In the absence of adequate published guidance, Iowa researchers produce a five-tiered classification of procedures, encompassing "clean, aseptic, sterile-superficial, sterile-invasive," and "surgical-like procedures."
A team of physicians from the University of Iowa Hospitals and Clinics has put forward a strategy that aims to standardize infection prevention guidelines for procedures performed outside the operating room.
The team contends that for most procedures, from skin biopsies to chest tube insertions, there is no authoritative guidance on infection prevention.
The strategy emerged from a hospital epidemiology leadership meeting, says Vincent Masse, MD, the study's lead author.
They discussed a scenario whereby an interventional radiologist had been asked to wear a surgical hat and a mask while doing a fine needle aspiration. The radiologist had not worn the protection in 20 years of doing the procedure.
So the clinician asked what the hospitals policy was.
"Not only were we unable to provide evidence to support this practice, but we also had no comprehensive policy regarding infection prevention practices for medical procedures performed outside an operating room," the authors write.
Masse and his fellow researchers looked at what kind of research had been done.
"We realized that there is very little data for most procedures and there is no simple model to follow," he said.
The researchers reviewed the available literature: textbooks, technical notes, and practice guides, but described them as unhelpful.
The Spaulding Classification guides the disinfection of devices and equipment, but does not go far enough, in the eyes of the study authors. "It would be nice if there were a similar model for outside-the-OR procedures," says Masse.
"Most of these sources referred, at some point, to 'your local policy'," they write.
The 5-Tiered Proposed Model
So Masse and his team used the data they could find combined with their own clinical experience to produce a five-tiered classification of procedures, encompassing "clean, aseptic, sterile-superficial, sterile-invasive," and "surgical-like procedures."
Each tier lists examples of procedures and whether gloves, masks, surgical gowns, and hats are needed. A skin biopsy is listed as "aseptic," which does not call for a surgical drape. A bone marrow biopsy is listed as "sterile superficial" and does require a drape.
He says that while it is not data-driven, the paper presents a sound first attempt at offering guidance. "Sometimes, there is just no data available to tell you what is optimal."
Clinicians often make decisions based on what would be appropriate in similar, but not identical situations. And while it is good to allow individual physicians to make the call, some may not be providing optimal care, Glatt says.
Don't Overdo It
The tiered system needs more review, but appears to offers a logical alternative.
"It's always easy to be very stringent – to say do everything, treat every procedure like it's the OR," he said. "But, that's not cost-effective, it's burdensome, and sometimes difficult to do. "
She thinks the paper overstates the lack of guidance for procedures outside of the operating room, and notes that the Spaulding Classification guide the practices and equipment needed to protect both the providers and the patient.
Those guidelines describe require precautions such as hand hygiene and the use of PPE – personal protective equipment.
The study authors do note that Standard Precautions cover procedures such as a lumbar puncture. There are also guidelines calling for barrier precautions for central venous catheter placement and steps for the prevention of catheter-associated urinary tract infections.
For most procedures, "healthcare personnel do as they were trained, and pass the details along when they train someone new. This is true for the technical elements and the type of personal protective equipment used," they write.
The authors are clear that the paper is "intended to be a starting point for future efforts and not to be definitive."
Masse describes it as the group's "honest opinion…This is a very focused assessment. It's not a systematic literature review. I'm happy to get it out there. It's an idea to start a discussion."
A study of sepsis cases using EHR rather than claims data finds little change in either incidence of infection or mortality over a four-year period.
Is the incidence of sepsis stable or is it increasing?
Awareness campaigns and clinical education programs would suggest a rise in the potentially fatal condition, which the Centers for Disease Control and Prevention describes as a "complication caused by the body's overwhelming and life-threatening response to infection."
Now, a study based on data from electronic health records suggests that the rate of sepsis and it corresponding death rate may have stabilized between 2009 and 2014.
The study authors make the case that data from EHRs offers a more accurate measure of the condition than billing data, which indicates that sepsis rose more than 10% during the period, but that mortality declined.
Not that the findings of the study are anything to celebrate.
More than 20% of them died in the hospital or were discharged to hospice.
Study author Chanu Rhee, MD, says the findings will give hospitals an objective way to measure sepsis incidence rates – something health systems have been trying hard to bring down.
Rhee said his hospital, Brigham and Women's in Boston, has numerous programs designed to educate staff about sepsis. "While we do that, we need objective ways to assess the impact of those efforts," he says.
"If we rely on diagnostic codes and claims data, we can easily get fooled about the impact we are having."
Sepsis is notoriously hard to recognize. There are no diagnostic tests for it and its symptoms are not unique to the condition. At the same time, it's fast moving and potentially deadly. The treatment: antibiotics, which hospitals have been trying to use less frequently to prevent resistance.
Related: Meet the Doctor Behind the $40 Sepsis Treatment Critics Call 'Hocus-Pocus'
The attempt to quantify the overall incidence of sepsis has also been challenging.
The JAMA paper notes that other studies have come up with a range of incidence levels, from 900,000 to 3.1 million per year. Based on the EHR clinical findings, 1.7 million patients in the US will develop sepsis and 270,000 will die from it.
"I think awareness sepsis is rising, diagnosis and coding for sepsis is increasing, but… is the disease is becoming more common? I think our study cast doubt on that," Rhee said.
The debate over the value of claims (or billing) data versus clinical data is ongoing, but it usually doesn't find its way into the hospital setting. Still, as EHRs become the norm rather than the exception, the study suggests hospitals have the opportunity to more precisely identify and address potential quality trouble spots by running their own numbers.
"Claims data has traditionally been used because its readily available," Rhee said. "Chart reviews are great. You can't beat the granularity of expert physicians reviewing the charts. The problem with that is the resources and time involved. We believe EHRs have a nice balance of both."
An 'Outstanding' Study
Craig Coopersmith, MD, is a surgeon and researcher at the Emory University School of Medicine. He calls the study "outstanding" and agrees that claims data can be subjective.
He notes that professional organizations and grass roots advocacy groups have been working together to raise awareness of sepsis. Increased recognition often leads to more diagnoses, not a rise in incidence.
Claims can also be confounded by providers who may be upcoding to maximize reimbursement. Clinicians who are not knowledgeable about sepsis can also miscode the condition, Coopersmith says.
"Accurate coding, even when everybody has the best possible intentions, can be challenging," he said.
In addition to offering a more precise accounting, Coopersmith said Rhee's group has "operationalized" its findings by modifying the existing definition of sepsis that could be used in EHR analysis at any hospital.
"You have to build a program in order to query your EHRs, but it can be done relatively simply," he said.
Incidence of Sepsis Remains High
The researchers looked at clinical data from 2.9 million patients treated in 409 academic, community and VA hospital hospitals. In addition to incidence and mortality, they learned that sepsis is present in 35% of all hospitalizations that end in death. (The CDC notes that most cases of sepsis are acquired outside the hospital.)
Rhee says he wants to be clear that his group and their findings should not be interpreted as minimizing the threat of sepsis. The incidence rate they found is high. He thinks more work needs to be done to better prevent and treat sepsis.
His team's finding offers a new approach to surveillance: "We need to makes sure we have objective and efficient surveillance methods so we can target our interventions and understand their impact and know what is working and what it not working."
The relationship between transitions of care and medical errors is so clear, that leadership teams should be aware of what's required to protect patient safety.
What happens at a hospital when a patient is transferred among care teams, treatment facilities, or from hospital to home?
If the process doesn't go much beyond white boards or wheelchairs, it is time for an update.
That's essentially the advice of The Joint Commission, which has released a sentinel event alert on communications during transitions of care.
"While it sounds simple, a high-quality hand-off is complex," says the document. "Failed hand-offs are a longstanding, common problem in healthcare. Nevertheless, gaps in communication during hand-off processes continue to exist, thereby increasing patient safety risk."
The relationship between transitions of care and medical errors is so clear, that some of the key statistics in the document come from the research arm of a malpractice insurer.
The sentinel event alert is not a notice of a new standard hospitals will have to meet as part of the commission's accreditation process. Instead, it is designed to give providers and hospital administrators a heads-up on potential problem areas.
Ana McKee, MD, is the executive vice president and chief medical officer of The Joint Commission. The organization decided to issue the alert, in part, because the number of handoffs has increased dramatically, she says, and because communication during hand-offs can be a challenge for hospitals.
A Call for Leadership
She thinks problems with handoff have been ignored or invisible for a long time. Hospital leaders need to know what is at stake.
"If it is not recognized as a high-risk opportunity, it goes unaddressed," she says. "We are still working to educate leadership of the risks of hand-off communication"
One heralded approach to hand-offs is the I-PASS program. A 2013 pilot study at Boston Children's Hospital produced dramatic results. Medical errors declined from 33.8 per 100 admissions to 18.3 per 100 admissions after the I-PASS program was adopted.
Implementing the approach more broadly, however, may be difficult.
Across town, staff at the 1,000 bed-Massachusetts General Hospital more than 6,000 doctors, nurses and therapists have been trained to use the program. That was the easy part, according to a study on the first phase of their effort published in the journal BMJ Quality and Safety.
"I-PASS education is straightforward, whereas assuring consistent and sustained adoption across all services is more challenging, requiring adaptation of the basic I-PASS structure to local needs and workflows," the authors write.
McKee says that's not surprising; change is always difficult.
"That's the change management challenge," she said. "It has to be done artfully, strategically and in a way that it can be sustained."
Researchers at the University of Kentucky are part of a research project known as Project ACHIEVE, an acronym for "Achieving Patient-Centered Care and Optimized Health in Care Transitions by Evaluating the Value of Evidence."
In 2015, members of the project team traveled to 22 sites, including community hospitals and academic health systems, and talked to 810 people including management, transitional care teams, community partners, patients, and family caregivers.
They published some of their findings in the September edition of The Joint Commission Journal on Quality and Patient Safety.
Among those findings: In multiple hospitals, members of "leadership teams" reported that "making care transitions a strategic priority among the executive leadership team created an organizational culture focused on transitional care, which in turn improved the quality of transitional care services within the organization."
Mark Williams, MD, one of the study authors, suggests that administrators learn how transition are handled in their institution if they don't already know. He suggests they find out whether staff are engaged in the practice of "teach back" with patients and with each other.
Clinicians explaining discharge instructions should be follow up with something like this, he says. "'Teach it back to me. Tell me, what you are supposed to do when you leave the hospital.'"
Williams thinks getting confirmation of understanding, a skill called "readback," is critical. He notes that some hospitals have made it a core competency for nurses.
It also happens to be the skill that providers at Mass General have found to be the most challenging feature of the I-PASS approach to implement.
Many clinician "find it awkward," and unworkable in discharges that don't occur face-to-face methods, according to the study.
McKee at The Joint Commission says, "there is a lot of opportunity for improvement" in the way the C-suite addresses this issue. They should be overseeing the process.
Data is thin, but the search is on for the best ways to measure the quality of healthcare that is being delivered via telehealth to remote patients.
Remember when you had to go to the video store to catch up on (and return) the movies you wanted to see?
Fast and cheap digital bandwidth enabled the digital streaming that essentially put video stores out of business. Now broadband is changing the way healthcare is delivered.
It is now even cheaper and faster to move large data files than it was only a few years ago. But how good is the quality of care that is delivered via a video screen?
Providers say that for many consults, telemedicine is just as good as in-person care delivered in a clinic or exam room. But the evidence to support these assertions is thin.
Now comes the National Quality Forum's attempt to start the discussion on quality measures for telemedicine. The 80-page report does not endorse any measures – although it suggests some candidates. The report instead offers "a framework to support the development of measures."
A Step Forward
"It's another example of how the field is maturing," says Joseph Kvedar, MD, the vice-president for connected health at Partners Healthcare. His operation has been holding annual Connected Health meetings for 12 years. The next one is next month in Boston.
Telemedicine was initially seen as a way to extend access to care to rural communities. That was a couple of decades ago. Now "anything that has to do with connectivity seems be moving at the speed of light," Kvedar says.
Quality remains a hurdle, however.
One fast-growing area is teledermatology and other direct-to-consumer services. Walgreens got in the game this past summer with its "Dermatologist on Call" program. A company called First Derm invites customers to send in a selfie for a diagnosis.
Speaking in industry-wide terms, there is concern about the lack of internal policing of direct-to-consumer sites, says Kvedar, a dermatologist by training.
Right now, telemedicine is governed by and subject to some federal rules and a patchwork of policies and regulations that vary from state to state.
Many state laws call for parity in payment, but coverage varies from payer to payer. Still, US hospitals are plugged in. More than 80% report using at least one "connected health tool" according a 2016 survey from The Healthcare Information and Management Systems Society (HIMSS).
The survey also found that 67% of hospitals report deploying multiple tools from a list that includes telemedicine, phone apps, patient portals, text messaging, and patient monitoring.
Divergent Standards for Telemedicine
Brian Wayling notes that standards of care and practice models diverge widely across the broader practice of medicine. He is the assistant vice president for telemedicine services at Intermountain Healthcare, a 22-hospital health system based in Salt Lake City, UT.
"We are seeing evidence of the same thing in telehealth, which should be no surprise, simply because the standards of care are not well established," he says.
Intermountain is considered a leader in telemedicine, offering services for seven different specialties including cancer and mental health. It has 1,200 access points, which are either rooms or mobile carts equipped with cameras to serve remote patients.
Wayling knows telemedicine has limitations, both in the type of care it can deliver and the quality of information it can return to providers. With that in mind, if a provider in his program isn't comfortable with a video visit, the patient gets a face-to-face appointment.
Steps are being taken to address quality concerns. For example, the use of antibiotics in the system's telemedicine program is in line with the hospital's guidelines.
"Some of the direct-to-consumer provider groups are readier to prescribe," Wayling says. "We take a more cautious approach."
Intermountain also uses the system to validate the use of clinical practice models. Wayling thinks adherence to the models is going up because of the telemedicine validation.
Sabrina Smith of the American Telemedicine Association says she sees the NQF report which as an "important first step" in the discussion of quality issues for telemedicine.
ATA reports that it represents 10,000 industry leaders and is promoting quality care through practice guidelines, she says. The group has also brought in a third-party partner to boost its accreditation efforts.
ATA wants telemedicine to be governed by the same health quality measures that apply to in-person exams, Smith says.
Quality data looks good in ads and on hospital and health system websites. A little too good at times.
A hospital website would seem like an obvious place to deliver healthcare information, especially information about the quality of services. But, for the uninitiated, the marketing piece of the website may be difficult to distinguish from the clinical piece.
Not that hospitals shouldn't promote themselves. But as more data about infection rates and readmissions becomes available, health systems need to ensure that the information they share actually reflects the quality they offer.
That's the call from Peter Pronovost, MD, and his team at the Johns Hospital Medicine.
They make their case in a JAMA Viewpoint essay published online earlier this month. This is not Pronovost's first call for standards and auditing. But this latest call is directed specifically at hospitals and health systems. He thinks they need to take the lead.
"Before healthcare provider organizations ask others to meet standards, we ought to make sure our own house is in order," Pronovost said in a telephone interview with HealthLeaders.
In some cases, hospitals may be misusing quality data in ways that are at best confusing, and at worst deceptive, he says.
"There is some data that hospitals might be incentivized to make themselves look more positive when they report publicly," he said. "It wouldn't surprise anyone that that happens."
Pronovost found one hospital website urging patients to "Come to us, we have no infections." Without any information about which type of infections, or how and how long infection rates were measured, the claim is essentially meaningless.
But the JAMA piece doesn't dwell on misleading hospitals ads. Pronovost says his goal is to offer a "positive step forward to begin to mature the field. "
The opportunities for getting it wrong grow with each data point and every step toward greater transparency.
Hospitals and health systems now have volumes of data they can use (or not use or misuse) to promote the quality of their care, such as mortality rates for specific procedures.
Consumers are now accustomed to comparison shopping and there are plenty of places for them to do that, from Medicare Compare to state-run websites, to Facebook. But, not all are patient-friendly or scientifically accurate.
Yael Schenker, MD, a researcher at the University of Pittsburgh, has explored the issue. She looked at 400 ads from more than 100 cancer centers and found that they promote cancer therapy with "emotional appeals that evoke hope and fear while rarely providing information about risks, benefits, costs, or insurance availability."
The public trusts information from hospitals, she wrote in response to an email query.
"Inaccurate or imbalanced information on hospital websites should therefore be an area of significant concern," Schenker wrote.
"The proposal [for standards] represents an important opportunity to clarify the line between quality reporting and advertising, and to provide value to the public."
One big question is who will hold hospitals to the standards? The Hopkins team proposes an outside entity that would "make transparent the extent to which reporting by each organization adheres to these standards."
If that sounds vague, it is meant to, says Pronovost. "We wanted to use this piece to initiate a conversation rather than offer a conclusion."
A full third of the JAMA piece is devoted to the challenges of the approach. For example, the piece acknowledges "numerous calls for less measurement in medicine rather than more."
The authors argue the standards approach "could help to complement this effort by seeking to improve the accuracy of reported measures." Again, just how more auditing would mean less measurement is left open for discussion.
But the aggregation of data into rankings or scores is not the issue. In fact, Leah Binder of the LeapFrog Group and Ben Harper of U.S. News are listed as contributors to the JAMA piece.
It's the measures themselves, the evidence supporting them, and the way they are presented that are the issue.
For an example, Pronovost returns to the ad from the hospital claiming a zero infection rate.
"On the surface, it is sounds really good. No infections. The public probably trusts that as positive. [But] scientifically, it is kind of a meaningless statement."
No infections for a week is different than a measure of multiples type of infections over five years.
In the past, and in the JAMA piece, Pronovost has argued that quality reports should be audited in the same way that financial statements are audited.
"Your company's financial statements are audited in a systematic way, just as IBM's and Johns Hopkins' are," he said. "When people file a financial statement, there is some confidences that what was put in there is accurate. And that doesn't exist right now in health care quality."
No one knows for sure how long a patient should take an antibiotic, new research suggests.
Conventional wisdom is that patients who fail to complete a prescribed course of antibiotics put themselves and others at risk of antibiotic resistance.
But a recent analysis fails to find evidence to support the notion and throws conventional thinking into question.
The World Health Organization endorses the full course of infection-fighting drugs, as do clinical recommendations in Australia, Canada, the United States, and Europe.<
The authors of a recent BMJ analysis point out, however, that in most cases, no one really knows how long a patient should take an antibiotic.
They write that the idea of "stopping antibiotic treatment early encourages antibiotic resistance is not supported by evidence. At the same time taking antibiotics for longer than necessary has the opposite effect, increasing the risk of resistance."
Tim E.A. Peto, a professor of infectious disease at Oxford Biomedical Research Centre in Oxford, England, is one of the study's authors. His group contends that there is a need for more evidence on the optimal course of antibiotic treatment.
A competent physician, for example, may have a good sense of an individual patient and know when it makes sense to stop treatment. Others will need guidance.
Peto's team is looking at one approach, instituting a formal review 24 to 48 hours after starting antibiotics, to assess the need to continue.
"What we haven't got is a nice algorithm that people can follow without thinking," he said. "That needs to be developed."
A hospital may have an antibiotic stewardship program, but "there may not be a good evidence base behind what they are prescribing," Peto says.
"It's just that most of the guidelines thus far have been based upon older studies," Pasko said. Those studies don't include the advanced antibiotics in use today.
Pasko says her group is optimistic about newer studies suggesting a shorter course of antibiotics might be appropriate for certain bacterial infections, such as sinusitis. If additional research shows good outcomes with shorter durations, then her group would partner with other organizations, such as the Infectious Diseases Society of America, to consider changes to the guidelines.
Evidence seems to be moving in the direction of the shorter course.
Several studies have suggested patients with community-acquired pneumonia can be treated for five days, not ten. Clinical researchers at several US academic medical centers are currently recruiting volunteers for trial that will test a short course for children with the condition.
Once the evidence is in, getting providers to apply it is the next task. That involves changing long-entrenched ideas and behavior, and that's never easy.
A paper published in June reported that fewer than half of antibiotics prescribed to veterans with respiratory infections or cystitis at one VA center were done so according to guidelines.
Most cases involved the use of an antibiotic when it was not needed.
Daniel Livorsi, an infectious disease specialist at University of Iowa Hospitals & Clinics, is one of the authors on that study and several others looking at physicians antibiotic prescribing patterns.
Doctors tend to give longer courses of antibiotics longer because they are more concerned about an infection than about a patient developing adverse effects, he said. In some cases, doctors are not aware of the evidence.
Even when they were "we found that it is really hard to get doctors to change their prescribing behavior," Livorsi says. One way to do it is through audited feedback for physicians.
Livorsi thinks focusing on the length of therapy is useful. Doctors can agree on a diagnosis of an infection. A conversation about how long to treat is an opportunity to bring evidence into the discussion, he said.
Even without definitive evidence, prescribers can rely on diagnostic tools and expert opinion to help guide decisions about how long to continue care, he says.
After interviewing 30 physicians in two Indianapolis hospitals, Livorsi and his team concluded that " that antibiotic decisions are not entirely based on reason." Over use is "recognized, but generally accepted," according to a 2016 paper on the study.
Here's how one resident put it: "When it is 3:00 in the morning, depending on how busy you are, the easiest solution is to throw vancomycin and piperacillin-tazobactam at every patient because you do not have time to read the confusing guidelines that tell you 16 different things you would potentially do."
Pasko of ASHP recommends bringing the hospital pharmacist into the decision-making process. In some cases, "we have resources such as diagnostic tests that we can use to determine whether to stop or extend therapy," she says.
The debate continues over whether hospitals that treat a lot of low-income patients should get a break on readmissions penalties levied by Medicare.
Intuitively, it makes sense. Using readmissions as a measure of high quality care means that readmissions measures should be adjusted for hospitals that treat sicker patients.
Data shows that some social factors, such as the trappings of poverty, can make patients sicker.
So, should hospitals that treat a lot of low-income patients with sub-standard housing and limited access to healthful food get a break on readmission penalties levied by Medicare?
It is a raging debate in health policy world. The latest development comes from the National Quality Forum, a national clearinghouse for quality measures. The group has declined to endorse adding social risk factors to most of the Centers for Medicare & Medicaid Services readmissions measures.
The report puts it this way:
"At this time, the CSAC (Consensus Standards Approval Committee) supports continued endorsement of the hospital readmission measures without SDS (sociodemographic.) adjustment based on available measures and risk adjustors."
The next sentence is a bit clearer: "The CSAC recognizes the complexity of the issue and that it is not resolved."
It is far from resolved, some would say.
Medicare's readmission measures adjust for age, medical history, and comorbidities. But some argue that it is unfair to expect safety-net hospitals to be as effective in preventing readmissions as other facilities because their patients are sicker.
Others argue that an adjustment to the readmissions measures could give poor quality hospitals a pass.
Safety Net Hospitals: Socioeconomic Status Matters
Beth Feldbush is the group's vice president of policy and advocacy. She says the NQF findings are not a surprise. Still, NQF is not closing the door on adjusting readmission rates. More and better research is needed, she says.
"Throughout the process, NQF had acknowledged that the lack of data is problem. Without data, it is hard to come to a conclusion one way or another."
John B. Bulger, DO, is the chief medical officer, population health at the Geisinger Health System, a 12-hospital system based in Danville, PA. He is also the co-chair of the readmissions committee of the NQF's measure endorsement project.
An Evidence-based Stance
Bulger says the committee was very open minded in considering the possible impact of social factors on readmission measures. But because committee members can only review the measures that are brought before them, their task is to make recommendations based on the reliability of those measures.
"We purposely did not want it construed that the committee thinks social determinants don't matter, or [that] socioeconomic status doesn't matter," he says.
"That is absolutely not what our conclusion was. The conclusion was, as it was tested in the measures that were in front of us, it didn't make a discernable difference."
Detractors: Adjustments Would Create a Double Standard of Care
Harlan Krumholz is a cardiologist and the director of Center for Outcomes Research and Evaluation (CORE) at Yale. His team helped develop CMS's readmission measures. In a written response to questions from HealthLeaders, he pointed out that many hospitals serving patients with low socioeconomic status do well with readmissions.
It is not clear, however, that those that do poorly do so because of social risk factors not accounted for in the readmission measures, he noted.
It is possible that these patients get less attention or less help in the transition from hospital to home. But overall, there is practically no effect in adding socioeconomic status to the risk models, according to Krumholz. His team published findings last summer asserting this idea.
Krumholz is in the camp, along with The LeapFrog Group and Consumers Union, that believes adjustments will make it difficult to identify poor performing hospitals and will essentially create a double standard in quality of care.
Feldbush said her member hospitals are "insulted" by the suggestion that at safety net hospitals provide inferior care.
"That's implying that our patients' lives are not valuable and our hospitals don't care," she said, "That is patently false."
Both NQF and safety net hospitals agree that more research is needed to examine the link between readmissions, social risk factors, and quality.
In the meantime, Congress has stepped in. A provision in the sprawling 21st Centuries Care Act, a grab bag of measures passed late last year, mandates that CMS start adjusting readmission measures to account for the social determinants of health.
The agency has proposed an adjustment based on dual eligibility the status of patients who are old enough to qualify for Medicare and needy enough to also qualify for Medicaid.
For a full update on the debate, see the comments section of the proposed rule in the Federal Register. Some systems and groups support it, others want more data from CMS, and others would like to see the measures refined.
Ranking hospitals means constant tweaks and occasional errors in the effort to get it right. The effort is still a work in progress, but transparency and access to better data would help move things along.
A headline this month in The Boston Globe about a VA hospital in Manchester, NH couldn't have been any clearer: "At a Four-star Veteran's Hospital: Care Gets 'Worse and Worse.'"
It was remarkable, given the fact that late last year, the VA had "raised Manchester's quality rating from three stars to four, putting it in the top third of the entire VA system," according to the Globe.
Two days later, US News & World Report announced that it was delaying the official release of its annual hospital rankings after hospitals found errors during a preview of the data.
Measuring the quality of hospital care is an extremely complicated endeavor, both technically and politically. And the stakes are higher than ever for hospitals now that the Centers for Medicare & Medicaid Services has linked payment to quality.
Hospital ranking programs take that data to consumers, who are increasingly shopping around for health services. But when media reports challenge the analysis of the data, the question emerges: Are consumers losing confidence in hospital rankings?
Brian Kelly, the editor and chief content officer at US News, doesn't think so.
"Our audience has grown," he says. "We have 100,000 people a day coming to us to look at this information. And we feel very good about it. We think we are providing very comprehensive and very clear information for patients making decisions."
The discrepancy in this year's data emerged when hospitals reviewing their US News rankings prior to the public release pointed out "some things that looked out of whack," Kelly says.
His team went back, found a calculation error, fixed it, and rechecked all of the data. The publication date was moved from August 1 to August 8.
Like other ranking programs, US News is constantly refining its methodology.
This year's changes were particularly challenging, Kelly says.
Analysts expanded the definition of transfer cases to be fairer to hospitals that accept high-risk patients. They used dual eligibility for Medicaid and Medicare to account for socioeconomic status in the calculation of mortality risk in 12 specialties. (CMS is also considering using dual eligibility to adjust for social risk factors.)
And, US News dropped two of the six patient safety indicators (PSI) that it used last year. Both were for complications so uncommon they had little impact on rankings. (That move tracks with concerns about the validity of the PSIs.)
The Leapfrog Group
Even those with confidence in one set of quality measures find it's not unusual to find the same hospital ranked highly on one site and not on another.
Leah Binder, the president of The Leapfrog Group, does not think that's a problem. She likes to point out that each ranking program, including Leapfrog's, has its own formula for evaluating quality. Variation in results is expected.
Consumers are used to that, Binder said. She says reads reviews of products on the Amazon website and trusts them more when they don't agree with each other.
"The public isn't frustrated," she says, but "hospitals are frustrated when they see that various reviews differ."
That's because they've been late to the game of reviews and ratings, Binder says.
"[Hospitals are] struggling with the new world. I understand that and I'm sympathetic, but it is the new world and it's not going away. It's time for them to start to lean into it and get better at coping with transparency."
Lisa McGiffert directs the Safe Patient Project for the Consumers Union, a policy arm of the Consumer Reports organization. (It is best known for ranking electronics and cars, but the group also ranks hospitals.)
She thinks consumer are confused. It can be hard to get it right and they see conflicting results that emerge from different rating programs. Quality review is a complicated process made harder by limited access to good data.
"The state of the art is not refined yet," McGiffert said. "There is a lot of data that is not available. So, what we have available is often not exactly what we would like to have."
At the same time, before the hospital rankings started to emerge, there was little for consumers to go on, McGiffert said.
"Every five to ten years a researcher would do a project on three or four hospitals and they would extrapolate," she said.
US News has been in the ranking business for 27 years. Kelly says that it sees its data as just one of multiple information sources patients and providers can take advantage of when making healthcare decisions.
The site is "not a one-stop shop. It's not Amazon," he says.
"To me, it is part of the consumer journey. The consumer has to be better informed to make decisions. But they can't assume that the decision is going to come from a page on the Internet."
"Collaborative healthcare" describes the necessary shift away from "pseudo patient-centeredness," says an advocate for patients.
"Collaborative healthcare," says writer, consultant, and patient advocate Michael L. Millenson, is "a shifting constellation of collaborations for sickness care that is shaped by people based on their life circumstances."
Writing in the BMJ, he argues that as patients gain more control and seek out non-traditional sources of care, providers will have to be less paternalistic. That means being part of, but not always the center of "a well-being and care relationship."
Millenson spoke with HealthLeaders Media recently about how the concept of collaborative care will help physicians, hospitals, and health systems respond and offer true patient-centered care. The transcript below has been lightly edited.
HLM: Where did the concept of collaborative health come from?
Millenson: I've been going to Health 2.0 meetings for many years. I could see the rise of Internet and participatory medicine, as well as concerns about the social determinants of health.
Yet, they were treated as different phenomena. So, I started to think there was a common theme here that has to do with a loss of control by the profession and the entrance of non-medical actors.
HLM: Why does that lead you to say "patient-centered is no longer enough? "
Millenson: The term patient-centered doesn't fit in these circumstances. This is a description of something that is happing outside the healthcare system's control and will sometimes exclude the traditional healthcare system.
HLM: Why is this change such a challenge for doctors, and how can they respond?
Millenson: This is difficult for medical professionals to put their minds around, that they can be excluded. Talking about shared information, shared engagement, and shared accountability starts to give them a framework to adjust to this.
I want the healthcare systems to adapt and be a good partner… It's better for patient. It's better for the healthcare system. But to do that, they have to understand that they are going to have to give up a measure of control so they can face the future.
This concept [of collaborative care] is dynamic and it recognizes shifting boundaries.
That has not always been the case. It's an ecosystem. Sometimes I'll be engaged with my health plan. I might be engaged with another vendor, and not with my doctors.
Sometimes I want my doctor to engage with those people… It is dynamic. This is what makes it difficult. Boundaries blur.
HLM: You talk about retail stores collecting fitness data and widespread access to interactive web sites. Is that why you mean by a shift of control away from doctors?
Millenson: It's saying that we, the individuals, will control when we interact with the healthcare system and, often, how we interact with the healthcare system.
It may be something that looks like a traditional relationship; it may be a very different relationship. That is going to originate from patients and our collaboration with you (the provider), not your pseudo-patient centeredness.
HLM: Can you describe pseudo-patient centeredness?
Millenson: Most of what is done as patient-centered care is customer service.
Customer service is great, but genuine sharing of power, being out in the community, that's what hospitals need to do.
Also, much of what the healthcare system talks about as engagement and patient centeredness is really compliance in nicer language. 'I want to engage you so you understand why you should do what I told you to do.'
Sometimes there is nothing wrong with that. Your doctor told you take the meds and you ought to take your meds, and now your providers are going to engage you in a different way so you take your meds.
But often, for the provider, it is simply 'I came to a decision. This is what I think you should do and I'm going to engage you until you realize that I'm right and do what I told you.'
HLM: How does the recognition that meeting social needs such as housing and transportation fit into the concept of collaborative health?
Millenson: Theoretically in the best of all possible worlds, our society would be taking care of public health and homelessness…Even if you are middle class and you are going home all alone, because you are elderly there would be help from a social service agency or a church or a synagogue.
None of this would be the responsibility of the healthcare system, but that is not the real world. What's happened is we are making social needs the responsibility of the healthcare system and breaking down the boundaries.
Now all of the sudden if you [the providers] are talking to me about my need for a wheelchair ramp and my home life, you are engaging me in a different way.
If now my health plan is providing foods and someone from the plan calls and asks how I am doing, that changes my relationship with my doctor.
HLM: What do health systems need to know about this new paradigm?
Millenson: If they wait until they are forced out of the old system, if they try to cling to control for too long, they will lose out and patients will lose out.
People who go into healthcare go into it to do good. People who decide to become hospital administrators, their second choice was not headge fund manage. They care about people. They want to do well, but they get caught up in the system.
They should understand that the relationships are changing and they need to change. I think this is a great opportunity for hospital to reset.
When there is change, and you act on the change, you can come out on top.
HLM: Will collaborative care save money?
Millenson: The real answer is we don't know. Everything is always touted as cost saving. We don't know whether or not these electronic interventions are truly going to be cost saving. We do know that addressing the social determinant of health saves money.
Data derived from the non-medical drivers of a patient's health can improve quality of care and enrich the utility of so-called intelligent machines.
The small crowd at Tuesday's "On the Front Lines of Healthcare" event in Boston included a patient activist, a state health systems analyst, and even a doctor who was in town for a gastroenterologist meeting.
But the gathering, held in an airy space on 33rd floor of a downtown high rise, was not a professional or academic meeting. Organized by The Atlantic and the STAT, a national science and medicine publication, the public event offered an ambitious overview of a range of weighty issues.
Three big topics that resonated throughout the day: the social determinants of health, data, and machine learning—computers that can digest data and use it to answer questions about patient care.
For hospitals and health systems, the sessions presented different scenarios of how the three can meet.
The message: Data derived from the non-medical drivers of a patient's health can improve quality of care and enrich the utility of so-called intelligent machines, such as IBM's Watson.
The day started with what was described as a wide-angle lens on "The State of Health Care in America." Audrey Shelto, president of the Blue Cross Blue Shield of Massachusetts Foundation, made a major pitch for improving care by addressing social as well of medical issues.
There needs to be greater recognition than "what's involved in getting people healthy. And keeping people healthy only has a small amount to do with what happens in the clinical system," she said.
"A lot of it has to do with the issues of poverty. It's housing. It's food. It's all the things that make it hard to focus on your health."
After the panel, Shelto told Health Leaders that, in Massachusetts, the rise of accountable care organizations and a Medicaid waiver are allowing state providers to better address social needs.
For example, the installation of an air conditioner might do more to help a person with asthma than anything that happens during an office visit.
Still, breaking down the silos that separate health, social services, and housing is going to be a challenge, Shelto said.
There might be a way to do that by figuratively linking that AC unit to another machine, the Watson Health supercomputer. Much like Watson beat two humans on the game show "Jeopardy," Watson Health is an IBM supercomputer that can digest and analyze data, from individual patient records to the contents of millions of journal articles.
Watson Health offers products that promise to identify high-risk patients and suggest individualized care plans. Kyu Rhee, the chief health officer of Watson Health, said the predictive capacity of such programs would benefit from including information not found in clinical records.
"A lot of the data we have in health care is incredibly valuable, but it needs to be linked to the other data about the other determinants of health, whether social, environmental or behavioral," he said. "Where you live (has) as much of an impact as what doctor you have. You could argue even more so. "
And by adding information such as address or income, Watson may be able to do a better job of calculating what a patient needs.
On the population health front, Monica Bharel, MD, the Massachusetts Commissioner of Public Health, said she found that a lot of healthcare data sits in silos.
"We don't always do as good of job in taking that data and turning it into digestible, actionable information," she said.
Bharel called for "precision public health" that, much like precision medicine, uses data to target the most effective ways to address health issues. For example, Bharel's staff collected data from various sources that might impact on the opioid epidemic: death records, prescriptions drug monitoring records, and data from corrections and mental health agencies.
They were able to learn that only a small percentage of non-fatal overdoses patients were treated with medications that reduce the subsequent risk of death and actual overdose deaths by 50%.
"I really think this is the future of public health," she said.
Other sessions covered pending changes to the Affordable Care Act, opioid abuse, antibiotics, and medical education.