Here are the top quality challenges healthcare providers will face in 2011—many, such as imaging exposure effects, central line infections, and medical data breaches dominated headlines in 2010.
1. Imaging Scan Radiation Exposure and Overutilization
This issue caught the number one spot for several reasons.
Concerns about overutilization of imaging involving radiation, especially the use of CT, have been snowballing over the last two years. Scientists writing in the Journal of the American Medical Association said the situation may have gone too far.
In July, David J. Brenner of the Center for Radiological Research, Columbia University Medical Center and Hricak, MD of the Department of Radiology, at Memorial Sloan-Kettering Cancer Center, suggested that the time for national regulation of the industry has come.
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"Radiation exposure from medical radiographic imaging is comparatively unregulated; this is in striking contrast to radiation exposure in occupational settings, which is stringently regulated despite it contributing a far smaller population exposure," he and his colleagues said in their research.
They noted that the average radiation dose to which persons in the U.S. are exposed to has doubled in 30 years, and that while background doses have not changed, "the average radiation dose from medical imaging has increased more than 6-fold."
The cost of imaging has also come under critique in an article published in an April issue of the Journal of the American Medical Association.Imaging tests in cancer care for Medicare patients accounted for 57% of all cancer costs in 2004, suggesting that the study population "represented the majority of cancer costs borne by Medicare beneficiaries."
In 2011, this quality issue remains a pressing concern.
Attention is often focused on the number of patients who are referred for imaging tests by physicians who own the machinery. A series of articles in a recent issue of the journal Health Affairs say they don't result in shorter length of illness, as many physicians who defend the practice claim.
And rather than reducing costs, the price per episode of care generally averages 4% to 10% higher when the physician self-refers a patient.
Even Massachusetts Rep. Edward J. Markey has weighed in to the controversy by saying that hundreds if not thousands of people were being unwittingly exposed to radioactive isotopes simply because they had been in close proximity of patients who had recently undergone therapy with high doses of radioactive isotopes.
With the concern that too many doctors are ordering too many unnecessary tests involving radiation, the Centers for Medicare & Medicaid Services has even launched a demonstration project to build a decision support system. The idea is that physicians who aren't sure about whether a test is warranted could use such tools to make the right choices for their patients.
2. Dialysis Mortality
The number of patients with end-stage renal disease continues to take a toll on the federal budget as the number of Americans receiving federally supported dialysis as a lifelong treatment option sits more than 400,000, at costs as high as $77,000 per patient per year. Dialysis mortality makes our list of top quality issues for 2011 as regulations come under scrutiny.
Care for dialysis patients is plagued with disparity and extremely high death rates, depending on where one receives care. For every five people who begin dialysis at the beginning of the year, one won't be alive at the end of it. But at some facilities, the death rate is as high as 30% per year.
ProPublica this year has exposed some of the reasons for the disparity such as high infection rates, low quality standards, and poor regulation of the industry. It said "two corporate chains that dominate the dialysis-care system are consistently profitable, together making about $2 billion in operating profits a year."
Under the Patient Protection and Affordable Care Act, change for patients with end stage renal disease is in the wings in the form of bundled payments and tighter scrutiny.
3. Central Line Infections
The battle against central line infections rages on for healthcare leaders in 2011. Will safer infection control practices (such as minimal catheter use and checklists) make a difference in quality of care?
Mandatory reporting now in place in 17 states was said to be the reason for an 18% decline in central line-associated bloodstream infections during the first six months of 2009, according to the Centers for Disease Control and Prevention.
In a May news conference, Peter Pronovost, MD, medical director of the Center for Innovations in Quality Patient Care at Johns Hopkins University called central line infections "the polio campaign for the 21st century." He said the CDC's efforts mark a turning point for healthcare transparency and accountability."
And while CDC would not release hospital specific CLABSI rates, they said those numbers are coming soon in future reports.
4. Patient Involvment in Care
Donald Berwick, Centers for Medicare & Medicaid Services Administrator, predicts that putting the patient first will become a theme for medicine in 2011 along with transparency.
In the new year, Medicare will be reimbursing hospitals in part on a formula based on patient satisfaction, which is anathema under the old school way of thinking about things.
5. EHR Adoption
Payment and quality are all tied in to the scramble to achieve meaningful use with appropriate and effective electronic health records for physicians and hospitals in 2011.
Meaningful use guidelines released earlier this year call for these elements to satisfy the criteria. To kick off the new year, providers are looking to adopt EHRs that work for their practices while still meeting regulation standards.
6. Transparency
Increasingly, payers and the public have access online to an amazing amount of detail about providers' quality of care at a hospital and at a physician level. The Centers for Medicare & Medicaid Services is updating its Physician Compare website, and an increasing amount of information about hospital quality will be available on Hospital Compare and other federal and state health websites as well.
Hospital executives will have to decide how to market the information in their favor, and they will have to figure out whether to fight back against advertising campaigns launched by competitors who have scores that are better than their own.
How risk adjustment formula are used to calculate these scores to account for tougher patient mix is an area that's due for some scrutiny and probable refinement.
There have always been medical errors in the healthcare industry and year 2011 will be no exception. Medical errors makes our list of top quality issues because of the high attention and cost these errors received in 2010, sure to carry over into 2011.
8. Nurses' Role
State legislators and hospital leadership teams are continuing to debate about whether to impose nurse-patient staffing ratios, as California has done. Hospital groups have sued to block such ratios, saying they impede flexible flow and cost too much. Nursing groups, predicably, believe otherwise.
Advocates say nurses are happier, fewer leave the profession, the number of mistakes has dropped and patient satisfaction scores, becoming increasingly important, are higher.
Most controversial is the requirement that one nurse be on staff for every two patients in the intensive care, critical care, and neonatal intensive care units, as well as in post-anesthesia recovery, labor and delivery, and when patients in the emergency room require intensive care.
National nursing researcher Linda Aiken's June report sided with the nurses, saying there's less burnout when staff ratios are lower, and that nurses have greater ability to actually care for their patients.
9. SGR Cuts
This "kick-the-can-down-the-road" is provoking angst among Congress and the House of Medicine, in a debate with consequences continuing into 2011.
Doctor groups have said that their members will leave the Medicare program entirely, limit the number of beneficiaries they would see, and/or refuse to accept new Medicare patients or retire early and go fishing if the 25% pay cut takes effect.
But as Congress has consistently done, the issue has merely been postponed another 12 months. So look for the Doc Pay Fix, the repeal of the sustainable growth rate formula that would cut physician pay even more, to rear its head again in 2011.
10. Data Breaches
Along with meaningful use and the move to the electronic health record, there's increasing concern about how healthcare providers can keep patient information privacy sacrosanct.
Even officials state of California, which has fined hospitals more than $2 million so far for accidental as well as purposeful violations of patient confidentiality, realizes how difficult it is.
In an embarrassing news release last week, the Department of Public Health acknowledged that even it violated its own rules. Material dealing with facility investigations, which include on patients, residents of skilled nursing facilities, and facility employees and even state workers may have gotten into the wrong hands.
Apparently an encrypted magnetic tape bound from the West Covina office to Sacramento was removed or fell out of its envelope. Names, social security numbers, medical diagnoses, mailing addresses, e-mail addresses and other sensitive and confidential information was on those tapes.
Electronic health records and health information technology is evolving with the requirements for meaningful use, but protecting patient confidentiality when so much information can be immediately and widely disseminated is sure to remain an issue.