The importance of reducing unneeded medical testing and medications can be a complicated message for consumers to absorb, physicians say.
The ABIM Foundation has awarded a second round of grants for its Choosing Wisely campaign, which aims to educate clinicians and patients about reducing unneeded medical testing, procedures, and medication use.
The grants, which are funded by the Robert Wood Johnson Foundation, have been awarded to seven initiatives, all of which will work toward reducing the use of antibiotics for viral infections by at least 20% over nearly three years.
Lisa Letourneau, MD, MPH
The grantees each also chose at least two other Choosing Wisely recommendations to focus on, from the dozens of tests and procedures that Choosing Wisely recommends be scaled back, such as reducing imaging for low-back pain and reducing prescriptions for benzodiazepines for adults 60 and over.
The importance of reducing unneeded testing and medications can be a complicated message, especially for consumers, who have been conditioned to think that "more is better," says Lisa Letourneau, MD, MPH, executive director for Maine Quality Counts, one of the grantees.
"It's so counterintuitive to the culture in terms of accessing healthcare," she says.
The Maine Quality Country regional health improvement collaborative will work with other health organizations throughout Maine's Midcoast and Greater Bangor regions to spread the Choosing Wisely messages not only with patients, but also with clinicians.
Maine Quality Counts was a grantee during the first round, too, and heard a loud "we get it" from physicians, who said they felt like they were "swimming upstream" with patients who demand certain tests and medications when they're not feeling well.
"Stop beating us up," Letourneau said she heard physicians express. "Spend your time with the public."
This time around the focus will be not only on communicating the "choosing wisely" message to the public, but also figuring out the best way to do it. Letourneau says the key to spreading the word and making things click with the public is by conveying a complicated message in a succinct way.
She compares the "choosing wisely" message to other public health campaigns such as "don't drink and drive." But acknowledges that "choosing wisely" is more complex because it's not simply a question of convincing the public to stop a specific behavior.
"You don't want people to skimp on care they do need," she says. "What really resonates with people?"
The message for patients is: "Get the care you need and not the care you don't," she says. But in order for it to stick in people's minds and catch their imagination, "it's got to be a little sexier and catchier than that."
"I don't think anybody has really figured out the social marketing strategy," Letourneau says, but over the course of the 34-month grant period, her organization and its partners will work to find out.
Mary Riordan
She points as an example to Maine's "5-2-1-0 Let's Go" childhood obesity campaign, which conveys a similarly complicated message: five fruits and veggies; two hours or less of recreational screen time; one hour or more of physical activity; and zero sugary drinks and more water.
"If you ask most school kids in Maine, they'll know what it means," she says. It's that kind of catchy messaging and recognition that Letourneau hopes they'll achieve around their Choosing Wisely work.
The Wisconsin Collaborative for Healthcare Quality is another second-round grantee that will work to spread the Choosing Wisely message more widely. Mary Riordan, the organization's director of member and community engagement, agrees that patient expectations can stand in the way of physicians implementing Choosing Wisely goals.
"A lot of patients have a cold, and they think they will rush in right away and get an antibiotic," she says, adding that the first round of their work helped physicians open up dialogue with patients about making the right healthcare choices. "Physicians are not just prescribing willy-nilly."
Still, when patients take time out of work and pay a co-pay to see a physician when they don't feel well, they expect help and answers, and also want to their money's worth. No one wants to be told that they might have to just have to cough for a month and that antibiotics won't work.
"Most of the barriers are related to consumer requests," echoes Judy Nowicki, MPA, BSN, RN, quality improvement specialist for the Wisconsin Collaborative for Healthcare Quality. "When you have low back pain you want something done."
And it's a predicament for physicians, who have limited time during each visit and want their patients to be satisfied.
"The physician gets squeezed sometimes when it comes to consumer requests," Nowicki says.
And yes, sometimes doctors cave-in to these requests. But perhaps this campaign will lead to fewer requests from patients and less caving-in by doctors.
"They certainly, understandably, respond to patients in a way that they don't think is the most evidence-based approach," sometimes, agrees Letourneau. "The risk of getting the test is something that we often don't talk about… It's really about having the conversation with the patient."
The American Society of Clinical Oncology is working on a tool for assessing the value of new cancer treatment options based on clinical benefit, side effects, and cost.
Cancer treatment is expensive. For patients, sometimes cripplingly so. New cancer treatments can cost tens of thousands of dollars per month, out-of-pocket expenses are sky-high, and a recent survey shows that more than one third of patients are worried about bankruptcy.
Whether high costs and novel treatments lead to a better value and what value really means in the context of cancer care, are yet to be determined.
Lowell Schnipper, MD
To attempt to answer those questions, the American Society of Clinical Oncology (ASCO) has published an initial version of a conceptual framework for assessing the value of new cancer treatment options based on clinical benefit, side effects, and cost.
ASCO has opened up its framework for public comment through August 21. Eventually, the framework will become a tool for physicians and patients to use to help guide their cancer treatment decision making.
"Should doctors even think about cost in the context of what we want to do for our patients?" asks Lowell Schnipper, MD, chair of the ASCO Value in Cancer Care Task Force and clinical director of the Cancer Center and Chief of Hematology and Oncology at Beth Israel Deaconess Medical Center in Boston. Over the years, it's become apparent that doctors should be considering cost, and more importantly, value.
Schnipper points to ASCO's 2009 guidance statement about the cost of cancer care as the "launching pad" for this discussion.
"There's an abiding sense that we want the best cancer care to be available to all people on this country in the most affordable possible way," he says.
Schnipper says ASCO embraced the general concept that "value" is the quality of the service delivered and the outcome in relation to its cost. With this in mind, data about the clinical benefits and toxicity of each treatment regimen are used to calculate a combined "Net Health Benefit" score (NHB) which represents the added benefit that patients can expect to receive from the new therapy, versus the current standard of care.
According to Schnipper, it asks, to "what degree did the new treatment extend survival as opposed to standard of care?"
Side effects are also considered. If a new treatment doubles survival but is much more toxic than standard treatment, that also needs to be factored in. Those factors taken together represent the NHB. "Bonus points" are given for certain things in the advanced cancer setting that are indicators of better health, such as symptom or pain relief.
This NHB score is presented alongside cost information; a low NHB score with high out-of-pocket and acquisition costs would point to lower value. Conversely, high costs might be justified if the NHB score is also very high.
"If you were buying an automobile and you wanted one that went as fast as possible or was as sleek as possible, you might buy a Maserati, and you wouldn't expect to pay bargain basement price," Schnipper says.
Why not integrate cost right into it and come up with a single evaluation? Schnipper says it's because there are so many other, variable costs associated with cancer care that are nearly impossible to calculate or predict, such as lost wages, hospitalizations, ED visits, and physician costs.
"The costs of cancer care are far more, and more extensive, than just the medications involved," he says.
Once the comment period is over, Schnipper says his team will "huddle" and make needed changes to the framework that he says isn't fully "baked" yet.
Tool to Come "We've already changed it in response to some of the suggestions," he says.
He and his team have already begun talking with software developers to design a Web- and/or mobile-based tool that uses the framework's variables and would be prepopulated from the prevailing medical literature with the results of studies looking at survival, toxicity, and costs of agents.
Such a tool would enable a patient and doctor to come up with the value for several different therapies at the patient-doctor interface. It would also allow patients to have a say in cancer care in relation to what they value. Perhaps someone wants to miss as little work as possible, or a pianist might want to avoid a drug that causes neuropathy so she could keep playing.
"It's a way of personalizing the choices that exist," Schnipper says.
Finally, another question he wants to resolve is whether the framework's final iteration will be of any use in policymaking around promoting high value in healthcare.
"We need to think about the impact, not only on our patient, who is no doubt our major constituent," he says, "but on our responsibility as a stewards of society's resources."
A proposal to set a floor and a ceiling on health insurance payments is an effort to eliminate disparities, but the Massachusetts Hospital Association's board of trustees calls the bill "overly simplistic."
In an effort to make the payment system more equitable between different hospitals for the same procedures, a bill in Massachusetts is aiming to set limits on what private insurers can pay hospitals.
"We have vast discrepancies, well beyond the cost of care that's provided and well beyond the outcome," says State Senator Benjamin B. Downing (D- Pittsfield), who filed the bill.
Benjamin B. Downing
Bill S.574, "An Act relative to equitable healthcare pricing," would prohibit payments that are 20% higher or 10% lower than the average payment for similar settings. The ceiling wouldn't apply to certain specialty or geographically isolated hospitals.
"My thinking, generally, was related to some of the issues that I've seen in my district," Downing says, referring to the sudden and shocking closure last year of the financially beleaguered North Adams Regional Hospital.
"This bill by no means would have solved all of those problems," Downing acknowledges. But he says the way that healthcare is paid for now "drives costs up and drives people away from settings where they could get just as high-quality [care] and be closer to home."
He adds that making payments more evenly distributed would not only help ensure access to care, but also stabilize communities and "anchor institutions" that are major employers in some of the state's most economically challenged places. Moreover, he says, they're providing high-quality care, but being paid much less for it.
"We are blessed to have remarkable academic medical centers" in Massachusetts, he says. "The question is, do we need to rely on them for as much care as we do?"
Opposition
Timothy F. Gens, Massachusetts Hospital Association's executive vice president and general counsel, says the bill is flawed and could potentially "destabilize the healthcare system." the Massachusetts Hospital Association's board of trustees has voted to oppose it, he says.
Timothy F. Gens
Gens says current reforms—namely the healthcare cost containment law Chapter 224—haven't been fully implemented and need to be given a chance to work. "We do think they should give that approach an opportunity to succeed before they make major changes," he says.
But beyond that, Gens says there are a number of "practical problems that suggest that this bill won't work."
A few that he ticks off: That healthcare costs are about utilization as well as price; that severity of illness is different from one hospital to the next; that costs change from year-to-year as hospitals negotiate different contracts; and that there's a move away from fee-for-service payment models.
"The variables are numerous," Gens says. "When we see these overly simplistic ideas….it raises serious concerns."
Moreover, the bill doesn't address a major issue: Low government reimbursements.
"There are hospitals that are in financial stress, and if you look at those hospitals, I think a common denominator would be low government payment. And it's becoming a more significant issue," Gens says. "Those are areas where hospitals are really having financial trouble. If you were looking at taking an immediate step, that's where it should be.
Downing says he knows the bill isn't perfect, or the "be all, end all," and says that he's willing to work on alternative solutions. But, "If not this, then what? No one, I think, would say that the status quo is sustainable or ideal."
"We all have the same goals in mind," Downing says. "We've got to do something to make the payment system make more sense than it does right now."
The capabilities of health information technology tools aren't always aligned with physician priorities, research finds. And the care coordination activities that matter most to clinicians aren't ones that are best supported by health IT.
Using health IT to support care coordination is inconsistent in primary care practices, especially when it comes to the care coordination activities that matter most to clinicians, according to new research in theAnnals of Family Medicine.
"The activities that the clinicians were most interested in were not ones that were necessarily most supported by health IT," says lead author Suzanne Morton, MPH, MBA, senior healthcare analyst for the National Committee for Quality Assurance.
In addition, the research found that the care-coordination activities that practices had most commonly implemented were not the ones with the greatest degree of health IT support.
Suzanne Morton, MPH, MBA
The researchers surveyed primary care practices (both physician-owned and hospital/health system–affiliated) that achieved patient-centered medical home recognition and participated in the Meaningful Use program, as well as community health clinics with patient-centered medical home recognition.
Having a clinical summary for patients that's pertinent to the office visit, not just an abstract from the medical record
Using computerized provider order entry for referrals/transition of care orders
Providing a summary of care record for each site transition or referral when transition or referral occurs with available information
Ensuring that the provider receiving a referral acknowledges receipt of external information and provides referral results to the requesting provider
Getting electronic notification of a significant healthcare event in a timely manner to key members of the patient's care team, including arrival at an emergency department, admission to a hospital, discharge from an emergency department or hospital, or death
Generating lists of patients for multiple specific conditions and present near real-time patient-oriented dashboards
"We found moderate use of health IT for care coordination objectives… we were a little surprised that it was not higher than when it was," Morton says. "We also found that it varied depending on the type of activity that was being asked about."
And high health IT use and the perceived importance of certain activities didn't match up.
For example, providing clinical summaries to patients was the activity most frequently supported by health IT, with 76.6% of practices doing this with health IT. However, just 47.7% of those surveyed considered this activity very important.
On the flip side, 78% of respondents said timely notification of hospital discharges is very important, but just 48.7% used health IT systems for it.
According to the authors, this disconnect signals that the capabilities of health IT tools aren't always aligned with physician priorities.
Within an EHR it's easy to generate a referral, Morton points out, and indeed, 68.6% of surveyed practices routinely use health IT to do this, according to the study, making it one of the care coordination activities that's most well-supported by health IT.
But it's not as easy for clinicians to get that information back, illustrated by the only 53.4% of practices who routinely use health IT to provide referral results to the requesting provider.
That's not to say they're not performing these care coordination activities at all; they're just doing it without health IT. For instance, 82% of practices routinely provide referral results to the requesting provider. Likewise, 63.1% of the practices say they routinely identify patients who have had an emergency department visit, but only 39.4% routinely use health IT to do so.
"There need to be improvements in the ability for different health IT systems to talk to each other," Morton says. "There needs to be both technical support and financial support to do more of this communication across different platforms."
Health IT-supported care coordination was more likely in practices with fewer financial concerns, as well as in practices where a non-clinician was in charge of care coordination. Practices with a stronger capacity for systemic change were also more likely to have care coordination supported by health IT.
"If you're not used to making a lot of changes, and taking a structured approach and having… support for that, it can be more difficult to implement changes," Morton says.
She says the next step is to find out what kind of support and incentives would be best for increasing health IT-supported care coordination.
"It will be interesting to see which types of financial incentives will help," she says.
Patients with complications after major surgery are 26% more likely to survive if they return to the hospital where they had their operation, researchers find.
Patients with complications after major surgery have better survival odds if they're readmitted to the same hospital where the surgery was performed, throwing into doubt the assumption that traveling long distances to high-volume hospitals necessarily leads to the best outcomes.
"There's a trade-off involved," says lead study author Benjamin Brooke, MD, PhD assistant professor of surgery at the University of Utah and director of the Utah Intervention Quality and Implementation Research (U-INQUIRE) group.
"Sure, you might get better surgical outcomes from going to a high-volume hospital initially," he says. But "our data suggests that there is a potential downside to that."
Benjamin Brooke
The observational cohort study of more than 9 million Medicare patients, published inThe Lancet, found that patients with complications after major surgery are 26% more likely to survive if they return to the hospital where they had their operation compared to those readmitted to a different hospital.
The findings suggest the importance of continuity of care. "Having the familiarity with that patient was more important than the fact that they did a lot of operations," Brooke says.
The researchers used Medicare claims data from between January 1, 2001, and November 15, 2011, to assess patients who needed hospital readmission within 30 days after 12 different procedures:
Open abdominal aortic aneurysm repair
Infrainguinal arterial bypass
Aortobifemoral bypass
Coronary artery bypass surgery
Oesophagectomy
Colectomy
Pancreatectomy
Cholecystectomy
ventral hernia repair
Craniotomy
Hip replacement
Knee replacement
"The perception is [that] when complications occur after a major operation, it doesn't really matter where patients go," Brooke says. Instead the emphasis is placed on where patients have their initial procedure.
Although Brooke says he and his team hypothesized that patients would get better outcomes if they went to the same hospital, "we were fairly surprised that it was the same across all operations at the same level," even after adjusting for hospital volume.
Although the reimbursement trend might be toward centers of excellence and regionalized surgery, it's intuitive that continuity of care would also be a critical factor.
"It makes sense that if you meet a patient, you learn the patient's medical history, you perform the operation, you're very familiar with that patient's anatomy," Brooke says. "You're the same physician who already has all of that in-depth, contextual known of that patient… having that familiarity with that patient is what drives a lot of the mortality benefit in this study."
Continuity of Care
Researchers also found that having the same surgeon taking care of patients for surgery and readmission provided the greatest mortality benefit.
"That really emphasizes this whole concept of continuity of care," Brooke says.
There are a couple of next steps for providers and policy makers, Brooke says. At the local level, the takeaway is implementing a change in how patients are triaged if they have complications during the post-op period.
If a patient is stable, ambulance companies could make efforts to take him back to the index hospital where he had his surgery. Or if a patient shows up in a different ED, the ED team should make every effort to get that patient back to the index hospital. Ideally, there would be an automated system of initiating this transfer process.
"By showing the results of the data that we have, maybe we can influence the decisions," Brooke says.
At the policy level, Brooke says there should be plans in place to keep surgical patients who do travel for surgery near the index hospital for a few weeks post-op, especially since the majority of readmissions occur within the first two weeks after surgery. For instance, a program could provide affordablelodging so patients can have their first post-op visit with their own surgical team.
Brooke says he's not debating the value of high-quality operations, but "if we set up these programs to regionalize major surgery, we to need have a strategy to account for these complications that occur."
Data shows that mandated nurse-patient staffing ratios are good for nurses, but patient safety benefits have not been clearly demonstrated. In California, where a similar law has been in effect for 11 years, hospital operating expenses have risen.
Eleven years after passage in California, the country's first mandated nurse-patient ratio law has largely resolved the nurse burnout problem.
Still, the Massachusetts Health Policy Commission voted unanimously this month to approve the state's first nurse staffing mandate. It calls for no more than two patients to be assigned to a single nurse in all ICUs, including burn units and NICUs, and in some cases, just one patient per nurse.
To determine proper staffing levels, hospitals must use an acuity tool to, according to the final rule. A nurse manager will intervene if there's a disagreement between an RN and the tool. Also, hospitals must report on four ICU quality measures:
Patricia M. Noga, PhD, RN
Central line-associated blood stream infection
Catheter-associated urinary tract infection
Hospital-acquired pressure ulcers, and
Patient falls with injury
Although there are no monetary or other specific penalties in the law, Patricia M. Noga, PhD, RN,vice president of clinical affairs for the Massachusetts Hospital Association, says the law will have a financial impact.
"There will be costs associated with implementing the law, such as developing acuity tools," she said, responding to questions by email. "We'll be monitoring the implementation of the regulations to assess the cost over time."
Massachusetts joins California as the only other state in the nation to have adopted a mandated nurse-patient ratio. However, California's law goes far beyond ICUs, mandating minimum nurse-to-patient ratios at all times on a unit. And 11 years after its passage, it remains to be seen whether it's a model or a cautionary tale.
"I think it's a bit of both," says Patrick S. Romano, MD,professor of medicine and pediatrics and senior faculty in the Graduate Groups in Epidemiology, Public Health, Clinical Research, and Nursing Science and Healthcare Leadership at the University of California Davis.
"I think it's a cautionary tale in that it was certainly expensive, and the benefit in terms of patient safety has not been clearly demonstrated, and the process has certainly been contentious," he says. "But on the other hand it is a model, perhaps, because it has largely resolved the [nurse] burnout problem."
Romano was one of the co-investigators who did work for the state of California in the early 2000s to estimate the impact of different ratio proposals.
Because of the California law, hiring increases happened almost across the board. Although a few hospital leaders said staffing was already at or above mandate levels, most "reported that they needed to hire more RNs to meet the requirements, particularly to cover meals and breaks," according to a California HealthCare Foundation study.
Continuous Coverage
In fact, Romano notes that hospitals had to create a new position: A break nurse, because under the law, hospitals have to meet the ratio at all times. "That's been the biggest point of controversy," he says. "Even if a nurse has to go to the bathroom, someone has to be covering."
Whether having constant coverage is actually needed or is beneficial has "never been subjected to rigorous scrutiny. Do you really need to have coverage every minute, or could you get by with short periods of shared coverage?" Romano adds.
That won't be the case in Massachusetts, though.
"The law does not call for the ratios to be applied at all times and the HPC explicitly said that the staffing requirements apply on all shifts, but not at all moments during the shift," says Joan M. Vitello, PhD, RN, president of the Organization of Nurse Leaders, MA, RI & NH and associate chief nurse at Brigham and Women's Hospital in Boston.
"For practical reasons," she said via email, "there are situations during every shift that, if the ratio were literally applied at all times, it would create problems for maintaining good patient care."
Joan M. Vitello, PhD, RN
In California, the ramp-up in hiring certainly increased costs for hospitals. Romano points to 2012 research that concluded that "Relative to hospitals in comparison states," operating margins declined significantly for many hospitals in California. Operating expenses increased significantly in many of them, too.
"It probably did have some effect on the financial performance," Romano says. "Particularly concentrated in the hospitals that had to make the largest increase in their staffing levels."
But "it hasn't been a bloodbath," he adds. And even though some hospital closures were blamed on the law, those hospitals likely were at a financial tipping point anyhow, he says. "It's hard to find any disastrous long-range impact."
Effect on Patient Outcomes
Whether it has improved patient outcomes is also unclear. For instance, a 2013 study published in the journal Health Services Research, found that although the California law succeeded in boosting nurse staffing, the staffing increase had only "mixed effects on quality." Another showed that "Higher registered nurse staffing per patient day had a limited impact on adverse events in California hospitals," showing that mandates are not a silver bullet.
Noga contends that there wasn't any "evidence or documentation that there was a quality of care, safety, or staffing problem in Massachusetts hospital ICUs. The law was a political resolution of a political problem, not a clinical problem."
The "political problem" she's referring to was a ballot initiative, proposed by the Massachusetts Nurses Association, which would have mandated certain staffing levels across the board.
As Noga noted, it will take time to determine the cost impact in Massachusetts. But in California, there has been one area where hospital costs may have actually gone down as a result of the law.
Paul Leigh
"The occupational injuries dropped. They dropped around 30%," according to Paul Leigh, a professor of public health sciences and an investigator with the Center for Healthcare Policy and Research at UC Davis, who published the findings last year. The researchers said that the "evidence suggests that the law was effective in reducing occupational injury and illness rates for both RNs and LPNs."
As the number of occupational injuries drop, so do worker's compensation costs. Although his study didn't publish cost data, Leigh says he has calculated it himself, and found that because injuries dropped more than hiring rose, the law likely resulted in a decline in worker's compensation costs for hospitals.
"The hospital is not thinking per nurse," Leigh says. "The hospital is thinking of the total dollar amount."
Caution Urged
Romano says that before the law was passed, some hospitals in California had unacceptably low staffing levels. He would have liked to have seen a remedy in the form of voluntary action, such as reporting staffing levels, rather than mandates.
Vitello and Noga are urging caution, too, pointing to potential issues that could arise from the new MA law, such as separating twins when one may not need to be in the NICU, or with ICU patients who don't need critical care because they're awaiting discharge or being transferred.
"The new law requires that all patients in an ICU, whether they need critical care or not, receive nurse staffing levels used for critical care patients," Vitello says. "Patients and caregivers should always be concerned any time something as sensitive, complex, and ever-changing as registered nurse staffing in hospitals is set into statute."
Mandatory state reporting of adverse medical errors is lagging and changes are needed in the way hospitals and health systems define and analyze so-called "never events," researchers say.
Changes are needed in the way the health system defines, collects information about, and analyzes so-called "never events," according to Johns Hopkins patient safety experts writing in The Joint Commission Journal on Quality and Patient Safety .
Never events are serious adverse events that, as the name says, should "never" happen. But efforts to identify, report, and prevent them have been uneven.
And they are occurring "with a troubling frequency," the authors write. They also note that "Lapses in patient safety are a major quality problem in health care, causing more than 200,000 deaths, 2.4 billion extra hospital days, and between $17 billion and $29 billion in excess hospital costs in the United States each year."
In addition, the Centers for Medicare & Medicaid Services "does not pay hospitals a higher reimbursement for certain" healthcare-acquired conditions that result from never events.
Variable Event Reporting
Although the Institute of Medicine called for mandatory state reporting of adverse medical errors more than a decade ago in its landmark To Err Is Human report, only 26 states and the District of Columbia are doing so, and the extent of what they actually report varies.
Georgia, for example, requires hospitals to report adverse events, but doesn't require them to publicly report individual hospital data. It also doesn't report aggregated data.
"Public reporting plays an important role, and really speaks to accountability," says the study's lead author, J. Matthew Austin, PhD, assistant professor in the Johns Hopkins Armstrong Institute for Patient Safety and Quality and in the Johns Hopkins University School of Medicine Department of Anesthesiology and Critical Care Medicine.
Another problem is the definition of term itself, on which there is no universal agreement.
What is a Never Event? "One of the challenges we have with never events is that different organizations have adopted different definitions of what constitutes a never event," Austin says. For instance, there's disagreement about whether never events should include adverse events that are entirely avoidable, or ones that are mostly avoidable.
There's also no standard list of adverse events that qualify for never event status. For instance, the paper says that the National Quality Forum defines wrong site surgery as a never event, whereas CMS does not. CMS does, however, define any catheter-associated urinary tract infection as a never event, while the National Quality Forum does not, the paper says.
And then there are what The Joint Commission calls sentinel events, which "signal the need for immediate investigation and response."
J. Matthew Austin
Assistant Professor
Johns Hopkins University
In light of these nuances and discrepancies, the resulting disjointed reporting, and the rate that never-events occur, the authors offer several recommendations.
They call first for establishing standard definitions and measures for never events, as well as a standard set of adverse events that would be defined as never events, such as the one developed by theNational Quality Forum.
"It is shocking," that there isn't a standard definition already, Austin says.
Increased transparency is also needed.
"We hold up the state of Minnesota… as [having] a format that we think other states should aspire to… They report out their events by facility and they report out what the impact was to patient," Austin says. Hospitals in Minnesota must report when one of 29 adverse events occurs, and the state's department of health issues an annual report about adverse health events. Last year it released a 10-year longitudinal review of its data.
Austin also says healthcare leaders, policymakers, providers, and other stakeholders should find better ways to work together to focus on quality improvement efforts.
And there's a role for individual hospitals to play, too.
Each hospital can work to understand what events it's had, conduct analyses of those events, and ensure that systems are in place or get adjusted to prevent such events from occurring again. "All of that happens at a very local level," he says.
Local collaboration should also be encouraged, Austin says. Although hospitals are often operating in a competitive environment, there still needs to be knowledge and information sharing across institutions. Austin says hospitals can share finding with others to incorporate learning into different organizations and prevent events for all patients.
"It's really this idea of local implementation, but more global sharing," Austin says. "Sharing information is a key component to seeing improvements and success. That's the willingness to share with friends, and perhaps competitors, what issues their own hospital has experienced and a global effort to reduce patient harm."
Researchers find that functional status, rather than comorbidity, is a better predictor of whether someone will be readmitted to the hospital.
The way the Centers for Medicare & Medicaid Services predicts readmissions is likely neither the most accurate nor the fairest, researchers at Harvard Medical School claim.
A study published in the May issue of the Journal of General Internal Medicine found that functional status, rather than comorbidities, was a better predictor of whether someone would be readmitted to the hospital.
"This raises a question of whether Medicare is really using the best predictors to really understand readmission," as well as questions about how fairly hospitals are being financially penalized, says principal investigatorJeffrey Schneider, MD, medical director of the Trauma, Burn and Orthopedic Program at Spaulding Rehabilitation Hospital in Boston and assistant professor of physical medicine and rehabilitation at Harvard Medical School.
Jeffrey Schneider, MD
Schneider points out that CMS fined more than 2,200 hospitals a total of $280 million in 2013 for excess 30-day hospital readmissions, so having accurate readmission models is critical.
But the ones CMS uses "are not very good predictive models, and they have relied heavily on simple demographic data like age and gender and comorbidities," he says.
Moreover, "there's mounting evidence that function is a good predictor of all sorts of hospital outcomes."
The researchers conducted a retrospective study of 120,957 patients in the Uniform Data System for Medical Rehabilitation database who were admitted to inpatient rehabilitation facilities under the medically complex impairment group code between 2002 and 2011.
Schneider says they chose to study this "medical complex" population "because it is heterogeneous and we think well-represents a wide swath of patients who are in a hospital for medical reasons."
"Rehabilitation hospitals routinely collect functional measures and that data is available in a large administrative database," he says. The researchers measured functional status using the Functional Independence Measure (FIM), which looks at 18 tasks such as eating, dressing, bathing, toileting, grooming, and climbing stairs. Each of the 18 items is rated on a seven-point scale from completely dependent on someone else for help to totally independent.
FIM data is collected on a patient's admission to a rehab facility—which is usually on the same day as their discharge from an acute care facility. "In that way it's also a surrogate marker of their functional status when they left acute care," he says.
Function or Comorbidity?
Researchers built models based on functional status and gender to predict readmission at three, seven, and 30 days, and compared them to three different models based on comorbidities and gender.
"We really just wanted to answer this question: If function was a better measure of readmission than comorbidity," Schneider says. "We didn't seek to build the best model."
The researchers then determined the c-statistic—the measure of a model's overall ability to predict an outcome, which ranges from 0.5 (chance) to 1 (perfect predictor)—of the models.
They found that the model with gender and function was significantly better at predicting readmissions, Schneider says.
Models based on function and gender for three-, seven-, and 30-day readmissions (c-statistics 0.691, 0.637, and 0.649, respectively) performed significantly better than even the best-performing model based on comorbidities and gender (c-statistics 0.572, 0.570, and 0.573, respectively).
Even adding comorbidities to the function-based models didn't help much, creating c-statistic differences of only 0.013, 0.017, and 0.015 for 3-, 7-, and 30-day readmissions, respectively, for the best-performing model.
'It's So Intuitive'
Why is function a good predictor? Schneider says it may represent something else, such as the severity of a patient's illness. Cancer patients, for instance, have a wide degree of functional statuses depending on how sick they are. In this way, "it's so intuitive" that function would be a good predictor of readmissions, he says. If you can't care for yourself, you'll likely end up back in the hospital.
In addition, "comorbidity is a fixed variable," Schneider says, but function is not. And since function is a better predictor of readmission, even at shorter time intervals, assessing a patient's functional status and doing things to improve it could be a way of reducing preventable readmissions, especially the three- and seven-day readmissions.
"Acute care hospitals are not routinely collecting a functional measure of their patients," Schneider says. He also points out that recent research on functional interventions—such as early mobilization in the ICU—in acute care hospitals is showing to improve patient outcomes.
Next Steps
"I think the next wave for hospitals… is [thinking about] how to make use of this information," Schneider says, by piloting functional interventions and determining functional measures at discharge to help with risk-stratifying for readmissions.
On a larger scale, there's also the policy perspective that CMS's readmissions models aren't as good as they could be. Schneider says he and his colleagues are conducting another, even larger study, using the same framework, but looking at but all patients in a rehab hospital, not only at medically complex ones. He says it hasn't been published yet, but the findings will be pretty similar.
Major medical groups grumble that provider utilization and payment data may be misinterpreted, but researchers are eager for their first chance to access and work with it.
Reaction to the Centers for Medicare & Medicaid Services recent release of inpatient and outpatient hospital utilization and payment data is polarized.
Major medical groups are grumbling the opportunity for newly released Medicare claims data to be misinterpreted, but innovators and entrepreneurs are eager for the chance to access and work with the data like never before.
Although the American Hospital Association and the American Hospital Association acknowledge that payment data transparency is needed, both groups point to shortcomings with how the data is organized, its potential for being misleading, and how it might be misinterpreted.
"Medicare payments are not reflective of hospital costs," says Caroline Steinberg, vice president of trends analysis for the AHA, in an emailed statement. "They are set by law and government programs underpay and don't cover the cost of care. Underpayment by Medicare and Medicaid to U.S. hospitals was $51 billion in 2013. Medicare reimbursed 88 cents and Medicaid reimbursed 90 cents for every dollar hospitals spent caring for these patients."
The AMA is equally skeptical of the data released by CMS. Although AMA acknowledges that there is a "key improvement" in this year's claims data release—the separation of Part B drugs from payment for physician services, so drug reimbursement isn't confused with physician income—the organization still points to "significant shortcomings" in the 2013 data.
An emailed statement from outgoing AMA President Robert M. Wah, MD, says the data does not "provide actionable information on the quality of care that patients and physicians can use to make any meaningful conclusions. The data also do[es] not provide enough context to prevent the types of inaccuracies, misinterpretations and false assertions that occurred the last time the administration released Medicare Part B claims data."
Open to Innovation
In a related move, CMS for the first time is making Medicare claims data to available to "innovators and entrepreneurs." These groups were previously restricted from accessing detailed CMS data for the purpose of using it to develop products or tools to sell.
In September, applicants may request access to granular data, which will be available via the Virtual Research Data Center (VRDC). It's a move that Tina Olson Grande, senior vice president for policy at the Healthcare Leadership Council in Washington, DC, applauds. In a telephone interview [edited and condensed for clarity] she explains why:
Tina Olson Grande
HLM: What was released?
Tina Olson Grande: CMS holds a number of different types of files of data, and their availability varies. They have released more of the files to certain types of researchers that were previously restricted… It's open to a legitimate researcher regardless of the institution where that researcher is employed. And that's the big difference.
HLM: What kind of data is it?
TOG: Medicare claims data is a big example. [But] CMS has stated that it's all privacy-protected, so it's not as if, carte blanche, CMS is handing over the identities of Medicare patients to researchers. That's not at all what it is. CMS still has very tight control over who they would agree to release the information to, and…you still would have to prove you're a legitimate researcher, you have a legitimate hypothesis, [and] that the research you're doing is going to improve the Medicare program…and the lives of Medicare beneficiaries.
[Researchers also must] agree to all of the privacy-related protections that CMS requires when you're handling the data.
HLM: Was this a surprise to you?
TOG: I wouldn't say it was necessarily a surprise for the Healthcare Leadership Council. I've been working for a couple of years now to encourage CMS to release this type of data.
Our member organizations are really involved in new types of delivery models of healthcare that are more efficient and [provide] better quality for consumers. And a lot of the work that they're doing to try to [better] manage these coordinated care models was hampered by their inability to get data quickly [and] get the level of data that they needed in order to do meaningful research. Limited data sets (LDS) and research identifiable files (RIF)… are two types of files that are really needed in order to target populations where you want to make a difference… It's just going to be much easier to do meaningful research… now that researchers will have access to those types of files.
HLM: What kinds of tools or programs can you envision coming out of this?
TOG: There's a lot going on in analytics and predictive modeling. It also might help with benchmarking…I think it's going to help in terms of transparency tools. I think it's really sort of endless, the possibilities that are there from a business model standpoint for entrepreneurs and innovators.
HLM: Anything else to note?
TOG: They're making the data available more often than they used to: Now they're going to release it quarterly. If you want information, and you want it to be a little more real-time, it's going to be much more useful now. It's just a three-month lag, rather than a year lag, which was a huge complaint of our member organizations.
Also, I want to strongly emphasize that CMS still controls who they sell the data to. They certainly can put the kibosh on anything that does not look like it's legitimate.
It can't be used for marketing. There's no marketing allowed. This is legitimate research with a hypothesis that has a stated expected outcome, [and] that improves the Medicare program and the health of Medicare beneficiaries.
Healthcare providers, clinical associations, and other stakeholders at a first-of-its-kind forum announce multi-year commitments to slow the emergence of antibiotic-resistant bacteria and infections.
Antibiotic stewardship took center stage this week when the White House hosted a first-of-its-kind forum involving more than 150 stakeholders including healthcare organizations, clinical societies, and pharmaceutical companies.
Participants gathered to highlight the commitments they're making over the next five years to slow the emergence of antibiotic-resistant bacteria and infections.
At least 2 million people become infected with antibiotic-resistant bacteria every year, and at least 23,000 of them die as a direct result of these infections, according to the CDC.
According to a fact sheetprovided by the White House:
Ascension Health will establish facility-based antimicrobial stewardship programs in all Ascension hospitals and adopt the CDC's Core Elements of Hospital Antibiotic Stewardship Programsand submit antibiotic use and resistance data to CDC
Hospital Corporation of America will develop and implement new clinical decision support and real-time antibiogram tracking (the result of a laboratory test for the sensitivity of an isolated bacterial strain to different antibiotics) to rapidly respond to lab results, catch bug-drug mismatches, implement strategy to prevent health-care associated infections in adult intensive care unit patients, and strengthen national efforts to identify and report cases of antibiotic resistance.
Kaiser Permanente will support antibiotic stewardship programs and guide prescribing practices for antimicrobials at every Kaiser Medical Center with electronic alerts and order sets.
Lisa Davidson, MD
Three other healthcare organizations committed to the White House effort to combat antibiotic resistance detailed their plans in response to questions from HealthLeaders Media:
"One of the big issues of our time is the rise of antibiotic resistance," says Lisa Davidson, MD, medical director of Carolinas HealthCare System's Antimicrobial Support Network and attending faculty physician in the Infectious Disease Division at Carolinas Medical Center.
Davidson says Charlotte, NC-based Carolinas HealthCare is already considered a leader in this area, having established the six-hospital Antimicrobial Support Network (ASN), which uses prospective audits and feedback to help clinicians make better antimicrobial treatment decisions.
Davidson says physicians respond well to data, which makes prescribing data collection and sharing important elements of efforts to reduce the inappropriate use of antibiotics. The program tracks physician prescribing habits and contacts them when necessary.
"It's really individual-patient based and individual-physician based," Davidson says.
In 2014, its first full year of reporting, hospitals in the ASN saw about an 8% drop in days of therapy and a decrease of more than 12% in cost for antibiotics. In some classes of antibiotics, a 20 to 30% decrease in usage, was observed, Davidson says.
As part of its new commitment, Carolinas HealthCare System plans to expand its ASN to include 13 inpatient and rehabilitation facilities by the end of the year, and in the longer-term, to expand stewardship across the system's 900 care locations.
"Clinically, the focus on antibiotic stewardship for the last 10 years has really been in the inpatient [side]," Davidson says. "To really move the needle on antibiotic resistance, you can't just limit it to inpatient facilities."
The health system also plans to incorporate information about antibiotic indicators and appropriate duration of therapy within its EMRs and to develop disease-specific care pathways for antibiotic prescribing best-practices.
Doug Smith, MD
Davidson believes the federal government will move toward requiring hospitals to report their rates of antibiotic use, just as they report rates of healthcare-associated infections. Davidson says Carolinas will provide input to the CDC about what a national stewardship agenda might look like.
"It's a team sport," Davidson says of stewardship efforts. "Everyone in the healthcare organization needs to have a stake in this because it's a huge public health issue."
"Generally if you give doctors the right data they'll make the right decisions," says Doug Smith, MD, associate chief medical officer for Intermountain Healthcare. The Salt Lake City, UT-based system uses a physician dashboard that drills down into individual prescribing data at the physician and the clinic level.
Intermountain, which has 22 hospitals more than 185 physician clinics, and an affiliated health insurance company, has set a goal for itself as part of the White House commitment: To reduce inappropriate outpatient antibiotic use for upper respiratory conditions by 50% by 2020.
"We've already built [the] tool," Smith says. "Now we can feed that data back to our clinicians."
All Intermountain Healthcare acute care hospitals are additionally committed to having antimicrobial stewardship programs by the end of 2017.
"One of the challenges we see going forward… is how to you do antimicrobial stewardship in a small hospital?" Smith says, because of challenges such as lack of access to infectious disease specialists.
The system is currently trying to answer this question by conducting astudy of 15 hospitals randomized into three groups, which are receiving different levels of intervention, ranging from high to low intensity. "It'll then allow us to decide what level of intervention makes the most sense," Smith says. "It'll also inform the whole country."
The study is supported by a grant from Pfizer and The Joint Commission.
Intermountain has also pledged to support telemedicine efforts to extend infectious disease expertise to rural healthcare settings.
APIC (the Association for Professionals in Infection Control and Epidemiology)
"Infection prevention has seen the firsthand the rise of antibiotic resistance," says Kirk Huslage, RN,vice-chair of APIC's public policy committee and associate director for the North Carolina Statewide Program for Infection Control & Epidemiology.
Kirk Huslage, RN
In conjunction with its participation in the White House forum, APIC has released an advocacy agenda to promote antibiotic stewardship. At its heart is education and public policy.
"We're doing a lot of education," Huslage says. "Not only just clinicians… but also doing a lot of consumer education through our Infection Prevention and You campaign."
In addition, an APIC letter-writing campaign encourages members to ask Congress to support funding for the CDC's National Healthcare Safety Network and Prevention Epicenters Program; the CDC's Antibiotic Resistance Solutions Initiative; and the Advanced Molecular Detection Initiative. APIC is also supporting relevant legislation, such as the Developing an Innovative Strategy for Antimicrobial Resistant Microorganisms (DISARM) Act, Huslage says.
At the hospital and healthcare system level, Huslage says getting buy-in from executives is critical to the success of stewardship programs. "If that's not there, the programs don't go anywhere."
Beyond buy-in, it takes a commitment and cooperation across the care-continuum. "This effort doesn't really go in a silo," Huslage says.