30-day risk-adjusted mortality rates. RESULTS Mortality rates for the 3 publicly reported conditions were changing at an absolute rate of -0.23% per quarter during process-only reporting, but this change slowed to a rate of -0.09% per quarter during process and mortality reporting (change, 0.13% per quarter; 95% CI, 0.12% to 0.14%). Mortality for nonreported conditions was changing at -0.17% per quarter during process-only reporting and slowed slightly to -0.11% per quarter during process and mortality reporting (change, 0.06% per quarter; CI, 0.05% to 0.07%). LIMITATION Administrative data may have limited ability to account for changes in patient complexity over time. CONCLUSION Changes in mortality trends suggest that reporting in Hospital Compare was associated with a slowing, rather than an improvement, in the ongoing decline in mortality among Medicare patients. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute.
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Campanella P, Vukovic V, Parente P, Sulejmani A, Ricciardi W, Specchia ML. The impact of Public Reporting on clinical outcomes: a systematic review and meta-analysis. BMC Health Serv Res 2016; 16:296. [PMID: 27448999 PMCID: PMC4957420 DOI: 10.1186/s12913-016-1543-y] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Accepted: 07/09/2016] [Indexed: 02/06/2023] Open
Abstract
Background To assess both qualitatively and quantitatively the impact of Public Reporting (PR) on clinical outcomes, we carried out a systematic review of published studies on this topic. Methods Pubmed, Web of Science and SCOPUS databases were searched to identify studies published from 1991 to 2014 that investigated the relationship between PR and clinical outcomes. Studies were considered eligible if they investigated the relationship between PR and clinical outcomes and comprehensively described the PR mechanism and the study design adopted. Among the clinical outcomes identified, meta-analysis was performed for overall mortality rate which quantitative data were exhaustively reported in a sufficient number of studies. Two reviewers conducted all data extraction independently and disagreements were resolved through discussion. The same reviewers evaluated also the quality of the studies using a GRADE approach. Results Twenty-seven studies were included. Mainly, the effect of PR on clinical outcomes was positive. Meta-analysis regarding overall mortality included, in a context of high heterogeneity, 10 studies with a total of 1,840,401 experimental events and 3,670,446 control events and resulted in a RR of 0.85 (95 % CI, 0.79-0.92). Conclusions The introduction of PR programs at different levels of the healthcare sector is a challenging but rewarding public health strategy. Existing research covering different clinical outcomes supports the idea that PR could, in fact, stimulate providers to improve healthcare quality. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1543-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Paolo Campanella
- Department of Public Health, Section of Hygiene, Catholic University of Sacred Heart, L.go F. Vito 1, 00168 Rome, Italy.
| | - Vladimir Vukovic
- Department of Public Health, Section of Hygiene, Catholic University of Sacred Heart, L.go F. Vito 1, 00168 Rome, Italy
| | - Paolo Parente
- Department of Public Health, Section of Hygiene, Catholic University of Sacred Heart, L.go F. Vito 1, 00168 Rome, Italy
| | - Adela Sulejmani
- Department of Public Health, Section of Hygiene, Catholic University of Sacred Heart, L.go F. Vito 1, 00168 Rome, Italy
| | - Walter Ricciardi
- Department of Public Health, Section of Hygiene, Catholic University of Sacred Heart, L.go F. Vito 1, 00168 Rome, Italy
| | - Maria Lucia Specchia
- Department of Public Health, Section of Hygiene, Catholic University of Sacred Heart, L.go F. Vito 1, 00168 Rome, Italy
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Has Public Reporting of Hospital Readmission Rates Affected Patient Outcomes?: Analysis of Medicare Claims Data. J Am Coll Cardiol 2016; 67:963-972. [PMID: 26916487 DOI: 10.1016/j.jacc.2015.12.037] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 11/04/2015] [Accepted: 12/01/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND In 2009, the Centers for Medicare & Medicaid Services (CMS) began publicly reporting 30-day hospital readmission rates for patients discharged with acute myocardial infarction (MI), heart failure (HF), or pneumonia. OBJECTIVES This study assessed trends of 30-day readmission rates and post-discharge care since the implementation of CMS public reporting. METHODS We analyzed Medicare claims data from 2006 to 2012 for patients discharged after a hospitalization for MI, HF, or pneumonia. For each diagnosis, we estimated trends in 30-day all-cause readmissions and post-discharge care (emergency department visits and observation stays) by using hospitalization-level regression models. We modeled adjusted trends before and after the implementation of public reporting. To assess for a change in trend, we tested the difference between the slope before implementation and the slope after implementation. RESULTS We analyzed 37,829 hospitalizations for MI, 100,189 for HF, and 79,076 for pneumonia from >4,100 hospitals. When considering only recent trends (i.e., since 2009), we found improvements in adjusted readmission rates for MI (-2.3%), HF (-1.8%), and pneumonia (-2.0%), but when comparing the trend before public reporting with the trend after reporting, there was no difference for MI (p = 0.72), HF (p = 0.19), or pneumonia (p = 0.21). There were no changes in trends for 30-day post-discharge care for MI or pneumonia; however, the trend decreased for HF emergency department visits from 2.3% to -0.8% (p = 0.007) and for observation stays from 15.1% to 4.1% (p = 0.04). CONCLUSIONS The release of the CMS public reporting of hospital readmission rates was not associated with any measurable change in 30-day readmission trends for MI, HF, or pneumonia, but it was associated with less hospital-based acute care for HF.
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Gupta N, Kotler PL, Dudley RA. Analytic Reviews: Considerations in the Development of Intensive Care Unit Report Cards. J Intensive Care Med 2016. [DOI: 10.1177/088506602237105] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Concerns over health care quality have prompted calls for the public release of performance data, or “report cards,” as one strategy for improving quality. Any initiative to create a report card should start with the selection of valid quality indicators. This is complicated by the need to account for variations in case mix among intensive care units (ICUs), the difficulty in defining which patients are receiving critical care, and the fact that pre-ICU and post-ICU care can influence the outcomes of care for ICU patients. The difficulties in measuring quality accurately make some providers reluctant to release performance data to the public, but advocates of public disclosure point to examples of improved quality after publication of report cards. Consumer and purchaser demand for report cards continues to increase, so public reporting of performance data likely will become more common. In light of this trend, it is important for physicians to become involved in the development of report cards to ensure that quality measurement is valid and that the data are used for quality improvement.
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Affiliation(s)
- Nisha Gupta
- Institute for Health Policy Studies, University of California, San Francisco
| | - Pam L. Kotler
- Institute for Health Policy Studies, University of California, San Francisco
| | - R. Adams Dudley
- Institute for Health Policy Studies, University of California, San Francisco,
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Affiliation(s)
- Allen Kachalia
- From Brigham & Women's Hospital, Harvard Medical School, Boston, MA (A.K.); Stanford University School of Medicine and Stanford Law School, CA (M.M.M., D.M.S.); and University of Michigan Medical School, Ann Arbor (B.K.N.).
| | - Michelle M Mello
- From Brigham & Women's Hospital, Harvard Medical School, Boston, MA (A.K.); Stanford University School of Medicine and Stanford Law School, CA (M.M.M., D.M.S.); and University of Michigan Medical School, Ann Arbor (B.K.N.)
| | - Brahmajee K Nallamothu
- From Brigham & Women's Hospital, Harvard Medical School, Boston, MA (A.K.); Stanford University School of Medicine and Stanford Law School, CA (M.M.M., D.M.S.); and University of Michigan Medical School, Ann Arbor (B.K.N.)
| | - David M Studdert
- From Brigham & Women's Hospital, Harvard Medical School, Boston, MA (A.K.); Stanford University School of Medicine and Stanford Law School, CA (M.M.M., D.M.S.); and University of Michigan Medical School, Ann Arbor (B.K.N.)
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Saxena A, Newcomb AE, Dhurandhar V, Bannon PG. Application of Clinical Databases to Contemporary Cardiac Surgery Practice: Where are We now? Heart Lung Circ 2016; 25:237-42. [DOI: 10.1016/j.hlc.2015.01.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 01/10/2015] [Accepted: 01/13/2015] [Indexed: 12/01/2022]
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Sen R, Heim GR. Managing Enterprise Risks of Technological Systems: An Exploratory Empirical Analysis of Vulnerability Characteristics as Drivers of Exploit Publication*. DECISION SCIENCES 2016. [DOI: 10.1111/deci.12212] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Ravi Sen
- Department of Information and Operations Management; Mays Business School, Texas A&M University; 320S Wehner Building College Station TX 77843-4217
| | - Gregory R. Heim
- Department of Information and Operations Management; Mays Business School, Texas A&M University; 320U Wehner Building College Station TX 77843-4217
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Collaborative quality improvement vs public reporting for percutaneous coronary intervention: A comparison of percutaneous coronary intervention in New York vs Michigan. Am Heart J 2015; 170:1227-33. [PMID: 26678645 DOI: 10.1016/j.ahj.2015.09.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 09/14/2015] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Public reporting (PR) is a policy mechanism that may improve clinical outcomes for percutaneous coronary intervention (PCI). However, prior studies have shown that PR may have an adverse impact on patient selection. It is unclear whether alternatives to PR, such as collaborative quality improvement (CQI), may drive improvements in quality of care and outcomes for patients receiving PCI without the unintended consequences seen with PR. METHODS Using National Cardiovascular Data Registry CathPCI Registry data from January 2011 through September 2012, we evaluated patients who underwent PCI in New York (NY), a state with PR (N = 51,983), to Michigan, a state with CQI (N = 53,528). We compared patient characteristics, the quality of care delivered, and clinical outcomes. RESULTS Patients undergoing PCI in NY had a lower-risk profile, with a lower proportion of patients with ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, or cardiogenic shock, compared with Michigan. Quality of care was broadly similar in the 2 states; however, outcomes were better in NY. In a propensity-matched analysis, patients in NY were less likely to be referred for emergent, urgent, or salvage coronary artery bypass surgery (odds ratio [OR] 0.67, 95% CI 0.51-0.88, P < .0001) and to receive blood transfusion (OR 0.7, 95% CI 0.61-0.82, P < .0001), and had lower in-hospital mortality (OR 0.72, 95% CI 0.63-0.83, P < .0001). CONCLUSIONS Public reporting of PCI data is associated with fewer high-risk patients undergoing PCI compared with CQI. However, in comparable samples of patients, PR is also associated with a lower risk of mortality and adverse events. The optimal quality improvement method may involve combining these 2 strategies to protect access to care while still driving improvements in patient outcomes.
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Abstract
RATIONALE Public reporting of hospital performance is designed to improve healthcare outcomes by promoting quality improvement and informing consumer choice, but these programs may carry unintended consequences. OBJECTIVE To determine whether publicly reporting in-hospital mortality rates for intensive care unit (ICU) patients influenced discharge patterns or mortality. METHODS We performed a retrospective cohort study taking advantage of a natural experiment in which California, but not other states, publicly reported hospital-specific severity-adjusted ICU mortality rates between 2007 and 2012. We used multivariable logistic regression adjusted for patient, hospital, and regional characteristics to compare mortality rates and discharge patterns between California and states without public reporting for Medicare fee-for-service ICU admissions from 2005 through 2009 using a difference-in-differences approach. MEASUREMENTS AND MAIN RESULTS We assessed discharge patterns using post-acute care use and acute care hospital transfer rates and mortality using in-hospital and 30-day mortality rates. The study cohort included 936,063 patients admitted to 646 hospitals. Compared with control subjects, admission to a California ICU after the introduction of public reporting was associated with a reduced odds of post-acute care use in post-reform year 2 (ratio of odds ratios [ORs], 0.94; 95% confidence interval [CI], 0.91-0.96) and increased odds of transfer to another acute care hospital in both post-reform years (year 1: ratio of ORs, 1.08; 95% CI, 1.01-1.16; year 2: ratio of ORs, 1.43; 95% CI, 1.33-1.53). There were no significant differences in in-hospital or 30-day mortality. CONCLUSIONS Public reporting of ICU in-hospital mortality rates was associated with changes in discharge patterns but no change in risk-adjusted mortality.
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The Society of Thoracic Surgeons Voluntary Public Reporting Initiative. Ann Surg 2015; 262:526-35; discussion 533-5. [DOI: 10.1097/sla.0000000000001422] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Affiliation(s)
- Ben Bridgewater
- University Hospital of South Manchester NHS Foundation Trust
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Affiliation(s)
- Karen E. Joynt
- From the Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital; Department of Health Policy and Management, Harvard School of Public Health; and Department of Medicine, Cardiology and Vascular Medicine Section, VA Boston Healthcare System, Boston, MA
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Englum BR, Saha-Chaudhuri P, Shahian DM, O'Brien SM, Brennan JM, Edwards FH, Peterson ED. The impact of high-risk cases on hospitals' risk-adjusted coronary artery bypass grafting mortality rankings. Ann Thorac Surg 2015; 99:856-62. [PMID: 25583462 DOI: 10.1016/j.athoracsur.2014.09.048] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Revised: 08/10/2014] [Accepted: 09/22/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Risk-adjusted mortality (RAM) models are increasingly used to evaluate hospital performance, but the validity of the RAM method has been questioned. Providers are concerned that these methods might not adequately account for the highest levels of risk and that treating high-risk cases will have a negative impact on RAM rankings. METHODS Using cases of isolated coronary artery bypass grafting (CABG) performed at 1002 sites in the United States participating in The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database from 2008 to 2010 (N = 494,955), the STS CABG RAM model performance in high-risk patients was assessed. The ratios of observed to expected (O/E) perioperative mortality were compared among groups of hospitals with varying expected risks. Finally, RAM rates during the overall study period for each site were compared with its performance in a simulated "nightmare year" in which the site's highest risk cases over a 3-year period were concentrated into a 1-year period of exceptional risk. RESULTS The average predicted mortality for center risk groups ranged from 1.46% for the lowest risk quintile to 2.87% for the highest. The O/E ratios for center risk quintiles 1 to 5 during the overall period were 1.01 (95% confidence interval, 0.96% to 1.06%), 1.00 (0.95% to 1.04%), 0.98 (0.94% to 1.03%), 0.97 (0.93% to 1.01%), and 0.80 (0.77% to 0.84%), respectively. The sites' risk-adjusted mortality rates were not increased when the centers' highest risk cases were concentrated into a single "nightmare year." CONCLUSIONS Our results show that the current risk-adjusted models accurately estimate CABG mortality and that hospitals accepting more high-risk CABG patients have equal or better outcomes than do those with predominately lower-risk patients.
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Affiliation(s)
- Brian R Englum
- Department of Surgery, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | | | - David M Shahian
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sean M O'Brien
- Duke Clinical Research Institute, Durham, North Carolina
| | - J Matthew Brennan
- Duke Clinical Research Institute, Durham, North Carolina; Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Fred H Edwards
- Shands Hospital, University of Florida, Jacksonville, Florida
| | - Eric D Peterson
- Duke Clinical Research Institute, Durham, North Carolina; Department of Medicine, Duke University Medical Center, Durham, North Carolina.
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Epstein AM, Joynt KE, Jha AK, Orav EJ. Access to coronary artery bypass graft surgery under pay for performance: evidence from the premier hospital quality incentive demonstration. Circ Cardiovasc Qual Outcomes 2014; 7:727-34. [PMID: 25160840 DOI: 10.1161/circoutcomes.114.001024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although pay for performance (P4P) has become common, many worry that P4P will lead providers to avoid offering surgical procedures to the sickest patients out of concern that poor outcomes will lead to financial penalties. METHODS AND RESULTS We used Medicare data to compare change in rates of coronary artery bypass graft surgery between 2002 to 2003 and 2008 to 2009 among patients with acute myocardial infarction (AMI) admitted to 126 hospitals participating in Medicare's Premier Hospital Quality Incentive Demonstration P4P program with patients in 848 control hospitals participating in public reporting through the Health Quality Alliance. We examined rates for all patients with AMI and those in the top decile of predicted mortality based on demographics, medical comorbidities, and AMI characteristics. We identified 91 393 patients admitted for AMI in Premier hospitals and 502 536 Medicare patients admitted for AMI in control hospitals. Coronary artery bypass graft surgery rates for patients with AMI in Premier decreased from 13.6% in 2002 to 2003 to 10.4% in 2008 to 2009; there was a comparable decrease in non-Premier hospitals (13.6%-10.6%; P value for comparison of changes between Premier and non-Premier, 0.67). Coronary artery bypass graft surgery rates for high-risk patients in Premier decreased from 8.4% in FY 2002 to 203 to 8.2% in 2008 to 2009. Patterns were similar in non-Premier hospitals (8.4%-8.3%; P value for comparison of changes between Premier and non-Premier, 0.82). CONCLUSIONS Our results show no evidence of a deleterious effect of P4P on access to coronary artery bypass graft surgery for high-risk patients with AMI. These results should be reassuring to those concerned about the potential negative effect of P4P on high-risk patients.
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Affiliation(s)
- Arnold M Epstein
- From the Department of Health Policy and Management (A.M.E., K.E.J., A.K.J.) and Department of Biostatistics (E.J.O.), Harvard School of Public Health, Boston, MA; Department of Medicine, Division of General Medicine, (A.M.E., A.K.J., E.J.O.) and Division of Cardiovascular Medicine (K.E.J.), Brigham and Women's Hospital, Boston, MA; and Department of Medicine, VA Boston Healthcare System, Boston, MA (K.E.J., A.K.J.).
| | - Karen E Joynt
- From the Department of Health Policy and Management (A.M.E., K.E.J., A.K.J.) and Department of Biostatistics (E.J.O.), Harvard School of Public Health, Boston, MA; Department of Medicine, Division of General Medicine, (A.M.E., A.K.J., E.J.O.) and Division of Cardiovascular Medicine (K.E.J.), Brigham and Women's Hospital, Boston, MA; and Department of Medicine, VA Boston Healthcare System, Boston, MA (K.E.J., A.K.J.)
| | - Ashish K Jha
- From the Department of Health Policy and Management (A.M.E., K.E.J., A.K.J.) and Department of Biostatistics (E.J.O.), Harvard School of Public Health, Boston, MA; Department of Medicine, Division of General Medicine, (A.M.E., A.K.J., E.J.O.) and Division of Cardiovascular Medicine (K.E.J.), Brigham and Women's Hospital, Boston, MA; and Department of Medicine, VA Boston Healthcare System, Boston, MA (K.E.J., A.K.J.)
| | - E John Orav
- From the Department of Health Policy and Management (A.M.E., K.E.J., A.K.J.) and Department of Biostatistics (E.J.O.), Harvard School of Public Health, Boston, MA; Department of Medicine, Division of General Medicine, (A.M.E., A.K.J., E.J.O.) and Division of Cardiovascular Medicine (K.E.J.), Brigham and Women's Hospital, Boston, MA; and Department of Medicine, VA Boston Healthcare System, Boston, MA (K.E.J., A.K.J.)
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Hawkins BM, Fitzgerald-McKeon LM, Yeh RW. High-risk percutaneous coronary intervention in the era of public reporting: clinical and ethical considerations in the care of an elderly patient with critical left main disease and shock. Circulation 2014; 129:258-65. [PMID: 24421361 DOI: 10.1161/circulationaha.113.004604] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Beau M Hawkins
- Cardiovascular Section, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma (B.M.H.); Division of Cardiology, Massachusetts General Hospital, Boston, MA (R.W.Y.); and Amo et Doceo Liberi Center, East Walpole, MA (L.M.F.-M.)
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Chatterjee P, Joynt KE. Do cardiology quality measures actually improve patient outcomes? J Am Heart Assoc 2014; 3:e000404. [PMID: 24510114 PMCID: PMC3959669 DOI: 10.1161/jaha.113.000404] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Accepted: 12/20/2013] [Indexed: 11/16/2022]
Affiliation(s)
- Paula Chatterjee
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA (P.C., K.E.J.)
- Harvard Medical School, VA Boston Healthcare System, Boston, MA (P.C., K.E.J.)
| | - Karen E. Joynt
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA (P.C., K.E.J.)
- Cardiovascular Division, Brigham & Women's Hospital, Boston, MA (K.E.J.)
- Harvard Medical School, VA Boston Healthcare System, Boston, MA (P.C., K.E.J.)
- Cardiology Service, VA Boston Healthcare System, Boston, MA (K.E.J.)
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Risk factors for in-hospital mortality and prolonged length of stay in older patients with solid tumor malignancies. J Geriatr Oncol 2013; 4:310-8. [PMID: 24472473 DOI: 10.1016/j.jgo.2013.05.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Revised: 04/10/2013] [Accepted: 05/24/2013] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Hospitalized adult patients with cancer and with major comorbidities have higher mortality rates and longer duration of hospitalization. There is limited understanding of risk factors that contribute to prolonged hospitalization and mortality in older patients with solid tumors. MATERIALS AND METHODS Risk factors associated with in-hospital mortality and prolonged length of stay (LOS) in older patients with cancer were investigated in a retrospective cohort study. Data from the University HealthSystem Consortium database included 386,377 patients age ≥ 65 years with solid tumors hospitalized between 1995 and 2003 at 133 U.S. academic medical centers. RESULTS The overall mortality rate was 7.3%. Mortality in older patients with cancer was strongly associated with longer LOS. Almost twice as many deaths were observed among those with LOS ≥ 10 days (p<0.0001). Nearly 38% of older cancer patients who died in hospital had potentially curable disease. Primary central nervous system malignancies were most strongly associated with in-hospital mortality (OR=1.81; 1.59-2.07), followed by esophageal (OR=1.74; 1.54-1.97) and lung cancer (OR=1.57; 1.43-1.72). Male gender, African-American race, and Hispanic and Asian race/ethnicity were associated with increased risk of mortality (p<0.0001). Additional risk factors included metastatic disease, infection, neutropenia, renal, lung, hepatic, cerebrovascular disease, arterial/venous thromboembolism, heart failure, and red blood cell transfusion. Risk factors for prolonged LOS included gastric cancer, infection, venous thromboembolism and red blood cell transfusion. CONCLUSIONS Prolonged LOS was strongly associated with mortality. Risk factors such as infection, neutropenia and red blood cell transfusion, when modified, could potentially reduce rates of prolonged LOS and mortality in older patients with cancer.
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Abstract
Cardiac interventions are among the most quantitatively studied therapies. It is important for all involved with cardiac interventions to understand how information generated from observations made during patient care is transformed into data suitable for analysis, to appreciate at a high level what constitutes appropriate analyses of those data, to effectively evaluate inferences drawn from those analyses, and to apply new knowledge to better care for individual patients.
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Affiliation(s)
- Eugene H Blackstone
- Clinical Investigations, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, JJ40, Cleveland, OH 44195, USA.
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Joynt KE, Blumenthal DM, Orav EJ, Resnic FS, Jha AK. Association of public reporting for percutaneous coronary intervention with utilization and outcomes among Medicare beneficiaries with acute myocardial infarction. JAMA 2012; 308:1460-8. [PMID: 23047360 PMCID: PMC3698951 DOI: 10.1001/jama.2012.12922] [Citation(s) in RCA: 164] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
CONTEXT Public reporting of patient outcomes is an important tool to improve quality of care, but some observers worry that such efforts will lead clinicians to avoid high-risk patients. OBJECTIVE To determine whether public reporting for percutaneous coronary intervention (PCI) is associated with lower rates of PCI for patients with acute myocardial infarction (MI) or with higher mortality rates in this population. DESIGN, SETTING, AND PATIENTS Retrospective observational study conducted using data from fee-for-service Medicare patients (49,660 from reporting states and 48,142 from nonreporting states) admitted with acute MI to US acute care hospitals between 2002 and 2010. Logistic regression was used to compare PCI and mortality rates between reporting states (New York, Massachusetts, and Pennsylvania) and regional nonreporting states (Maine, Vermont, New Hampshire, Connecticut, Rhode Island, Maryland, and Delaware). Changes in PCI rates over time in Massachusetts compared with nonreporting states were also examined. MAIN OUTCOME MEASURES Risk-adjusted PCI and mortality rates. RESULTS In 2010, patients with acute MI were less likely to receive PCI in public reporting states than in nonreporting states (unadjusted rates, 37.7% vs 42.7%, respectively; risk-adjusted odds ratio [OR], 0.82 [95% CI, 0.71-0.93]; P = .003). Differences were greatest among the 6708 patients with ST-segment elevation MI (61.8% vs 68.0%; OR, 0.73 [95% CI, 0.59-0.89]; P = .002) and the 2194 patients with cardiogenic shock or cardiac arrest (41.5% vs 46.7%; OR, 0.79 [95% CI, 0.64-0.98]; P = .03). There were no differences in overall mortality among patients with acute MI in reporting vs nonreporting states. In Massachusetts, odds of PCI for acute MI were comparable with odds in nonreporting states prior to public reporting (40.6% vs 41.8%; OR, 1.00 [95% CI, 0.71-1.41]). However, after implementation of public reporting, odds of undergoing PCI in Massachusetts decreased compared with nonreporting states (41.1% vs 45.6%; OR, 0.81 [95% CI, 0.47-1.38]; P = .03 for difference in differences). Differences were most pronounced for the 6081 patients with cardiogenic shock or cardiac arrest (prereporting: 44.2% vs 36.6%; OR, 1.40 [95% CI, 0.85-2.32]; postreporting: 43.9% vs 44.8%; OR, 0.92 [95% CI, 0.38-2.22]; P = .03 for difference in differences). CONCLUSIONS Among Medicare beneficiaries with acute MI, the use of PCI was lower for patients treated in 3 states with public reporting of PCI outcomes compared with patients treated in 7 regional control states without public reporting. However, there was no difference in overall acute MI mortality between states with and without public reporting.
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Affiliation(s)
- Karen E Joynt
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA.
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Hannan EL, Cozzens K, King SB, Walford G, Shah NR. The New York State cardiac registries: history, contributions, limitations, and lessons for future efforts to assess and publicly report healthcare outcomes. J Am Coll Cardiol 2012; 59:2309-16. [PMID: 22698487 DOI: 10.1016/j.jacc.2011.12.051] [Citation(s) in RCA: 121] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Revised: 11/10/2011] [Accepted: 12/17/2011] [Indexed: 10/28/2022]
Abstract
In 1988, the New York State Health Commissioner was confronted with hospital-level data demonstrating very large, multiple-year, interhospital variations in short-term mortality and complications for cardiac surgery. The concern with the extent to which these differences were due to variations in patients' pre-surgical severity of illness versus hospitals' quality of care led to the development of clinical registries for cardiac surgery in 1989 and for percutaneous coronary interventions in 1992 in New York. In 1990, the Department of Health released hospitals' risk-adjusted cardiac surgery mortality rates for the first time, and shortly thereafter, similar data were released for hospitals and physicians for percutaneous coronary interventions, cardiac valve surgery, and pediatric cardiac surgery (only hospital data). This practice is still ongoing. The purpose of this communication is to relate the history of this initiative, including changes or purported changes that have occurred since the public release of cardiac data. These changes include decreases in risk-adjusted mortality, cessation of cardiac surgery in New York by low-volume and high-mortality surgeons, out-of-state referral or avoidance of cardiac surgery/angioplasty for high-risk patients, alteration of contracting choices by insurance companies, and modifications in market share of cardiac hospitals. Evidence related to these impacts is reviewed and critiqued. This communication also includes a summary of numerous studies that used New York's cardiac registries to examine a variety of policy issues regarding the choice and use of cardiac procedures, the comparative effectiveness of competing treatment options, and the examination of the relationship among processes, structures, and outcomes of cardiac care.
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Affiliation(s)
- Edward L Hannan
- University at Albany, State University of New York, 12144-3456, USA.
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Stefan M, Lindenauer PK. Improving the Quality and Outcomes of Perioperative Care. Perioper Med (Lond) 2012. [DOI: 10.1002/9781118375372.ch3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Ryan AM, Nallamothu BK, Dimick JB. Medicare's public reporting initiative on hospital quality had modest or no impact on mortality from three key conditions. Health Aff (Millwood) 2012; 31:585-92. [PMID: 22392670 DOI: 10.1377/hlthaff.2011.0719] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Hospital Compare, Medicare's public reporting initiative, began reporting measures of hospital quality for almost all US acute care hospitals in 2005. The impact of this public reporting initiative on patient mortality is unknown. We used Medicare claims data from the period 2000-08 to estimate the effect of Hospital Compare on thirty-day mortality for heart attack, heart failure, and pneumonia. Our analysis indicates that the fact that hospitals had to report quality data under Hospital Compare led to no reductions in mortality beyond existing trends for heart attack and pneumonia and led to a modest reduction in mortality for heart failure. We conclude that Medicare's public reporting initiative for hospitals has had a minimal impact on patient mortality.
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Affiliation(s)
- Andrew M Ryan
- Division of Outcomes and Effectiveness Research at Weill Cornell Medical College, New York City, NY, USA.
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Passaretti CL, Barclay P, Pronovost P, Perl TM. Public reporting of health care-associated infections (HAIs): approach to choosing HAI measures. Infect Control Hosp Epidemiol 2012; 32:768-74. [PMID: 21768760 DOI: 10.1086/660873] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To develop a method for selecting health care-associated infection (HAI) measures for public reporting. CONTEXT HAIs are common, serious, and costly adverse outcomes of medical care that affect 2 million people in the United States annually. Thirty-seven states have introduced or passed legislation requiring public reporting of HAI measures. State legislation varies widely regarding which HAIs to report, how the data are collected and reported, and public availability of results. DESIGN The Maryland Health Care Commission developed an HAI Technical Advisory Committee (TAC) that consisted of a group of experts in the field of healthcare epidemiology, infection prevention and control (IPC), and public health. This group reviewed public reporting systems in other states, surveyed Maryland hospitals to determine the current state of IPC programs, performed a literature review on HAI measures, and developed six criteria for ranking the measures: impact, improvability, inclusiveness, frequency, functionality, and feasibility. The committee and experts in the field then ranked each of 18 proposed HAI measures. A composite score was determined for each measure. RESULTS Among outcome measures, the rate of central line-associated bloodstream infections ranked highest, followed by the rate of post-coronary artery bypass grafting surgical-site infections. Among process measures, perioperative antimicrobial prophylaxis, compliance with central-line bundles, compliance with hand hygiene, and healthcare-worker influenza vaccination ranked highest. CONCLUSIONS Our qualitative criteria facilitated consensus on the HAI TAC and provided a useful framework for public reporting of HAI measures. Validation will be important for such approaches to be supported by the scientific community.
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Affiliation(s)
- C L Passaretti
- Department of Medicine, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, Maryland 21224, USA.
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Chen LM, Orav EJ, Epstein AM. Public Reporting on Risk-Adjusted Mortality After Percutaneous Coronary Interventions in New York State. Circ Cardiovasc Qual Outcomes 2012; 5:70-5. [DOI: 10.1161/circoutcomes.111.962761] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Since the advent of public reporting on risk-adjusted mortality for coronary artery bypass graft surgery, public reporting on outcomes has expanded to include a variety of dissimilar conditions and procedures. We have little evidence to support such broad-based efforts.
Methods and Results—
We examined the quality performance of 351 cardiologists at 48 hospitals in New York State, using publicly reported risk-adjusted mortality rates (RAMRs) for nonemergent percutaneous coronary interventions between 1998 and 2007. In the year after report release, we examined the following: (1) average RAMR for hospitals, (2) change in market share for hospitals and cardiologists, and (3) proportion of physicians leaving practice. We found that patients who picked a hospital that performed significantly better than expected in prior years had lower RAMRs (0.47, 0.61, and 0.72 for patients choosing hospitals whose prior reports were better than, as, and worse than expected;
P
=0.02). However, choosing a hospital in the top quartile (or decile) of performance in prior years did not decrease a patient's chance of dying (
P
=0.29, or
P
=0.27). Performance ranking was not associated with a change in market share for hospitals or for physicians, or with leaving practice (all
P
>0.05).
Conclusions—
Public reporting on nonemergent percutaneous coronary interventions in New York State identifies very high and low performers but provides insufficient information to differentiate between most hospitals. It appears to have had no effect on market share or physicians' decisions to leave practice. The utility of public reporting on RAMRs may differ for different conditions and procedures.
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Affiliation(s)
- Lena M. Chen
- From the Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI (L.M.C.); Division of General Medicine, University of Michigan, Ann Arbor, MI (L.M.C.); Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA (E.J.O., A.M.E.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, MA (A.M.E.)
| | - E. John Orav
- From the Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI (L.M.C.); Division of General Medicine, University of Michigan, Ann Arbor, MI (L.M.C.); Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA (E.J.O., A.M.E.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, MA (A.M.E.)
| | - Arnold M. Epstein
- From the Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI (L.M.C.); Division of General Medicine, University of Michigan, Ann Arbor, MI (L.M.C.); Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA (E.J.O., A.M.E.); and Department of Health Policy and Management, Harvard School of Public Health, Boston, MA (A.M.E.)
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Impact of Public Reporting of Coronary Artery Bypass Graft Surgery Performance Data on Market Share, Mortality, and Patient Selection. Med Care 2011; 49:1118-25. [DOI: 10.1097/mlr.0b013e3182358c78] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 58:e123-210. [PMID: 22070836 DOI: 10.1016/j.jacc.2011.08.009] [Citation(s) in RCA: 576] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:e652-735. [PMID: 22064599 DOI: 10.1161/cir.0b013e31823c074e] [Citation(s) in RCA: 390] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Shahian DM, Edwards FH, Jacobs JP, Prager RL, Normand SLT, Shewan CM, O'Brien SM, Peterson ED, Grover FL. Public Reporting of Cardiac Surgery Performance: Part 1—History, Rationale, Consequences. Ann Thorac Surg 2011; 92:S2-11. [DOI: 10.1016/j.athoracsur.2011.06.100] [Citation(s) in RCA: 123] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2010] [Revised: 06/07/2011] [Accepted: 06/09/2011] [Indexed: 11/24/2022]
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Roark RF, Shah BR, Udayakumar K, Peterson ED. The need for transformative innovation in hypertension management. Am Heart J 2011; 162:405-11. [PMID: 21884855 DOI: 10.1016/j.ahj.2011.06.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2010] [Accepted: 06/01/2011] [Indexed: 01/13/2023]
Abstract
Despite multiple available effective therapies for hypertension, many patients with high blood pressure in the United States are not adequately controlled. This inability to effectively manage hypertension can be attributed to patient, provider, and system failures. To create an effective model for hypertension management, current care delivery systems must be reorganized around the following principles: improved patient engagement and patient-provider communication, increased use of nonphysician providers, better performance monitoring and feedback systems, and better aligned reimbursement models. Transformation of care around these principles would lead to marked improvements in cost, quality, and access to care.
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Abstract
Recent trends in U.S. long-term care policy reflect three broad goals Americans have for the quality of long-term care: improving quality of life, reducing fragmentation of delivery and financing, and increasing use of home and community-based care. At the same time, market-based reforms--namely, public reporting and pay-for-performance--have taken on their own momentum, aimed at improving the clinical quality of care among nursing home and home health care providers. The focus of reporting systems should be broadened to include quality of life in addition to clinical quality and to make measures less dependent on the setting in which care is delivered.
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Jang WM, Eun SJ, Lee CE, Kim Y. Effect of repeated public releases on cesarean section rates. ACTA ACUST UNITED AC 2011; 44:2-8. [PMID: 21483217 DOI: 10.3961/jpmph.2011.44.1.2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Public release of and feedback (here after public release) on institutional (clinics and hospitals) cesarean section rates has had the effect of reducing cesarean section rates. However, compared to the isolated intervention, there was scant evidence of the effect of repeated public releases (RPR) on cesarean section rates. The objectives of this study were to evaluate the effect of RPR for reducing cesarean section rates. METHODS From January 2003 to July 2007, the nationwide monthly institutional cesarean section rates data (1,951,303 deliveries at 1194 institutions) were analyzed. We used autoregressive integrated moving average (ARIMA) time-series intervention models to assess the effect of the RPR on cesarean section rates and ordinal logistic regression model to determine the characteristics of the change in cesarean section rates. RESULTS Among four RPR, we found that only the first one (August 29, 2005) decreased the cesarean section rate (by 0.81 percent) and continued to have an impact period through the last observation in May 2007. Baseline cesarean section rates (OR, 4.7; 95% CI, 3.1 to 7.1) and annual number of deliveries (OR, 2.8; 95% CI, 1.6 to 4.7) of institutions in the upper third of each category at before first intervention had a significant contribution to the decrease of cesarean section rates. CONCLUSIONS We could not found the evidence that RPR has had the significant effect of reducing cesarean section rates. Institutions with upper baseline cesarean section rates and annual number of deliveries were more responsive to RPR.
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Affiliation(s)
- Won Mo Jang
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Korea
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Donelan K, Rogers RS, Eisenhauer A, Mort E, Agnihotri AK. Consumer Comprehension of Surgeon Performance Data for Coronary Bypass Procedures. Ann Thorac Surg 2011; 91:1400-5; discussion 1405-6. [DOI: 10.1016/j.athoracsur.2011.01.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2010] [Revised: 01/08/2011] [Accepted: 01/12/2011] [Indexed: 11/24/2022]
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50
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Glance LG, Neuman M, Martinez EA, Pauker KY, Dutton RP. Performance Measurement at a “Tipping Point”. Anesth Analg 2011; 112:958-66. [DOI: 10.1213/ane.0b013e31820e778d] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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