Everyone’s talking about quality. Encouraging high-value care is one of the stated objectives of the value-based purchasing program being rolled out by the Centers for Medicare & Medicaid Services (CMS). It’s also the subject of a new report to Congress from the Department of Health and Human Services (HHS), “National Strategy for Quality Improvement in Health Care” (www.healthcare.gov/center/reports/quality03212011a.html). For its part, SHM is placing added emphasis on a range of mentored quality-improvement (QI) initiatives for hospitalists.
Amid the flurry of activity, researchers are still attempting to address a central question that could determine the success or failure of many such efforts: How do you accurately measure what constitutes high-quality care?
Chris Murray, MD, DPhil, director of the Seattle-based Institute for Health Metrics and Evaluation, says the healthcare field traditionally has tried to assess quality in three main ways. One is to ask patients about their own experience: Were they satisfied with the level of care they received? Another is to assess what are known as process of care measures: Did the providers follow guidelines in providing patients with appropriate care? The third is to look at risk-adjusted outcomes: How did the patients ultimately fare?
Focused on Facts
CMS’s value-based purchasing program, at least initially, is focusing on the first two types of metrics. Process measures, Dr. Murray says, are popular in part because they’re relatively easy to gauge. For many of them, however, “the connection to improved health is a bit weak,” he says. Whether heart patients get a prescription for a beta-blocker drug, for example, doesn’t address the outcome. “The problem there is that we don’t know if they ever filled the prescription or if the patient takes the beta-blocker,” Dr. Murray says.
That uncertainty feeds into the larger question of how broadly to consider the accountability of providers when measuring quality. “Should we be thinking that quality means putting in place the supports required for a patient to actually achieve a good outcome, or just offering them?” Dr. Murray asks. The debate might be far from settled, but a growing number of tools and studies are at least helping researchers to connect the dots on how care is delivered, on what kind of practices might affect outcomes the most, and how a community’s underlying risks could influence both considerations.
A recent Annals of Internal Medicine study that scrutinized 30-day mortality rates for heart-attack patients found few quantitative differences between the top 5% and bottom 5% of hospitals, based on rates published on the CMS Hospital Compare website.1 Site visits and in-depth interviews with nearly 160 medical staff members, however, uncovered some telling distinctions.
The study found that following evidence-based protocols and processes, while important, likely is not sufficient to attain a high performance level in caring for heart-attack patients. Instead, “high-performing hospitals were characterized by an organizational culture that supported efforts to improve AMI [acute myocardial infarction] care across the hospital.” In other words, everyone from management to the medical staff was fully invested in QI efforts. Notably, the staff “reported the presence of physician champions and empowered nursing staff, pharmacist involvement in patient care, and high qualification standards for all staff.”
For its 13th annual HealthGrades Quality in America study, the Denver-based ratings organization HealthGrades tried to look more quantitatively at the link between top hospitals and patient outcomes. Its study coauthors culled data from roughly 40 million Medicare discharges from 2007 through 2009 for most of the nation’s 5,000 hospitals, and assigned ratings based on 26 measures related to mortality and complication rates (www.healthgrades.com/business/news/press-releases/hospital-quality-2010.aspx).