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Aspberg S, Kahan T, Johansson F. Lack of associations between hospital rating and outcomes in patients with an acute coronary syndrome. BMJ Open Qual 2024; 13:e002475. [PMID: 38514089 PMCID: PMC10961561 DOI: 10.1136/bmjoq-2023-002475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 03/02/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Public reporting of performance data has become a common tool in evaluation of healthcare providers. The rating may be misleading if the association between the measured variables and the outcome is weak. METHODS AND RESULTS Nationwide, register-based, cohort study. All Swedish patients hospitalised with an acute coronary syndrome during the time periods 2006-2010 and 2015-2017 were included in the study. Possible associations between cardiovascular morbidity and mortality for these patients and ranking scores for each hospital in a Swedish healthcare quality register for acute coronary syndromes were analysed. We found no association between the ranking score and mortality, and no or weak associations between the ranking score and readmissions. CONCLUSIONS Lack of associations between quality measurements and patient outcomes warrants improvement in ranking scores. Cautious use of the ranking results is necessary in comparisons between healthcare providers.
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Affiliation(s)
- Sara Aspberg
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Kahan
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Johansson
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
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Zogg CK, Metcalfe D, Judge A, Perry DC, Costa ML, Gabbe BJ, Schoenfeld AJ, Davis KA, Cooper Z, Lichtman JH. Learning From England's Best Practice Tariff: Process Measure Pay-for-Performance Can Improve Hip Fracture Outcomes. Ann Surg 2022; 275:506-514. [PMID: 33491982 PMCID: PMC9233527 DOI: 10.1097/sla.0000000000004305] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate England's Best Practice Tariff (BPT) and consider potential implications for Medicare patients should the US adopt a similar plan. SUMMARY BACKGROUND DATA Since the beginning of the Affordable Care Act, Medicare has renewed efforts to improve the outcomes of older adults through introduction of an expanding set of alternative-payment models. Among trauma patients, recommended arrangements met with mixed success given concerns about the heterogeneous nature of trauma patients and resulting outcome variation. A novel approach taken for hip fractures in England could offer a viable alternative. METHODS Linear regression, interrupted time-series, difference-in-difference, and counterfactual models of 2000 to 2016 Medicare (US), HES-APC (England) death certificate-linked claims (≥65 years) were used to: track US hip fracture trends, look at changes in English hip fracture trends before-and-after BPT implementation, compare changes in US-versus-English mortality, and estimate total/theoretical lives saved. RESULTS A total of 806,036 English and 3,221,109 US hospitalizations were included. After BPT implementation, England's 30-day mortality decreased by 2.6 percentage-points (95%CI: 1.7-3.5) from a baseline of 9.9% (relative reduction 26.3%). 90- and 365-day mortality decreased by 5.6 and 5.4 percentage-points. 30/90/365-day readmissions also declined with a concurrent shortening of hospital length-of-stay. From 2000 to 2016, US outcomes were stagnant (P > 0.05), resulting in an inversion of the countries' mortality and >38,000 potential annual US lives saved. CONCLUSIONS Process measure pay-for-performance led to significant improvements in English hip fracture outcomes. As efforts to improve US older adult health continue to increase, there are important lessons to be learned from a successful initiative like the BPT.
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Affiliation(s)
- Cheryl K. Zogg
- Yale School of Medicine, New Haven, Connecticut
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Yale School of Public Health, New Haven, Connecticut
| | - David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Andrew Judge
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Southmead Hospital, Bristol, United Kingdom
| | - Daniel C. Perry
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Matthew L. Costa
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Belinda J. Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Andrew J. Schoenfeld
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Orthopaedic Surgery, Brigham & Women’s Hospital, Boston, Massachusetts
| | | | - Zara Cooper
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Iloabuchi C, Dwibedi N, LeMasters T, Shen C, Ladani A, Sambamoorthi U. Low-value care and excess out-of-pocket expenditure among older adults with incident cancer - A machine learning approach. J Cancer Policy 2021; 30:100312. [PMID: 35559807 PMCID: PMC8916690 DOI: 10.1016/j.jcpo.2021.100312] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/05/2021] [Accepted: 10/27/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the association of low-value care with excess out-of-pocket expenditure among older adults diagnosed with incident breast, prostate, colorectal cancers, and Non-Hodgkin's Lymphoma. METHODS We used a retrospective cohort study design with 12-month baseline and follow-up periods. We identified a cohort of older adults (age ≥ 66 years) diagnosed with breast, prostate, colorectal cancers, or Non-Hodgkin's lymphoma between January 2014 and December 2014. We assessed low-value care and patient out-of-pocket expenditure in the follow-up period. We identified relevant low-value services using ICD9/ICD10 and CPT/HCPCS codes from the linked health claims and patient out-of-pocket expenditure from Medicare claim files and expressed expenditure in 2016 USD. RESULTS About 29 % of older adults received at least one low-value care procedure during the follow-up period. Low-value care differed by gender, and rates were higher in women with colorectal cancer (32.7 %) vs. (28.8 %) and NHL (40 %) vs. (39 %) compared to men. Individuals who received one or more low-value care procedures had significantly higher mean out-of-pocket expenditure ($8,726 ± $7,214) vs. ($6,802 ± $6,102). XGBOOST, a machine learning algorithm revealed that low-value care was among the five leading predictors of OOP expenditure. CONCLUSION One in four older adults with incident cancer received low-value care in 12-months after a cancer diagnosis. Across all cancer populations, individuals who received low-value care had significantly higher out-of-pocket expenditure. Excess out-of-pocket expenditure was driven by low-value care, fragmentation of care, and an increasing number of pre-existing chronic conditions. POLICY STATEMENT This study focuses on health policy issues, specifically value-based care and its findings have important clinical and policy implications for Centers for Medicare and Medicaid Services (CMS) which has issued a roadmap for states to accelerate the adoption of value-based care, with the Department of Health and Human Services (HHS) setting a goal of converting 50 % of traditional Medicare payment systems to alternative payment models tied to value-based care by 2022.
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Affiliation(s)
- Chibuzo Iloabuchi
- Department of Pharmaceutical Systems and Policy, West Virginia University School of Pharmacy, Robert C. Byrd Health Sciences Center [North], P.O. Box 9510, Morgantown, WV, 26506-9510, USA.
| | - Nilanjana Dwibedi
- Department of Pharmaceutical Systems and Policy, West Virginia University School of Pharmacy, Robert C. Byrd Health Sciences Center [North], P.O. Box 9510, Morgantown, WV, 26506-9510, USA.
| | - Traci LeMasters
- Department of Pharmaceutical Systems and Policy, West Virginia University School of Pharmacy, Robert C. Byrd Health Sciences Center [North], P.O. Box 9510, Morgantown, WV, 26506-9510, USA.
| | - Chan Shen
- Division of Outcomes Research and Quality, Department of Surgery, College of Medicine, Pennsylvania State University, Hershey, PA, USA.
| | - Amit Ladani
- Department of Medicine, Division of Rheumatology, West Virginia University Medicine, Morgantown, WV, USA.
| | - Usha Sambamoorthi
- Department of Pharmacotherapy, College of Pharmacy, "Vashisht" Professor of Disparities, Health Education, Awareness & Research in Disparities (HEARD) Scholar, Texas Center for Health Disparities, University of North Texas Health Sciences Center, 3500 Camp Bowie Blvd, Fort Worth, TX, 76107, USA.
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A decade of commitment to hospital quality of care: overview of and perceptions on multicomponent quality improvement policies involving accreditation, public reporting, inspection and pay-for-performance. BMC Health Serv Res 2021; 21:990. [PMID: 34544408 PMCID: PMC8450175 DOI: 10.1186/s12913-021-07007-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 09/07/2021] [Indexed: 01/02/2023] Open
Abstract
Background Quality improvement (QI) initiatives such as accreditation, public reporting, inspection and pay-for-performance are increasingly being implemented globally. In Flanders, Belgium, a government policy for acute-care hospitals incorporates aforementioned initiatives. Currently, questions are raised on the sustainability of the present policy. Objective First, to summarise the various initiatives hospitals have adopted under government encouragement between 2008 and 2019. Second, to study the perspectives of healthcare stakeholders on current government policy. Methods In this multi-method study, we collected data on QI initiative implementation from governmental and institutional sources and through an online survey among hospital quality managers. We compiled an overview of QI initiative implementation for all Flemish acute-care hospitals between 2008 (n = 62) and 2019 (n = 53 after hospital mergers). Stakeholder perspectives were assessed via a second survey available to all healthcare employees and a focus group with healthcare policy experts was consulted. Variation between professions was assessed. Results QI initiatives have been increasingly implemented, especially from 2016 onwards, with the majority (87%) of hospitals having obtained a first accreditation label and all hospitals publicly reporting performance indicators, receiving regular inspections and having entered the pay-for-performance initiative. On the topic of external international accreditation, overall attitudes within the survey were predominantly neutral (36.2%), while 34.5% expressed positive and 29.3% negative views towards accreditation. In examining specific professional groups in-depth, we learned 58% of doctors regarded accreditation negatively, while doctors were judged to be the largest contributors to quality according to the majority of respondents. Conclusions Hospitals have demonstrated increased efforts into QI, especially since 2016, while perceptions on currently implemented QI initiatives among healthcare stakeholders are heterogeneous. To assure quality of care remains a top-priority for acute-care hospitals, we recommend a revision of the current multicomponent quality policy where the adoption of all initiatives is streamlined and co-created bottom-up. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07007-w.
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Nguyen DD, Doll JA. Quality Improvement and Public Reporting in STEMI Care. Interv Cardiol Clin 2021; 10:391-400. [PMID: 34053625 DOI: 10.1016/j.iccl.2021.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Mortality rates for patients with ST-segment elevation myocardial infarction (STEMI) remain high despite development of novel drugs and interventions over the past several decades. There is significant variability between hospitals in use of evidence-based treatments, and substantial opportunities exist to optimize care pathways and reduce disparities in care delivery. Quality improvement interventions implemented at local, regional, and national levels have improved care processes and patient outcomes. This article reviews evidence for quality improvement interventions along the spectrum of STEMI care, describes existing systems for quality measurement, and examines local and national policy interventions, with special attention to public reporting programs.
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Affiliation(s)
- Dan D Nguyen
- Division of Cardiology, Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Jacob A Doll
- Division of Cardiology, Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA; VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA.
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Van Wilder A, Bruyneel L, De Ridder D, Seys D, Brouwers J, Claessens F, Cox B, Vanhaecht K. Is a hospital quality policy based on a triad of accreditation, public reporting and inspection evidence-based? A narrative review. Int J Qual Health Care 2021; 33:6278849. [PMID: 34013956 DOI: 10.1093/intqhc/mzab085] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 03/02/2021] [Accepted: 05/17/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Since 2009, hospital quality policy in Flanders, Belgium, is built around a quality-of-care triad, which encompasses accreditation, public reporting (PR) and inspection. Policy makers are currently reflecting on the added value of this triad. METHODS We performed a narrative review of the literature published between 2009 and 2020 to examine the evidence base of the impact accreditation, PR and inspection, both individually and combined, has on patient processes and outcomes. The following patient outcomes were examined: mortality, length of stay, readmissions, patient satisfaction, adverse outcomes, failure to rescue, adherence to process measures and risk aversion. The impact of accreditation, PR and inspection on these outcomes was evaluated as either positive, neutral (i.e. no impact observed or mixed results reported) or negative. OBJECTIVES To assess the current evidence base on the impact of accreditation, PR and inspection on patient processes and outcomes. RESULTS We identified 69 studies, of which 40 were on accreditation, 24 on PR, three on inspection and two on accreditation and PR concomitantly. Identified studies reported primarily low-level evidence (level IV, n = 53) and were heterogeneous in terms of implemented programmes and patient populations (often narrow in PR research). Overall, a neutral categorization was determined in 30 articles for accreditation, 23 for PR and four for inspection. Ten of these recounted mixed results. For accreditation, a high number (n = 12) of positive research on adherence to process measures was discovered. CONCLUSION The individual impact of accreditation, PR and inspection, the core of Flemish hospital quality, was found to be limited on patient outcomes. Future studies should investigate the combined effect of multiple quality improvement strategies.
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Affiliation(s)
- Astrid Van Wilder
- Leuven Institute for Healthcare Policy, KU Leuven-University of Leuven, Kapucijnenvoer 35, 3rd floor, box 3001, Leuven, Vlaams-Brabant 3000, Belgium
| | - Luk Bruyneel
- Leuven Institute for Healthcare Policy, KU Leuven-University of Leuven, Kapucijnenvoer 35, 3rd floor, box 3001, Leuven, Vlaams-Brabant 3000, Belgium.,Department of Quality Improvement, University Hospitals Leuven, Herestraat 49, Leuven, Vlaams-Brabant 3000, Belgium
| | - Dirk De Ridder
- Leuven Institute for Healthcare Policy, KU Leuven-University of Leuven, Kapucijnenvoer 35, 3rd floor, box 3001, Leuven, Vlaams-Brabant 3000, Belgium.,Department of Urology, University Hospitals Leuven, Belgium, Herestraat 49, Leuven, Vlaams-Brabant 3000, Belgium
| | - Deborah Seys
- Leuven Institute for Healthcare Policy, KU Leuven-University of Leuven, Kapucijnenvoer 35, 3rd floor, box 3001, Leuven, Vlaams-Brabant 3000, Belgium.,Department of Quality Improvement, University Hospitals Leuven, Herestraat 49, Leuven, Vlaams-Brabant 3000, Belgium
| | - Jonas Brouwers
- Leuven Institute for Healthcare Policy, KU Leuven-University of Leuven, Kapucijnenvoer 35, 3rd floor, box 3001, Leuven, Vlaams-Brabant 3000, Belgium
| | - Fien Claessens
- Leuven Institute for Healthcare Policy, KU Leuven-University of Leuven, Kapucijnenvoer 35, 3rd floor, box 3001, Leuven, Vlaams-Brabant 3000, Belgium
| | - Bianca Cox
- Leuven Institute for Healthcare Policy, KU Leuven-University of Leuven, Kapucijnenvoer 35, 3rd floor, box 3001, Leuven, Vlaams-Brabant 3000, Belgium
| | - Kris Vanhaecht
- Leuven Institute for Healthcare Policy, KU Leuven-University of Leuven, Kapucijnenvoer 35, 3rd floor, box 3001, Leuven, Vlaams-Brabant 3000, Belgium.,Department of Quality Improvement, University Hospitals Leuven, Herestraat 49, Leuven, Vlaams-Brabant 3000, Belgium
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Kinnear B, Kelleher M, Sall D, Schauer DP, Warm EJ, Kachelmeyer A, Martini A, Schumacher DJ. Development of Resident-Sensitive Quality Measures for Inpatient General Internal Medicine. J Gen Intern Med 2021; 36:1271-1278. [PMID: 33105001 PMCID: PMC8131459 DOI: 10.1007/s11606-020-06320-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/20/2020] [Accepted: 10/14/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Graduate medical education (GME) training has long-lasting effects on patient care quality. Despite this, few GME programs use clinical care measures as part of resident assessment. Furthermore, there is no gold standard to identify clinical care measures that are reflective of resident care. Resident-sensitive quality measures (RSQMs), defined as "measures that are meaningful in patient care and are most likely attributable to resident care," have been developed using consensus methodology and piloted in pediatric emergency medicine. However, this approach has not been tested in internal medicine (IM). OBJECTIVE To develop RSQMs for a general internal medicine (GIM) inpatient residency rotation using previously described consensus methods. DESIGN The authors used two consensus methods, nominal group technique (NGT) and a subsequent Delphi method, to generate RSQMs for a GIM inpatient rotation. RSQMs were generated for specific clinical conditions found on a GIM inpatient rotation, as well as for general care on a GIM ward. PARTICIPANTS NGT participants included nine IM and medicine-pediatrics (MP) residents and six IM and MP faculty members. The Delphi group included seven IM and MP residents and seven IM and MP faculty members. MAIN MEASURES The number and description of RSQMs generated during this process. KEY RESULTS Consensus methods resulted in 89 RSQMs with the following breakdown by condition: GIM general care-21, diabetes mellitus-16, hyperkalemia-14, COPD-13, hypertension-11, pneumonia-10, and hypokalemia-4. All RSQMs were process measures, with 48% relating to documentation and 51% relating to orders. Fifty-eight percent of RSQMs were related to the primary admitting diagnosis, while 42% could also be related to chronic comorbidities that require management during an admission. CONCLUSIONS Consensus methods resulted in 89 RSQMs for a GIM inpatient service. While all RSQMs were process measures, they may still hold value in learner assessment, formative feedback, and program evaluation.
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Affiliation(s)
- Benjamin Kinnear
- Department of Pediatrics, University of Cincinnati College of Medicine, , Cincinnati, OH, USA. .,Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Matthew Kelleher
- Department of Pediatrics, University of Cincinnati College of Medicine, , Cincinnati, OH, USA.,Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Dana Sall
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Daniel P Schauer
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Eric J Warm
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrea Kachelmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, , Cincinnati, OH, USA
| | - Abigail Martini
- Department of Pediatrics, University of Cincinnati College of Medicine, , Cincinnati, OH, USA
| | - Daniel J Schumacher
- Department of Pediatrics, University of Cincinnati College of Medicine, , Cincinnati, OH, USA
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Prang KH, Maritz R, Sabanovic H, Dunt D, Kelaher M. Mechanisms and impact of public reporting on physicians and hospitals' performance: A systematic review (2000-2020). PLoS One 2021; 16:e0247297. [PMID: 33626055 PMCID: PMC7904172 DOI: 10.1371/journal.pone.0247297] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 02/04/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Public performance reporting (PPR) of physician and hospital data aims to improve health outcomes by promoting quality improvement and informing consumer choice. However, previous studies have demonstrated inconsistent effects of PPR, potentially due to the various PPR characteristics examined. The aim of this study was to undertake a systematic review of the impact and mechanisms (selection and change), by which PPR exerts its influence. METHODS Studies published between 2000 and 2020 were retrieved from five databases and eight reviews. Data extraction, quality assessment and synthesis were conducted. Studies were categorised into: user and provider responses to PPR and impact of PPR on quality of care. RESULTS Forty-five studies were identified: 24 on user and provider responses to PPR, 14 on impact of PPR on quality of care, and seven on both. Most of the studies reported positive effects of PPR on the selection of providers by patients, purchasers and providers, quality improvement activities in primary care clinics and hospitals, clinical outcomes and patient experiences. CONCLUSIONS The findings provide moderate level of evidence to support the role of PPR in stimulating quality improvement activities, informing consumer choice and improving clinical outcomes. There was some evidence to demonstrate a relationship between PPR and patient experience. The effects of PPR varied across clinical areas which may be related to the type of indicators, level of data reported and the mode of dissemination. It is important to ensure that the design and implementation of PPR considered the perspectives of different users and the health system in which PPR operates in. There is a need to account for factors such as the structural characteristics and culture of the hospitals that could influence the uptake of PPR.
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Affiliation(s)
- Khic-Houy Prang
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Australia
| | - Roxanne Maritz
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Australia
- Rehabilitation Services and Care Unit, Swiss Paraplegic Research, Nottwil, Switzerland
- Department of Health Sciences and Health Policy, University of Lucerne, Lucerne, Switzerland
| | - Hana Sabanovic
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Australia
| | - David Dunt
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Australia
| | - Margaret Kelaher
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Australia
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Farrag A, Harris Y. A discussion of the United States’ and Egypt’s health care quality improvement efforts. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2021. [DOI: 10.1080/20479700.2019.1620454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Amel Farrag
- Technical Office, General Directorate of Quality, Ministry of Health and Population, Cairo, Egypt
| | - Yael Harris
- Health Research and Evaluation, American Institutes of Research, Washington, DC, USA
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Gupta A, Yu Y, Tan Q, Liu S, Masoudi FA, Du X, Zhang J, Krumholz HM, Li J. Quality of Care for Patients Hospitalized for Heart Failure in China. JAMA Netw Open 2020; 3:e1918619. [PMID: 31913489 PMCID: PMC6991250 DOI: 10.1001/jamanetworkopen.2019.18619] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Given the emerging heart failure (HF) epidemic in China, monitoring and improving the quality of care for heart failure is a top priority. OBJECTIVES To assess the quality of HF care provided to inpatients by examining the adherence to quality measures for HF care at the hospital level and to identify factors associated with the quality of care. DESIGN, SETTING, AND PARTICIPANTS In this multicenter, hospital-based, retrospective cross-sectional study in China, medical records of patients hospitalized for HF from January 1, 2015, to December 31, 2015, were analyzed from January 1, 2018, to May 20, 2019. In the first stage, simple random sampling stratified by economic-geographical regions in China was used to generate a list of participating hospitals. In the second stage, 15 538 hospitalizations from the 189 selected hospitals were systematically sampled, and 10 004 HF hospitalizations were included in the final sample. MAIN OUTCOMES AND MEASURES Adherence to the following 4 core performance measures at the hospital level: (1) left ventricular ejection fraction assessment during hospitalization; (2) evidence-based β-blocker (bisoprolol, carvedilol, or metoprolol succinate) for eligible patients at discharge; (3) angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for eligible patients at discharge; and (4) scheduled follow-up appointment at discharge. At the hospital level, a composite performance score (ranging from 0-1) was also calculated by averaging these measures. RESULTS In total, 10 004 hospital admissions for HF at 189 hospitals were included in this study. The median (interquartile range [IQR]) patient age at admission was 73 (65-80) years, and 5117 (51.1%) of the patients were men. Among all hospitals, the median rate of adherence to measure 1 was 66.7% (IQR, 45.5%-80.7%; range, 0%-100%). The rate for adherence to measure 2 was 14.8% (IQR, 0%-37.5%; range, 0%-81.8%), and the rate for measure 3 was 57.1% (IQR, 36.4%-75.0%; range, 0%-100%). For measure 4, the median rate of adherence was 11.5% (IQR, 3.3%-32.8%; range, 0%-96.7%). The median (IQR) composite performance score across all hospitals was 40.0% (26.9%-51.9%), with a range from 2.2% to 85.4%. The median odds ratios of adherence were 2.2 (95% CI, 2.0-2.4) for measure 1, 2.1 (95% CI, 1.8-2.4) for measure 2, 2.4 (95% CI, 2.0-2.9 for measure 3, and 4.8 (95% CI, 3.9-5.8) for measure 4 among hospitals. CONCLUSIONS AND RELEVANCE The findings of this study suggest that quality of care for patients with HF in China may be substandard, and there is wide heterogeneity in the quality of care for HF among hospitals. The findings also suggest the need for a national strategy to improve and standardize the quality of HF care in China.
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Affiliation(s)
- Aakriti Gupta
- Division of Cardiovascular Medicine, Columbia University Irving Medical Center, New York, New York
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut
| | - Yuan Yu
- National Health Commission Key Laboratory of Clinical Research for Cardiovascular Medications, Beijing, China
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Beijing, China
- Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
- Peking Union Medical College, Beijing, China
- National Clinical Research Center of Cardiovascular Diseases, Beijing, China
| | - Qi Tan
- Department of Biostatistics, Yale School of Public Health, Yale University, New Haven, Connecticut
| | - Shuling Liu
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut
| | | | - Xue Du
- National Health Commission Key Laboratory of Clinical Research for Cardiovascular Medications, Beijing, China
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Beijing, China
- Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
- Peking Union Medical College, Beijing, China
- National Clinical Research Center of Cardiovascular Diseases, Beijing, China
| | - Jian Zhang
- National Health Commission Key Laboratory of Clinical Research for Cardiovascular Medications, Beijing, China
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Beijing, China
- Peking Union Medical College, Beijing, China
- Heart Failure Center, Fuwai Hospital, Beijing, China
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Jing Li
- National Health Commission Key Laboratory of Clinical Research for Cardiovascular Medications, Beijing, China
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Beijing, China
- Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
- Peking Union Medical College, Beijing, China
- National Clinical Research Center of Cardiovascular Diseases, Beijing, China
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Voluntary Hospital Reporting of Performance in Cancer Care: Does Volume Make a Difference? J Healthc Qual 2019; 42:e75-e82. [PMID: 31599760 DOI: 10.1097/jhq.0000000000000225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Little is known about which hospitals participate in voluntary public reporting of quality processes and what influences their performance, particularly in cancer care. We hypothesize that patient volume is positively associated with both reporting and performance. In 2014, when Pennsylvania became the first and only state to have public reporting for cancer care, it became possible to test these hypotheses, which we did in cross-sectional study of the 72 Pennsylvania hospitals accredited by the Commission on Cancer. Hospitals that publicly reported their performance (57 of 72) had higher patient volumes than hospitals that did not release performance. Among reporting hospitals, no association was found between patient volume and performance on process of care metrics. These findings suggest the importance of attending to volume effects in public reporting of cancer care and recognizing that volume is not a predictor of performance for reporting hospitals, which indicates the need for research to identify other factors that differentiate performance within and across reporting and nonreporting hospitals.
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Barbayannis G, Chiu IM, Sargsyan D, Cabrera J, Beavers TE, Kostis JB, Cosgrove NM, Michel NE, Kostis WJ. Relation Between Statewide Hospital Performance Reports on Myocardial Infarction and Cardiovascular Outcomes. Am J Cardiol 2019; 123:1587-1594. [PMID: 30850213 DOI: 10.1016/j.amjcard.2019.02.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 02/01/2019] [Accepted: 02/11/2019] [Indexed: 10/27/2022]
Abstract
Healthcare systems may be judged on quality of care and access to health services. Studies on the association of hospital quality of care scores and clinical outcomes have yielded mixed results. With the help of a richer and more representative database, the aim of our study was to shed light on these inconsistencies. We examined the association of 4 process of care scores (prescription of aspirin, β blocker, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker used for left ventricular systolic dysfunction, and an overall composite score) for acute myocardial infarction (AMI), reported in the Hospital Performance Reports, with 30-day and 1-year rates of readmission for AMI and cardiovascular (CV) death. Clinical outcomes were from the Myocardial Infarction Data Acquisition System, an administrative database that comprises all patient CV disease admissions to acute care hospitals in New Jersey. CV death was related with overall score (adjusted odds ratio [OR] 0.821, 95% confidence interval [CI] 0.726 to 0.930, p = 0.002) at 30 days and with all 4 scores at 1 year (OR ranging from 0.829 to 0.997, p <0.01). Readmission due to AMI was associated with the overall score (OR 0.789, 95% CI 0.691 to 0.902, p <0.0001) and the aspirin score (OR 0.995, 95% CI 0.990 to 1, p = 0.046) at 30 days. Low hospital performance scores for AMI were associated with increased CV death and readmission for AMI. In conclusion, healthcare providers should allocate their resources to improving hospital performance to decrease AMI case fatality, AMI readmissions, and CV-related healthcare spending.
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de Cordova PB, Rogowski J, Riman KA, McHugh MD. Effects of Public Reporting Legislation of Nurse Staffing: A Trend Analysis. Policy Polit Nurs Pract 2019; 20:92-104. [PMID: 30922205 PMCID: PMC6813777 DOI: 10.1177/1527154419832112] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Public reporting is a tactic that hospitals and other health care facilities use to provide data such as outcomes to clinicians, patients, and payers. Although inadequate registered nurse (RN) staffing has been linked to poor patient outcomes, only eight states in the United States publicly report staffing ratios-five mandated by legislation and the other three electively. We examine nurse staffing trends after the New Jersey (NJ) legislature and governor enacted P.L.1971, c.136 (C.26:2 H-13) on January 24, 2005, mandating that all health care facilities compile, post, and report staffing information. We conduct a secondary analysis of reported data from the State of NJ Department of Health on 73 hospitals in 2008 to 2009 and 72 hospitals in 2010 to 2015. The first aim was to determine if NJ hospitals complied with legislation, and the second was to identify staffing trends postlegislation. On the reports, staffing was operationalized as the number of patients per RN per quarters. We obtained 30 quarterly reports for 2008 through 2015 and cross-checked these reports for data accuracy on the NJ Department of Health website. From these data, we created a longitudinal data set of 13 inpatient units for each hospital (14,158 observations) and merged these data with American Hospital Association Annual Survey data. The number of patients per RN decreased for 10 specialties, and the American Hospital Association data demonstrate a similar trend. Although the number of patients does not account for patient acuity, the decrease in the patients per RN over 7 years indicated the importance of public reporting in improving patient safety.
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Affiliation(s)
- Pamela B. de Cordova
- Rutgers, the State University School of Nursing, Faculty Researcher for the New Jersey Collaborating Center, Newark, NJ, USA
| | - Jeannette Rogowski
- Department of Health Policy and Administration, The Pennsylvania State University, University Park, PA, USA
| | - Kathryn A. Riman
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Matthew D. McHugh
- Nursing Education, Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
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Altieri MS, Yang J, Yin D, Bevilacqua LA, Spaniolas K, Talamini MA, Pryor AD. Defying public expectations: Publicly reported hospital scores do not always correlate with clinical outcomes. Surgery 2019; 165:985-989. [PMID: 30704630 DOI: 10.1016/j.surg.2018.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 11/17/2018] [Accepted: 12/03/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Publicly reported hospital scores are used by patients to make health care-related decisions; however, their relationship to clinical outcomes is unknown. METHODS Through the use of the New York Statewide Planning and Research Cooperative System database, the association between two commonly used scores (Healthgrades and Centers for Medicare & Medicaid Services Hospital Compare) and four clinical outcomes was evaluated in several surgical fields (general, colorectal, hepatobiliary, foregut, and bariatric). RESULTS After adjusting for patient-level factors, patients from facilities with greater Healthgrades scores were less likely to develop any complication after general surgery operations (P = .0013). Also, greater Healthgrades scores were associated with less 30-day readmissions and emergency department visits for general surgery operations only (P = .0061 and P = .0013, respectively). In addition, greater Healthgrades scores were significantly associated with a lesser hospital length of stay for colorectal, foregut, and general surgery operations. Greater Centers for Medicare & Medicaid Services Hospital Compare scores were significantly associated with less 30-day readmissions and lesser hospital length of stay for specific operative groups. CONCLUSION Although some specialties demonstrated a correlation, there was no consistent relationship between publicly reported hospital scores and surgical outcomes that contributed to clinically meaningful use for patients or operations.
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Affiliation(s)
- Maria S Altieri
- Division of Minimally Invasive Surgery, Washington University School of Medicine, St. Louis, MO.
| | - Jie Yang
- Department of Family, Population and Preventive Medicine, Stony Brook University, Medical Center, NY
| | - Donglei Yin
- Department of Applied Mathematics and Statistics, Stony Brook University, NY
| | | | - Konstantinos Spaniolas
- Division of Bariatric, Foregut and Advanced Gastrointestinal Surgery Department of Surgery, Stony Brook University Medical Center, NY
| | - Mark A Talamini
- Division of Bariatric, Foregut and Advanced Gastrointestinal Surgery Department of Surgery, Stony Brook University Medical Center, NY
| | - Aurora D Pryor
- Division of Bariatric, Foregut and Advanced Gastrointestinal Surgery Department of Surgery, Stony Brook University Medical Center, NY
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15
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Venkatesh AK, Slesinger T, Whittle J, Osborn T, Aaronson E, Rothenberg C, Tarrant N, Goyal P, Yealy DM, Schuur JD. Preliminary Performance on the New CMS Sepsis-1 National Quality Measure: Early Insights From the Emergency Quality Network (E-QUAL). Ann Emerg Med 2018; 71:10-15.e1. [DOI: 10.1016/j.annemergmed.2017.06.032] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 05/30/2017] [Accepted: 06/27/2017] [Indexed: 10/19/2022]
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16
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Bekelis K, Missios S, Coy S, Rahmani R, MacKenzie TA, Asher AL. Correlation of Subjective Hospital Compare Metrics With Objective Outcomes of Cranial Neurosurgical Procedures in New York State. Neurosurgery 2017; 80:401-408. [PMID: 28362962 DOI: 10.1093/neuros/nyw071] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Accepted: 11/11/2016] [Indexed: 11/12/2022] Open
Abstract
Background Public reporting is at the forefront of health care reform. Objective To investigate whether patient satisfaction as expressed in a public reporting platform correlates with objective outcomes for cranial neurosurgery patients. Methods We performed a cohort study involving patients undergoing cranial neurosurgery from 2009 to 2013 who were registered in the Statewide Planning and Research Cooperative System database. This cohort was merged with the corresponding data from the Centers for Medicare and Medicaid Services Hospital Compare website. The association of patient satisfaction metrics with outcomes was examined with the use of a propensity-adjusted regression model. Results Overall, 19 591 patients underwent cranial neurosurgery during the study. Using a propensity-adjusted multivariable regression analysis, we demonstrated that hospitals with a greater percentage of patient-assigned "high" scores had decreased mortality (OR, 0.60; 95% CI, 0.53-0.67), rate of discharge to rehabilitation (OR, 0.93; 95% CI, 0.88-0.98), length of stay (adjusted difference, -1.29; 95% CI, -1.46 to -1.13), and hospitalization charges (adjusted difference, -23%; 95% CI, -36% to -9%) after cranial neurosurgery. Similar associations were identified for hospitals with a higher percentage of patients, who would recommend these institutions to others. Conclusion In a Centers for Medicare and Medicaid Services Hospital Compare-Statewide Planning and Research Cooperative System merged dataset, we observed an association of higher performance in patient satisfaction measures with decreased mortality, rate of discharge to rehabilitation, hospitalization charges, and length of stay.
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Affiliation(s)
- Kimon Bekelis
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Symeon Missios
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Shannon Coy
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Redi Rahmani
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Todd A MacKenzie
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.,Department of Community and Family Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA
| | - Anthony L Asher
- Department of Neurosurgery, Carolina Neurosurgery and Spine Associates and Neuroscience Institute, Carolinas Healthcare System, Charlotte, North Carolina, USA
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Dharmarajan K, Wang Y, Lin Z, Normand SLT, Ross JS, Horwitz LI, Desai NR, Suter LG, Drye EE, Bernheim SM, Krumholz HM. Association of Changing Hospital Readmission Rates With Mortality Rates After Hospital Discharge. JAMA 2017; 318:270-278. [PMID: 28719692 PMCID: PMC5817448 DOI: 10.1001/jama.2017.8444] [Citation(s) in RCA: 154] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE The Affordable Care Act has led to US national reductions in hospital 30-day readmission rates for heart failure (HF), acute myocardial infarction (AMI), and pneumonia. Whether readmission reductions have had the unintended consequence of increasing mortality after hospitalization is unknown. OBJECTIVE To examine the correlation of paired trends in hospital 30-day readmission rates and hospital 30-day mortality rates after discharge. DESIGN, SETTING, AND PARTICIPANTS Retrospective study of Medicare fee-for-service beneficiaries aged 65 years or older hospitalized with HF, AMI, or pneumonia from January 1, 2008, through December 31, 2014. EXPOSURE Thirty-day risk-adjusted readmission rate (RARR). MAIN OUTCOMES AND MEASURES Thirty-day RARRs and 30-day risk-adjusted mortality rates (RAMRs) after discharge were calculated for each condition in each month at each hospital in 2008 through 2014. Monthly trends in each hospital's 30-day RARRs and 30-day RAMRs after discharge were examined for each condition. The weighted Pearson correlation coefficient was calculated for hospitals' paired monthly trends in 30-day RARRs and 30-day RAMRs after discharge for each condition. RESULTS In 2008 through 2014, 2 962 554 hospitalizations for HF, 1 229 939 for AMI, and 2 544 530 for pneumonia were identified at 5016, 4772, and 5057 hospitals, respectively. In January 2008, mean hospital 30-day RARRs and 30-day RAMRs after discharge were 24.6% and 8.4% for HF, 19.3% and 7.6% for AMI, and 18.3% and 8.5% for pneumonia. Hospital 30-day RARRs declined in the aggregate across hospitals from 2008 through 2014; monthly changes in RARRs were -0.053% (95% CI, -0.055% to -0.051%) for HF, -0.044% (95% CI, -0.047% to -0.041%) for AMI, and -0.033% (95% CI, -0.035% to -0.031%) for pneumonia. In contrast, monthly aggregate changes across hospitals in hospital 30-day RAMRs after discharge varied by condition: HF, 0.008% (95% CI, 0.007% to 0.010%); AMI, -0.003% (95% CI, -0.005% to -0.001%); and pneumonia, 0.001% (95% CI, -0.001% to 0.003%). However, correlation coefficients in hospitals' paired monthly changes in 30-day RARRs and 30-day RAMRs after discharge were weakly positive: HF, 0.066 (95% CI, 0.036 to 0.096); AMI, 0.067 (95% CI, 0.027 to 0.106); and pneumonia, 0.108 (95% CI, 0.079 to 0.137). Findings were similar in secondary analyses, including with alternate definitions of hospital mortality. CONCLUSIONS AND RELEVANCE Among Medicare fee-for-service beneficiaries hospitalized for heart failure, acute myocardial infarction, or pneumonia, reductions in hospital 30-day readmission rates were weakly but significantly correlated with reductions in hospital 30-day mortality rates after discharge. These findings do not support increasing postdischarge mortality related to reducing hospital readmissions.
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Affiliation(s)
- Kumar Dharmarajan
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Now with Clover Health, Jersey City, New Jersey
| | - Yongfei Wang
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Zhenqiu Lin
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
| | - Sharon-Lise T. Normand
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
| | - Joseph S. Ross
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- The Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Leora I. Horwitz
- Center for Healthcare Innovation and Delivery Science, NYU Langone Medical Center, New York, New York
- Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine, New York
- Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine, New York
| | - Nihar R. Desai
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Lisa G. Suter
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
- Section of Rheumatology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Elizabeth E. Drye
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
- Section of General Pediatrics, Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | - Susannah M. Bernheim
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- The Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- The Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
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Pross C, Busse R, Geissler A. Hospital quality variation matters - A time-trend and cross-section analysis of outcomes in German hospitals from 2006 to 2014. Health Policy 2017; 121:842-852. [PMID: 28733067 DOI: 10.1016/j.healthpol.2017.06.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 06/19/2017] [Accepted: 06/25/2017] [Indexed: 11/17/2022]
Abstract
Awareness of care variation and associated differences in outcome quality is important for patients to recognize and leverage the benefits of hospital choice and for policy makers, providers, and suppliers to adapt initiatives to improve hospital quality of care. We examine panel data on outcome quality in German hospitals between 2006 and 2014 for cholecystectomy, pacemaker implantation, hip replacement, percutaneous coronary intervention (PCI), stroke, and acute myocardial infarction (AMI). We use risk-adjusted and unadjusted outcomes based on 16 indicators. Median outcome and outcome variation trends are examined via box plots, simple linear regressions and quintile differences. Outcome trends differ across treatment areas and indicators. We found positive quality trends for hip replacement surgery, stroke and AMI 30-day mortality, and negative quality trends for 90-day stroke and AMI readmissions and PCI inpatient mortality. Variation of risk-adjusted outcomes ranges by a factor of 3-12 between the 2nd and 5th quintile of hospitals, both at the national and regional level. Our results show that simply measuring and reporting hospital outcomes without clear incentives or regulation - "carrots and sticks" - to improve performance and to centralize care in high performing hospitals has not led to broad quality improvements. More substantial efforts must be undertaken to narrow the outcome spread between high- and low-quality hospitals.
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Affiliation(s)
- Christoph Pross
- Berlin University of Technology, Department of Health Care Management, Germany
| | - Reinhard Busse
- Berlin University of Technology, Department of Health Care Management, Germany; European Observatory on Health Systems and Policies, Berlin Centre of Health Economics Research, Germany
| | - Alexander Geissler
- Berlin University of Technology, Department of Health Care Management, Germany.
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Abstract
Publicly reported hospital ratings aim to encourage transparency, spur quality improvement, and empower patient choice. Travel burdens may limit patient choice, particularly for older adults (aged 65 years and more) who receive most medical care. For 3 major hospital ratings systems, we estimated travel burden as the additional 1-way travel distance to receive care at a better-rated hospital.Distances were estimated from publicly available data from the US Census, US News Top Hospitals, Society of Thoracic Surgeons composite rating for coronary artery bypass grafting (STS-CABG), and Centers for Medicare and Medicaid Services Hospital Consumer Assessment of Healthcare Providers and Services (HCAHPS).Hospitals were rated for HCAHPS (n = 4656), STS-CABG (n = 470), and US News Top Hospitals (n = 15). Older adults were commonly located within 25 miles of their closest HCAHPS hospital (89.6%), but less commonly for STS-CABG (62.9%). To receive care at a better-rated hospital, travel distances commonly exceeded 25 miles: HCAHPS (39.2%), STS-CABG (62.7%), and US News Top Hospital (85.2%). Additional 1-way travel distances exceeded 25 miles commonly: HCAHPS (23.7%), STS-CABG (36.7%), US News Top Hospitals (81.8%).Significant travel burden is common for older adults seeking "better" care and is an important limitation of current hospital ratings for empowering patient choice.
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Bekelis K, Missios S, MacKenzie TA, O'Shaughnessy PM. Does Objective Quality of Physicians Correlate with Patient Satisfaction Measured by Hospital Compare Metrics in New York State? World Neurosurg 2017; 103:852-858.e1. [PMID: 28456743 DOI: 10.1016/j.wneu.2017.04.108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 04/15/2017] [Accepted: 04/17/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND It is unclear whether publicly reported benchmarks correlate with quality of physicians and institutions. We investigated the association of patient satisfaction measures from a public reporting platform with performance of neurosurgeons in New York State. METHODS This cohort study comprised patients undergoing neurosurgical operations from 2009 to 2013 who were registered in the Statewide Planning and Research Cooperative System database. The cohort was merged with publicly available data from the Centers for Medicare and Medicaid Services Hospital Compare website. Propensity-adjusted regression analysis was used to investigate the association of patient satisfaction metrics with neurosurgeon quality, as measured by the neurosurgeon's individual rate of mortality and average length of stay. RESULTS During the study period, 166,365 patients underwent neurosurgical procedures. Using propensity-adjusted multivariable regression analysis, we demonstrated that undergoing neurosurgical operations in hospitals with a greater percentage of patient-assigned "high" scores was associated with higher chance of being treated by a physician with superior performance in terms of mortality (odds ratio 1.90, 95% confidence interval 1.86-1.95), and a higher chance of being treated by a physician with superior performance in terms of length of stay (odds ratio 1.24, 95% confidence interval 1.21-1.27). Similar associations were identified for hospitals with a higher percentage of patients who claimed they would recommend these institutions to others. CONCLUSIONS Merging a comprehensive all-payer cohort of neurosurgery patients in New York State with data from the Hospital Compare website, we observed an association of superior hospital-level patient satisfaction measures with objective performance of individual neurosurgeons in the corresponding hospitals.
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Affiliation(s)
- Kimon Bekelis
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA; Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA; Population Health Research Institute of New York at Catholic Health Services of Long Island, Rockville Centre, New York, USA.
| | - Symeon Missios
- Center for Neuro and Spine, Cleveland Clinic-Akron General Hospital, Akron, Ohio, USA
| | - Todd A MacKenzie
- Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA; Population Health Research Institute of New York at Catholic Health Services of Long Island, Rockville Centre, New York, USA; Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA; Department of Community and Family Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Patrick M O'Shaughnessy
- Population Health Research Institute of New York at Catholic Health Services of Long Island, Rockville Centre, New York, USA
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21
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Chui PW, Parzynski CS, Nallamothu BK, Masoudi FA, Krumholz HM, Curtis JP. Hospital Performance on Percutaneous Coronary Intervention Process and Outcomes Measures. J Am Heart Assoc 2017; 6:JAHA.116.004276. [PMID: 28446493 PMCID: PMC5524055 DOI: 10.1161/jaha.116.004276] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Physician Consortium for Performance Improvement recently proposed percutaneous coronary intervention (PCI)-specific process measures. However, information about hospital performance on these measures and the association of PCI process and outcomes measures are not available. METHODS AND RESULTS We linked the National Cardiovascular Data Registry (NCDR) CathPCI Registry with Medicare claims data to assess hospital performance on established PCI process measures (aspirin, thienopyridines, and statins on discharge; door-to-balloon time; and referral to cardiac rehabilitation), newly proposed PCI process measures (documentation of contrast dose, glomerular filtration rate, and PCI indication; appropriate indication for elective PCI; and use of embolic protection device), and a composite of all process measures. We calculated weighted pair-wise correlations between each set of process metrics and performed weighted correlation analyses to assess the association between composite measure performance with corresponding 30-day risk-standardized mortality and readmission rates. We reported the variance in risk-standardized 30-day outcome rates explained by process measures. We analyzed 1 268 860 PCIs from 1331 hospitals. For many process measures, median hospital performance exceeded 90%. We found strong correlations between medication-specific process measures (P<0.01) and weak correlations between hospital performance on the newly proposed and established process measures. The composite process measure explained only 1.3% and 2.0% of the observed variation in mortality and readmission rates, respectively. CONCLUSIONS Hospital performance on many PCI-specific process measures demonstrated little opportunity for improvement and explained only a small percentage of hospital variation in 30-day outcomes. Efforts to measure and improve hospital quality for PCI patients should focus on both process and outcome measures.
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Affiliation(s)
- Philip W Chui
- Department of Internal Medicine, University of California Irvine School of Medicine, Orange, CA
| | - Craig S Parzynski
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT
| | - Brahmajee K Nallamothu
- Center for Clinical Management Research, Ann Arbor VA Medical Center, University of Michigan Medical School, Ann Arbor, MI.,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Frederick A Masoudi
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT.,Department of Health Policy and Management, Yale School of Public Health, New Haven, CT.,Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Jeptha P Curtis
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT .,Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
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22
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Bekelis K, Missios S, Coy S, Johnson JN. Does the ranking of surgeons in a publicly available online platform correlate with objective outcomes? J Neurosurg 2017:1-7. [PMID: 28306419 DOI: 10.3171/2016.8.jns16583.test] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The accuracy of public reporting in health care, especially from private vendors, remains an issue of debate. The authors investigated the association of the publicly reported physician complication rates in an online platform with real-world adverse outcomes of the same physicians for patients undergoing posterior lumbar fusion. METHODS The authors performed a cohort study involving physicians performing posterior lumbar fusions between 2009 and 2013 who were registered in the Statewide Planning and Research Cooperative System database. This cohort was merged with publicly available data over the same time period from ProPublica, a private company. Mixed-effects multivariable regression models were used to investigate the association of publicly available complication rates with the rate of discharge to a rehabilitation facility, length of stay, mortality, and hospitalization charges for the same surgeons. RESULTS During the selected study period, there were 8,457 patients in New York State who underwent posterior lumbar fusion performed by the 56 surgeons represented in the ProPublica Surgeon Scorecard over the same time period. Using a mixed-effects multivariable regression model, the authors demonstrated that publicly reported physician-level complication rates were not associated with the rate of discharge to a rehabilitation facility (OR 0.97, 95% CI 0.72-1.31), length of stay (adjusted difference -0.1, 95% CI -0.5 to 0.2), mortality (OR 0.87, 95% CI 0.49-1.55), and hospitalization charges (adjusted difference $18,735, 95% CI -$59,177 to $96,647). Similarly, no association was observed when utilizing propensity score-adjusted models, and when restricting the cohort to a predefined subgroup of Medicare patients. CONCLUSIONS After merging a comprehensive all-payer posterior lumbar fusion cohort in New York State with data from the ProPublica Surgeon Scorecard over the same time period, the authors observed no association of publicly available physician complication rates with objective outcomes.
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Affiliation(s)
- Kimon Bekelis
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Symeon Missios
- Department of Neurosurgery, Akron General Hospital, Akron, Ohio
| | - Shannon Coy
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts; and
| | - Jeremiah N Johnson
- Department of Neurosurgery, University of Texas Health Science Center, San Antonio, Texas
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Bekelis K, Missios S, Coy S, Johnson JN. Does the ranking of surgeons in a publicly available online platform correlate with objective outcomes? J Neurosurg 2016; 127:353-359. [PMID: 27834595 DOI: 10.3171/2016.8.jns16583] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The accuracy of public reporting in health care, especially from private vendors, remains an issue of debate. The authors investigated the association of the publicly reported physician complication rates in an online platform with real-world adverse outcomes of the same physicians for patients undergoing posterior lumbar fusion. METHODS The authors performed a cohort study involving physicians performing posterior lumbar fusions between 2009 and 2013 who were registered in the Statewide Planning and Research Cooperative System database. This cohort was merged with publicly available data over the same time period from ProPublica, a private company. Mixed-effects multivariable regression models were used to investigate the association of publicly available complication rates with the rate of discharge to a rehabilitation facility, length of stay, mortality, and hospitalization charges for the same surgeons. RESULTS During the selected study period, there were 8,457 patients in New York State who underwent posterior lumbar fusion performed by the 56 surgeons represented in the ProPublica Surgeon Scorecard over the same time period. Using a mixed-effects multivariable regression model, the authors demonstrated that publicly reported physician-level complication rates were not associated with the rate of discharge to a rehabilitation facility (OR 0.97, 95% CI 0.72-1.31), length of stay (adjusted difference -0.1, 95% CI -0.5 to 0.2), mortality (OR 0.87, 95% CI 0.49-1.55), and hospitalization charges (adjusted difference $18,735, 95% CI -$59,177 to $96,647). Similarly, no association was observed when utilizing propensity score-adjusted models, and when restricting the cohort to a predefined subgroup of Medicare patients. CONCLUSIONS After merging a comprehensive all-payer posterior lumbar fusion cohort in New York State with data from the ProPublica Surgeon Scorecard over the same time period, the authors observed no association of publicly available physician complication rates with objective outcomes.
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Affiliation(s)
- Kimon Bekelis
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center.,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Symeon Missios
- Department of Neurosurgery, Akron General Hospital, Akron, Ohio
| | - Shannon Coy
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts; and
| | - Jeremiah N Johnson
- Department of Neurosurgery, University of Texas Health Science Center, San Antonio, Texas
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Dharmarajan K. Comprehensive Strategies to Reduce Readmissions in Older Patients With Cardiovascular Disease. Can J Cardiol 2016; 32:1306-1314. [DOI: 10.1016/j.cjca.2016.01.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 01/29/2016] [Accepted: 01/29/2016] [Indexed: 02/01/2023] Open
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Jurkowski JM, Svistova J, Nguyen T, Dennison BA. Public Reporting of Hospital-Specific Breastfeeding Measures. J Hum Lact 2016; 32:666-674. [PMID: 27565202 DOI: 10.1177/0890334416663197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Establishing breastfeeding in the first days of an infant's life is important for longer term success in breastfeeding. In 2009, New York State (NYS) was the second state to require maternity care facilities to collect infant feeding information and to publicly disseminate hospital-specific infant feeding statistics. Public reporting of these statistics as performance measures is a strategy to prompt hospitals to improve breastfeeding support. OBJECTIVE This qualitative study sought to explore how maternity care administrators and clinical staff responded to the mandate for publicly reported performance measures and whether they used this information to improve maternity care practices. METHODS This study used a stratified random sample of NYS hospitals with maternity care units. Participants were recruited by email and telephone calls. A total of 25 hospitals participated in the study, and 37 hospital administrators and staff completed in-depth interviews by telephone. The interviews were analyzed using an explanatory framework in NVivo 8. RESULTS Publicly reported hospital-specific breastfeeding measures increased attention to breastfeeding performance. Hospital administrators and staff reported comparing their relative rankings to other hospitals in the state. Some hospitals used publicly reported breastfeeding measures to monitor performance, whereas others were prompted to generate additional measures for more frequent monitoring. Hospitals with relatively low breastfeeding statistics took certain actions to improve their maternity care practices to support breastfeeding. Limitations of the usefulness of publicly reported measures were reported by interview participants. CONCLUSION Publicly reported, hospital-specific breastfeeding measures may prompt hospitals to monitor and improve maternity care practices related to supporting breastfeeding.
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Affiliation(s)
- Janine M Jurkowski
- 1 Department of Health Policy, Management and Behavior, University at Albany School of Public Health, SUNY, Rensselaer, NY, USA
| | - Juliana Svistova
- 2 Department of Social Work, Kutztown University of Pennsylvania, Kutztown, PA, USA
| | - Trang Nguyen
- 3 Office of Public Health Practice, New York State Department of Health, Albany, NY, USA
| | - Barbara A Dennison
- 1 Department of Health Policy, Management and Behavior, University at Albany School of Public Health, SUNY, Rensselaer, NY, USA.,4 Policy and Research Translation, Division of Chronic Disease Prevention, New York State Department of Public Health, Albany, NY, USA
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Govindappagari S, Friedman AM, Chen L, Ananth CV, D’Alton ME, Hershman DL, Wright JD. Using publicly reported hospital data to predict obstetric quality. J Matern Fetal Neonatal Med 2016; 30:1984-1991. [DOI: 10.1080/14767058.2016.1236079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Shravya Govindappagari
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA,
- New York Presbyterian Hospital, New York, NY, USA,
| | - Alexander M. Friedman
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA,
- New York Presbyterian Hospital, New York, NY, USA,
| | - Ling Chen
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA,
| | - Cande V. Ananth
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA,
- Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA, and
| | - Mary E. D’Alton
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA,
- New York Presbyterian Hospital, New York, NY, USA,
| | - Dawn L. Hershman
- New York Presbyterian Hospital, New York, NY, USA,
- Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA, and
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Jason D. Wright
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA,
- New York Presbyterian Hospital, New York, NY, USA,
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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: 89] [Impact Index Per Article: 11.1] [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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Nguyen OK, Halm EA, Makam AN. Relationship between hospital financial performance and publicly reported outcomes. J Hosp Med 2016; 11:481-8. [PMID: 26929094 PMCID: PMC5362822 DOI: 10.1002/jhm.2570] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 01/13/2016] [Accepted: 02/03/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Hospitals that have robust financial performance may have improved publicly reported outcomes. OBJECTIVES To assess the relationship between hospital financial performance and publicly reported outcomes of care, and to assess whether improved outcome metrics affect subsequent hospital financial performance. DESIGN Observational cohort study. SETTING AND PATIENTS Hospital financial data from the Office of Statewide Health Planning and Development in California in 2008 and 2012 were linked to data from the Centers for Medicare and Medicaid Services Hospital Compare website. MEASUREMENTS Hospital financial performance was measured by net revenue by operations, operating margin, and total margin. Outcomes were 30-day risk-standardized mortality and readmission rates for acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia (PNA). RESULTS Among 279 hospitals, there was no consistent relationship between measures of financial performance in 2008 and publicly reported outcomes from 2008 to 2011 for AMI and PNA. However, improved hospital financial performance (by any of the 3 measures) was associated with a modest increase in CHF mortality rates (ie, 0.26% increase in CHF mortality rate for every 10% increase in operating margin [95% confidence interval: 0.07%-0.45%]). Conversely, there were no significant associations between outcomes from 2008 to 2011 and subsequent financial performance in 2012 (P > 0.05 for all). CONCLUSIONS Robust financial performance is not associated with improved publicly reported outcomes for AMI, CHF, and PNA. Financial incentives in addition to public reporting, such as readmissions penalties, may help motivate hospitals with robust financial performance to further improve publicly reported outcomes. Reassuringly, improved mortality and readmission rates do not necessarily lead to loss of revenue. Journal of Hospital Medicine 2016;11:481-488. © 2016 Society of Hospital Medicine.
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Affiliation(s)
- Oanh Kieu Nguyen
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
- Address for correspondence and reprint requests: Oanh Kieu Nguyen, MD, 5323 Harry Hines Blvd., Dallas, Texas 75390-9169; Telephone: 214-648-3135; Fax: 214-648-3232;
| | - Ethan A. Halm
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
| | - Anil N. Makam
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas
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Vermeulen MJ, Stukel TA, Boozary AS, Guttmann A, Schull MJ. The Effect of Pay for Performance in the Emergency Department on Patient Waiting Times and Quality of Care in Ontario, Canada: A Difference-in-Differences Analysis. Ann Emerg Med 2016. [DOI: 10.1016/j.annemergmed.2015.06.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Yoo S, Cho M, Kim E, Kim S, Sim Y, Yoo D, Hwang H, Song M. Assessment of hospital processes using a process mining technique: Outpatient process analysis at a tertiary hospital. Int J Med Inform 2016; 88:34-43. [DOI: 10.1016/j.ijmedinf.2015.12.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 11/28/2015] [Accepted: 12/23/2015] [Indexed: 11/27/2022]
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Missios S, Bekelis K. How well do subjective Hospital Compare metrics reflect objective outcomes in spine surgery? J Neurosurg Spine 2016; 25:264-70. [PMID: 26989975 DOI: 10.3171/2016.1.spine151155] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The accuracy of public reporting in health care is an issue of debate. The authors investigated the association of patient satisfaction measures from a public reporting platform with objective outcomes for patients undergoing spine surgery. METHODS The authors performed a cohort study involving patients undergoing elective spine surgery from 2009 to 2013 who were registered in the New York Statewide Planning and Research Cooperative System database. This cohort was merged with publicly available data from the Centers for Medicare and Medicaid Services (CMS) Hospital Compare website. A mixed-effects regression analysis, controlling for clustering at the hospital level, was used to investigate the association of patient satisfaction metrics with outcomes. RESULTS During the study period, 160,235 patients underwent spine surgery. Using a mixed-effects multivariable regression analysis, the authors demonstrated that undergoing elective spine surgery in hospitals with a higher percentage of patient-assigned high satisfaction scores was not associated with a decreased rate of discharge to rehabilitation (OR 0.77, 95% CI 0.57-1.06), mortality (OR 0.96, 95% CI 0.90-1.01), or hospitalization charges (β 0.04, 95% CI -0.16 to 0.23). However, it was associated with decreased length of stay (LOS; β -0.19, 95% CI -0.33 to -0.05). Similar associations were identified for hospitals with a higher percentage of patients who claimed they would recommend these institutions to others. CONCLUSIONS Merging a comprehensive all-payer cohort of spine surgery patients in New York state with data from the CMS Hospital Compare website, the authors were not able to demonstrate an association of improved performance in patient satisfaction measures with decreased mortality, rate of discharge to rehabilitation, and hospitalization charges. Increased patient satisfaction was associated with decreased LOS.
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Affiliation(s)
- Symeon Missios
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana; and
| | - Kimon Bekelis
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Lu N, Huang KC, Johnson JA. Reducing excess readmissions: promising effect of hospital readmissions reduction program in US hospitals. Int J Qual Health Care 2015; 28:53-8. [DOI: 10.1093/intqhc/mzv090] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2015] [Indexed: 01/09/2023] Open
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Wright JD, Tergas AI, Ananth CV, Burke WM, Hou JY, Chen L, Neugut AI, Richards CA, Hershman DL. Quality and Outcomes of Treatment of Hypercalcemia of Malignancy. Cancer Invest 2015; 33:331-9. [PMID: 26068056 DOI: 10.3109/07357907.2015.1047506] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Using a nationwide database, 4,874 patients with hypercalcemia of malignancy were identified. The in-hospital mortality rate was 6.8%. Overall, 1,971 (40.4%) patients received pamidronate and 1,399 (28.7%) received zoledronic acid during hospitalization. Calcitonin was utilized in 1,337 (27.4%) patients while glucocorticoids were administered to 1,311 (26.9%). Use of contraindicated medications was noted in 136 (2.8%) patients who received thiazide diuretics and 12 (0.2%) who received lithium. Tumor site, presence of bone metastases, and severity of illness were predictors of treatment. There was no association between treatment with bisphosphonates, calcitonin, or glucocorticoids and morbidity or mortality.
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Affiliation(s)
- Jason D Wright
- a Department of Obstetrics and Gynecology , Columbia University , New York , USA.,b Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons , Columbia University , New York , USA.,c New York Presbyterian Hospital , New York , USA
| | - Ana I Tergas
- a Department of Obstetrics and Gynecology , Columbia University , New York , USA.,b Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons , Columbia University , New York , USA.,c New York Presbyterian Hospital , New York , USA.,d Department of Epidemiology, Mailman School of Public Health , Columbia University , New York , USA
| | - Cande V Ananth
- a Department of Obstetrics and Gynecology , Columbia University , New York , USA.,d Department of Epidemiology, Mailman School of Public Health , Columbia University , New York , USA
| | - William M Burke
- a Department of Obstetrics and Gynecology , Columbia University , New York , USA.,b Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons , Columbia University , New York , USA.,c New York Presbyterian Hospital , New York , USA
| | - June Y Hou
- a Department of Obstetrics and Gynecology , Columbia University , New York , USA.,b Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons , Columbia University , New York , USA.,c New York Presbyterian Hospital , New York , USA
| | - Ling Chen
- a Department of Obstetrics and Gynecology , Columbia University , New York , USA
| | - Alfred I Neugut
- b Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons , Columbia University , New York , USA.,c New York Presbyterian Hospital , New York , USA.,d Department of Epidemiology, Mailman School of Public Health , Columbia University , New York , USA .,e Department of Medicine, College of Physicians and Surgeons , Columbia University , New York , USA
| | - Catherine A Richards
- d Department of Epidemiology, Mailman School of Public Health , Columbia University , New York , USA
| | - Dawn L Hershman
- b Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons , Columbia University , New York , USA.,c New York Presbyterian Hospital , New York , USA.,d Department of Epidemiology, Mailman School of Public Health , Columbia University , New York , USA .,e Department of Medicine, College of Physicians and Surgeons , Columbia University , New York , USA
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Merchant RM. Public report cards for in-hospital cardiac arrest: empowering the public with location-specific data. Circulation 2015; 131:1377-9. [PMID: 25792556 DOI: 10.1161/circulationaha.115.016023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Raina M Merchant
- From Department of Emergency Medicine and Penn Medicine Social Media and Health Innovation Lab, University of Pennsylvania, Philadelphia, PA.
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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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Aryankhesal A, Sheldon TA, Mannion R, Mahdipour S. The dysfunctional consequences of a performance measurement system: the case of the Iranian national hospital grading programme. J Health Serv Res Policy 2015; 20:138-45. [DOI: 10.1177/1355819615576252] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives Performance measurement systems are increasingly used to reward and improve provider performance. However, such initiatives may also inadvertently induce a range of unintended and dysfunctional side-effects. This study explores the unintended and adverse consequences induced by the Iranian national hospital grading programme, which incorporates financial incentives for meeting nationally defined standards. Methods We interviewed key informants across four key groups with a legitimate interest in healthcare performance: four purposively selected hospitals; four health insurance organizations; the Iranian hospital accreditation body; and one grading agency. The transcribed interviews and field notes were analysed thematically, and subsequently, member checking was conducted. Results Seven dysfunctional consequences were identified: misrepresentation of data by hospitals; increased anxiety and stress among hospital employees; tunnel vision; financial pressures on poorly graded hospitals; incentives to purchase unnecessary equipment; erosion of public trust; and restricting access to hospital services by patients. These were caused by the way the grading system was implemented: poor standards of audit; the way in which the audit process was conducted; and the timing of audits. The pay for performance element of the grading system and the focus on structural aspects in the standards made improvement in grading particularly difficult for those hospitals that had been assessed as under-performing. Conclusion Although the Iranian hospital grading system has resulted in a significant increase in the adoption of national standards, it has nevertheless induced a range of perverse outcomes. To mitigate these requires further refinement and recalibration of the system.
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Affiliation(s)
- Aidin Aryankhesal
- Assistant Professor, Health Management and Economics Research Centre, Iran University of Medical Sciences, Tehran, Iran
- Assistant Professor, Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | | | - Russell Mannion
- Professor, Health Services Management Centre, University of Birmingham, UK
| | - Saeade Mahdipour
- President, Office of Accreditation, Iran University of Medical Sciences, Iran
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Parast L, Doyle B, Damberg CL, Shetty K, Ganz DA, Wenger NS, Shekelle PG. Challenges in assessing the process-outcome link in practice. J Gen Intern Med 2015; 30:359-64. [PMID: 25564435 PMCID: PMC4351283 DOI: 10.1007/s11606-014-3150-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 09/10/2014] [Accepted: 11/26/2014] [Indexed: 11/26/2022]
Abstract
The expanded use of clinical process-of-care measures to assess the quality of health care in the context of public reporting and pay-for-performance applications has led to a desire to demonstrate the value of such efforts in terms of improved patient outcomes. The inability to observe associations between improved delivery of clinical processes and improved clinical outcomes in practice has raised concerns about the value of holding providers accountable for delivery of clinical processes of care. Analyses that attempt to investigate this relationship are fraught with many challenges, including selection of an appropriate outcome, the proximity of the outcome to the receipt of the clinical process, limited power to detect an effect, small expected effect sizes in practice, potential bias due to unmeasured confounding factors, and difficulties due to changes in measure specification over time. To avoid potentially misleading conclusions about an observed or lack of observed association between a clinical process of care and an outcome in the context of observational studies, individuals conducting and interpreting such studies should carefully consider, evaluate, and acknowledge these types of challenges.
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Affiliation(s)
- Layla Parast
- RAND Corporation, 1776 Main Street, PO Box 2138, Santa Monica, CA, 90407-2138, USA,
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Wright JD, Tergas AI, Ananth CV, Burke WM, Chen L, Neugut AI, Richards CA, Hershman DL. Relationship between surgical oncologic outcomes and publically reported hospital quality and satisfaction measures. J Natl Cancer Inst 2015; 107:dju409. [PMID: 25618899 PMCID: PMC4565527 DOI: 10.1093/jnci/dju409] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 09/09/2014] [Accepted: 11/07/2014] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Hospital-level measures of patient satisfaction and quality are now reported publically by the Centers for Medicare and Medicaid Services. There are limited metrics specific to cancer patients. We examined whether publically reported hospital satisfaction and quality data were associated with surgical oncologic outcomes. METHODS The Nationwide Inpatient Sample was utilized to identify patients with solid tumors who underwent surgical resection in 2009 and 2010. The hospitals were linked to Hospital Compare, which collects data on patient satisfaction, perioperative quality, and 30-day mortality for medical conditions (pneumonia, myocardial infarction [MI], and congestive heart failure [CHF]). The risk-adjusted hospital-level rates of morbidity and mortality were calculated for each hospital and the means compared between the highest and lowest performing hospital quartiles and reported as absolute reduction in risk (ARR), the difference in risk of the outcome between the two groups. All statistical tests were two-sided. RESULTS A total of 63197 patients treated at 448 hospitals were identified. For patients at high vs low performing hospitals based on Hospital Consumer Assessment of Healthcare Providers and Systems scores, the ARR in perioperative morbidity was 3.1% (95% confidence interval [CI] = 0.4% to 5.7%, P = .02). Similarly, the ARR for mortality based on the same measure was -0.4% (95% CI = -1.5% to 0.6%, P = .40). High performance on perioperative quality measures resulted in an ARR of 0% to 2.2% for perioperative morbidity (P > .05 for all). Similarly, there was no statistically significant association between hospital-level mortality rates for MI (ARR = 0.7%, 95% CI = -1.0% to 2.5%), heart failure (ARR = 1.0%, 95% CI = -0.6% to 2.7%), or pneumonia (ARR = 1.6%, 95% CI = -0.3% to 3.5%) and complications for oncologic surgery patients. CONCLUSION Currently available measures of patient satisfaction and quality are poor predictors of outcomes for cancer patients undergoing surgery. Specific metrics for long-term oncologic outcomes and quality are needed.
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Affiliation(s)
- Jason D Wright
- Affiliations of authors: Department of Obstetrics and Gynecology (JDW, AIT, CVA, WMB, LC), Department of Medicine (AIN, DLH), and Herbert Irving Comprehensive Cancer Center (JDW, AIT, AIN, DLH, WMB), Columbia University College of Physicians and Surgeons, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University (AIT, CVA, AIN, CAR, DLH).
| | - Ana I Tergas
- Affiliations of authors: Department of Obstetrics and Gynecology (JDW, AIT, CVA, WMB, LC), Department of Medicine (AIN, DLH), and Herbert Irving Comprehensive Cancer Center (JDW, AIT, AIN, DLH, WMB), Columbia University College of Physicians and Surgeons, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University (AIT, CVA, AIN, CAR, DLH)
| | - Cande V Ananth
- Affiliations of authors: Department of Obstetrics and Gynecology (JDW, AIT, CVA, WMB, LC), Department of Medicine (AIN, DLH), and Herbert Irving Comprehensive Cancer Center (JDW, AIT, AIN, DLH, WMB), Columbia University College of Physicians and Surgeons, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University (AIT, CVA, AIN, CAR, DLH)
| | - William M Burke
- Affiliations of authors: Department of Obstetrics and Gynecology (JDW, AIT, CVA, WMB, LC), Department of Medicine (AIN, DLH), and Herbert Irving Comprehensive Cancer Center (JDW, AIT, AIN, DLH, WMB), Columbia University College of Physicians and Surgeons, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University (AIT, CVA, AIN, CAR, DLH)
| | - Ling Chen
- Affiliations of authors: Department of Obstetrics and Gynecology (JDW, AIT, CVA, WMB, LC), Department of Medicine (AIN, DLH), and Herbert Irving Comprehensive Cancer Center (JDW, AIT, AIN, DLH, WMB), Columbia University College of Physicians and Surgeons, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University (AIT, CVA, AIN, CAR, DLH)
| | - Alfred I Neugut
- Affiliations of authors: Department of Obstetrics and Gynecology (JDW, AIT, CVA, WMB, LC), Department of Medicine (AIN, DLH), and Herbert Irving Comprehensive Cancer Center (JDW, AIT, AIN, DLH, WMB), Columbia University College of Physicians and Surgeons, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University (AIT, CVA, AIN, CAR, DLH)
| | - Catherine A Richards
- Affiliations of authors: Department of Obstetrics and Gynecology (JDW, AIT, CVA, WMB, LC), Department of Medicine (AIN, DLH), and Herbert Irving Comprehensive Cancer Center (JDW, AIT, AIN, DLH, WMB), Columbia University College of Physicians and Surgeons, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University (AIT, CVA, AIN, CAR, DLH)
| | - Dawn L Hershman
- Affiliations of authors: Department of Obstetrics and Gynecology (JDW, AIT, CVA, WMB, LC), Department of Medicine (AIN, DLH), and Herbert Irving Comprehensive Cancer Center (JDW, AIT, AIN, DLH, WMB), Columbia University College of Physicians and Surgeons, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University (AIT, CVA, AIN, CAR, DLH)
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Ukawa N, Ikai H, Imanaka Y. Trends in hospital performance in acute myocardial infarction care: a retrospective longitudinal study in Japan. Int J Qual Health Care 2014; 26:516-23. [DOI: 10.1093/intqhc/mzu073] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
Collaborative quality improvement has demonstrated success in improving quality and reducing health care costs in several state-based examples. Professional societies and payers are keen on identifying the most effective strategies to improve the safety and efficiency of surgical care. This review highlights the development and features of collaborative quality improvement programs, their advantages and examples of successful collaborations for several surgical conditions, and their potential application for surgeons caring for patients with upper extremity trauma and disability.
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Affiliation(s)
- Jennifer F Waljee
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical Center, University of Michigan Health System, 1500 East Medical Center Drive, 2131 Taubman Center, Ann Arbor, MI 48109, USA.
| | - Nancy J O Birkmeyer
- Michigan Bariatric Surgery Collaborative, Center for Healthcare Outcomes and Policy, North Campus Research Complex, 2800 Plymouth Road, B016, Ann Arbor, MI 48109, USA; Department of Surgery, University of Michigan Medical Center, 1500 East Medial Center Drive, Ann Arbor, MI 48109, USA
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Vermeulen MJ, Stukel TA, Guttmann A, Rowe BH, Zwarenstein M, Golden B, Nigam A, Anderson G, Bell RS, Schull MJ. Evaluation of an emergency department lean process improvement program to reduce length of stay. Ann Emerg Med 2014; 64:427-38. [PMID: 24999281 DOI: 10.1016/j.annemergmed.2014.06.007] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Revised: 03/24/2014] [Accepted: 06/06/2014] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE In recent years, lean principles have been applied to improve wait times in the emergency department (ED). In 2009, an ED process improvement program based on lean methods was introduced in Ontario as part of a broad strategy to reduce ED length of stay and improve patient flow. This study seeks to determine the effect of this program on ED wait times and quality of care. METHODS We conducted a retrospective cohort study of all ED visits at program and control sites during 3 program waves from April 1, 2007, to June 30, 2011, in Ontario, Canada. Time series analyses of outcomes before and after the program and difference-in-differences analyses comparing changes in program sites with control sites were conducted. RESULTS In before-after models among program sites alone, 90th percentile ED length of stay did not change in wave 1 (-14 minutes [95% confidence interval {CI} -47 to 20]) but decreased after wave 2 (-87 [95% CI -108 to -66]) and wave 3 (-33 [95% CI -50 to -17]); median ED length of stay decreased after wave 1 (-18 [95% CI -24 to -12]), wave 2 (-23 [95% CI -27 to -19]), and wave 3 (-15 [95% CI -18 to -12]). In all waves, decreases were observed in time to physician assessment, left-without-being-seen rates, and 72-hour ED revisit rates. In the difference-in-difference models, in which changes in program sites were compared with controls, the program was associated with no change in 90th percentile ED length of stay in wave 2 (17 [95% CI -0.2 to 33]) and increases in wave 1 (23 [95% CI 0.9 to 45]) and wave 3 (31 [95% CI 10 to 51]), modest reductions in median ED length of stay in waves 2 and 3 alone, and a decrease in time to physician assessment in wave 3 alone. CONCLUSION Although the program reduced ED waiting times, it appeared that its benefits were diminished or disappeared when compared with that of control sites, which were exposed to system-wide initiatives such as public reporting and pay for performance. This study suggests that further evaluation of the effectiveness of lean methods in the ED is warranted before widespread implementation.
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Affiliation(s)
| | - Therese A Stukel
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Dartmouth Institute for Health Policy and Clinical Practice, Giesel School of Medicine at Dartmouth, Hanover, NH
| | - Astrid Guttmann
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Paediatric and Emergency Medicine, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Merrick Zwarenstein
- Centre for Studies in Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Brian Golden
- Rotman School of Management, University of Toronto, Toronto, Ontario, Canada
| | - Amit Nigam
- Cass Business School, City University, London, UK
| | - Geoff Anderson
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Michael J Schull
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Trauma, Emergency and Critical Care Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Restuccia JD, Mohr D, Meterko M, Stolzmann K, Kaboli P. The association of hospital characteristics and quality improvement activities in inpatient medical services. J Gen Intern Med 2014; 29:715-22. [PMID: 24424776 PMCID: PMC4000331 DOI: 10.1007/s11606-013-2759-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 12/06/2013] [Accepted: 12/27/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Quality of U.S. health care has been the focus of increasing attention, with deficiencies in patient care well recognized and documented. However, relatively little is known about the extent to which hospitals engage in quality improvement activities (QIAs) or factors influencing extent of QIAs. OBJECTIVE To identify 1) the extent of QIAs in Veterans Administration (VA) inpatient medical services; and 2) factors associated with widespread adoption of QIAs, in particular use of hospitalists, non-physician providers, and extent of goal alignment between the inpatient service and senior managers on commitment to quality. DESIGN Cross-sectional, descriptive study of QIAs using a survey administered to Chiefs of Medicine (COM) at all 124 VA acute care hospitals. We conducted hierarchical regression, regressing QIA use on facility contextual variables, followed by use of hospitalists, non-physician providers, and goal alignment/quality commitment. MAIN MEASURES Outcome measures pertained to use of a set of 27 QIAs and to three dimensions--infrastructure, prevention, and information gathering--that were identified by factor analysis among the 27 QIAs overall. KEY RESULTS Survey response rate was 90 % (111/124). Goal alignment/quality commitment was associated with more widespread use of all four QIA categories [infrastructure (b = 0.42; p < 0.001); prevention (b = 0.24; p < 0.001); information gathering (b = 0.28; p = <0.001); and overall QIA (b = 0.31; p < 0.001)], as was greater use of hospitalists [infrastructure (b = 0.55; p = 0.03); prevention (b = 0.61; p < 0.001); information gathering (b = 0.75; p = 0.01); and overall QIAs (b = 0.61; p < 0.001)]; higher occupancy rate was associated with greater infrastructure QIAs (b = 1.05, p = 0.02). Non-physician provider use, hospital size, university affiliation, and geographic region were not associated with QIAs. CONCLUSION As hospitals respond to changes in healthcare (e.g., pay for performance, accountable care organizations), this study suggests that practices such as use of hospitalists and leadership focus on goal alignment/quality commitment may lead to greater implementation of QIAs.
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Affiliation(s)
- Joseph D Restuccia
- Center for Organizational Leadership and Management Research (COLMR), Boston VA Healthcare System, Boston, MA, USA,
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Mukamel DB, Haeder SF, Weimer DL. Top-Down and Bottom-Up Approaches to Health Care Quality: The Impacts of Regulation and Report Cards. Annu Rev Public Health 2014; 35:477-97. [DOI: 10.1146/annurev-publhealth-082313-115826] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Dana B. Mukamel
- School of Medicine and Health Policy Research Institute (HPRI), University of California, Irvine, California 92697-5800;
| | | | - David L. Weimer
- Department of Political Science,
- The La Follette School of Public Affairs, University of Wisconsin, Madison, Wisconsin 53706; ,
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46
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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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Benzer JK, Young GJ, Burgess JF, Baker E, Mohr DC, Charns MP, Kaboli PJ. Sustainability of quality improvement following removal of pay-for-performance incentives. J Gen Intern Med 2014; 29:127-32. [PMID: 23929219 PMCID: PMC3889947 DOI: 10.1007/s11606-013-2572-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 05/17/2013] [Accepted: 07/18/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although pay-for-performance (P4P) has become a central strategy for improving quality in US healthcare, questions persist about the effectiveness of these programs. A key question is whether quality improvement that occurs as a result of P4P programs is sustainable, particularly if incentives are removed. OBJECTIVE To investigate sustainability of performance levels following removal of performance-based incentives. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study that capitalized on a P4P program within the Veterans Health Administration (VA) that included adoption and subsequent removal of performance-based incentives for selected inpatient quality measures. The study sample comprised 128 acute care VA hospitals where performance was assessed between 2004 and 2010. INTERVENTION VA system managers set annual performance goals in consultation with clinical leaders, and report performance scores to medical centers on a quarterly basis. These scores inform performance-based incentives for facilities and their managers. Bonuses are distributed based on the attainment of these performance goals. MEASUREMENTS Seven quality of care measures for acute coronary syndrome, heart failure, and pneumonia linked to performance-based incentives. RESULTS Significant improvements in performance were observed for six of seven quality of care measures following adoption of performance-based incentives and were maintained up to the removal of the incentive; subsequently, the observed performance levels were sustained. LIMITATIONS This is a quasi-experimental study without a comparison group; causal conclusions are limited. CONCLUSION The maintenance of performance levels after removal of a performance-based incentive has implications for the implementation of Medicare's value-based purchasing initiative and other P4P programs. Additional research is needed to better understand human and system-level factors that mediate sustainability of performance-based incentives.
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Affiliation(s)
- Justin K Benzer
- Center for Organization, Leadership, and Management Research (COLMR) at the VA Boston Healthcare System (152 M), 150 South Huntington Avenue, Boston, MA, 02860, USA,
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Berger ZD, Joy SM, Hutfless S, Bridges JFP. Can public reporting impact patient outcomes and disparities? A systematic review. PATIENT EDUCATION AND COUNSELING 2013; 93:480-487. [PMID: 23579038 DOI: 10.1016/j.pec.2013.03.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 01/24/2013] [Accepted: 03/06/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Recent US healthcare reforms aim to improve quality and access. We synthesized evidence assessing the impact that public reporting (PR), which will be extended to the outpatient setting, has on patient outcomes and disparities. METHODS A systematic review using PRISMA guidelines identified studies addressing the impact of PR on patient outcomes and disparities. RESULTS Of the 1970 publications identified, 25 were relevant, spanning hospitals (16), nursing homes (5), emergency rooms (1), health plans (2), and home health agencies (1). Evidence of effect on patient outcomes was mixed, with 6 studies reporting a favorable effect, 9 a mixed effect, 9 a null effect, and 1 a negative effect. One study found a mixed effect of PR on disparities. CONCLUSION The evidence of the impact of PR on patient outcomes is lacking, with limited evidence that PR has a favorable effect on outcomes in nursing homes. There is little evidence supporting claims that PR will have an impact on disparities or in the outpatient setting. PRACTICE IMPLICATIONS Health systems should collect information on patient-relevant outcomes. The lack of evidence does not necessarily imply a lack of effect, and a research gap exists regarding patient-relevant outcomes and PR.
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Affiliation(s)
- Zackary D Berger
- Johns Hopkins University School of Medicine, Department of General Internal Medicine, Baltimore, USA.
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Ardati AK, Pitt B, Smith DE, Aronow HD, Share D, Moscucci M, Chetcuti S, Grossman PM, Gurm HS. Current medical management of stable coronary artery disease before and after elective percutaneous coronary intervention. Am Heart J 2013; 165:778-84. [PMID: 23622915 DOI: 10.1016/j.ahj.2013.01.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 01/17/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) for stable coronary artery disease (CAD) is not superior to optimal medical therapy. It remains unclear if patients who receive PCI for stable CAD are receiving appropriate medical therapy. METHODS We evaluated the medical management of 60,386 patients who underwent PCI for stable CAD between 2004 and 2009. We excluded patients with contraindications to aspirin, clopidogrel, statins, or β-blockers (BBs). We defined essential medical therapy of stable CAD as treatment with aspirin, statin, and BB before PCI and treatment with aspirin, clopidogrel, and statin after PCI. RESULTS Essential medical therapy was used in 53.0% of patients before PCI and 82.1% at discharge. Aspirin was used in 94.8% patients before PCI and 98.3% of after PCI. Statins were used in 69.5% of patients before PCI and 84.5% after PCI. β-Blockers were used in 72.8% of patients before PCI. Clopidogrel was used in 97.3% of patients after PCI. Patients with a history of myocardial infarction or revascularization before PCI had better medical therapy compared with patients without such a history (62.8% vs 34.3% [P < .001] before PCI and 83.6% vs 79.1% [P < .001] after PCI). After adjusting for confounders and clustering, women (odds ratio 0.74, 95% CI 0.71-0.78) and patients on dialysis (odds ratio 0.68, 95% CI 0.57-0.80) were less likely to receive a statin at discharge. CONCLUSIONS Medical therapy remains underused before and after PCI for stable CAD. Women are less likely to receive statin therapy. There are significant opportunities to optimize medical therapy in patients with stable CAD.
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Affiliation(s)
- Amer K Ardati
- Division of Cardiovascular Medicine, University of Illinois, Chicago, IL, USA
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Are AMI patients with comorbid mental illness more likely to be admitted to hospitals with lower quality of AMI care? PLoS One 2013; 8:e60258. [PMID: 23565212 PMCID: PMC3614995 DOI: 10.1371/journal.pone.0060258] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 02/24/2013] [Indexed: 12/04/2022] Open
Abstract
Objective Older patients with comorbid mental illness are shown to receive less appropriate care for their medical conditions. This study analyzed Medicare patients hospitalized for acute myocardial infarction (AMI) and determined whether those with comorbid mental illness were more likely to present to hospitals with lower quality of AMI care. Methods Retrospective analyses of Medicare claims in 2008. Hospital quality was measured using the five “Hospital Compare” process indicators (aspirin at admission/discharge, beta-blocker at admission/discharge, and angiotension-converting enzyme inhibitor or angiotension receptor blocker for left ventricular dysfunction). Multinomial logit model determined the association of mental illness with admission to low-quality hospitals (rank of the composite process score <10th percentile) or high-quality hospitals (rank>90th percentile), compared to admissions to other hospitals with medium quality. Multivariate analyses further determined the effects of hospital type and mental diagnosis on outcomes. Results Among all AMI admissions to 2,845 hospitals, 41,044 out of 287,881 patients were diagnosed with mental illness. Mental illness predicted a higher likelihood of admission to low-quality hospitals (unadjusted rate 2.9% vs. 2.0%; adjusted odds ratio [OR]1.25, 95% confidence interval [CI] 1.17–1.34, p<0.01), and an equal likelihood to high-quality hospitals (unadjusted rate 9.8% vs. 10.3%; adjusted OR 0.97, 95% CI 0.93–1.01, p = 0.11). Both lower hospital quality and mental diagnosis predicted higher rates of 30-day readmission, 30-day mortality, and 1-year mortality. Conclusions Among Medicare myocardial infarction patients, comorbid mental illness was associated with an increased risk for admission to lower-quality hospitals. Both lower hospital quality and mental illness predicted worse post-AMI outcomes.
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