Tag: Outcomes

What Business Can Learn From Cleveland Clinic: How To Report Quality To The Public

Sep 5, 2012

By David Whelan

This summer I spent some time exploring how big teaching hospitals publicly report clinical outcomes to the public. For a given set of patients, how many live or die? And with what complications?

Patients can rarely find this information before getting elective surgery, or when deciding to commit to a given institution for a long-term course of treatment.

The problem is that right now there are few short-term incentives for hospitals to be transparent to the public. Patients are used to finding care based on proximity, word-of-mouth, and referrals from trusted physicians. (None of these are bad methods, by the way.)

Meanwhile insurers and public programs rarely pay for better outcomes, so they do not build networks that steer patients to quality. Paternalism pervades the entire system, where insurers and providers alike do not trust patients to shop for the best care.

Thus it is only the most long-term focused institutions that decide to become radically transparent. And there’s one that stands out above the rest: Cleveland Clinic.

The Ohio institution is already known for excellent care, especially in cardiology, for being a “well-oiled machine”, and for being an economic bright spot in the otherwise dreary environs of Cuyahoga County. (Sorry, as Pittsburgher it’s hard for me to say nice things about the Mistake By The Lake.)

But something else Cleveland Clinic should be known for is its public outcomes reporting. Every year since at least 2005 Cleveland Clinic has published Outcomes Books on its Web site. For each clinical category it releases data on mortality, complication rates, and patient satisfaction. It also mails paper copies of these books to specialists around the country as a kind of transparency-marketing. No other hospital system comes close to reporting this level of detail about the quality of its care.

To Gauge Hospital Quality, Patients Deserve More Outcome Measures

Aug 17, 2012• 13

By PETER PRONOVOST, MD

Patients, providers and the public have much to celebrate. Recently, the Centers for Medicare and Medicaid Services’ Hospital Compare website added central line-associated bloodstream infections in intensive care units to its list of publicly reported quality of care measures for individual hospitals.

Why is this so important? There is universal support for the idea that the U.S. health care system should pay for value rather than volume, for the results we achieve rather than efforts we make. Health care needs outcome measures for the thousands of procedures and diagnoses that patients encounter. Yet we have few such measures and instead must gauge quality by looking to other public data, such as process of care measures (whether patients received therapies shown to improve outcomes) and results of patient surveys rating their hospital experiences.

Unfortunately, we lack a national approach to producing the large number of valid, reliable outcome measures that patients deserve. This is no easy task. Developing these measures is challenging and requires investments that haven’t yet been made.

The addition of bloodstream infections data is a huge step forward. These potentially lethal complications, measured using Centers for Disease Control and Prevention’s methods, are among the most accurately measured outcomes. In addition, the science of how to significantly reduce these infections is mature, and hundreds of hospitals of all types and sizes have nearly eliminated them. A program to reduce these infections that started at Johns Hopkins Hospital was spread throughout Michigan, and is now being implemented throughout the U.S., demonstrating substantial reductions.

See One, Do One, Harm One?

Aug 14, 2012• 28

By Peter Pronovost, MD

I recently cared for Ms. K, an elderly black woman who had been sitting in the intensive care unit for more than a month. She was, frail, weak and intermittently delirious, with a hopeful smile. She had a big problem: She had undergone an esophagectomy at an outside hospital and suffered a horrible complication, leading her to be transferred to The Johns Hopkins Hospital. Ms. K had a large hole in her posterior trachea, far too large to directly fix, extending from her vocal cords to where her trachea splits into right and left bronchus. She had a trachea tube so she can breathe, and her esophagus was tied off high in her throat so oral secretions containing bacteria did not fall through the hole and infect her heart and lungs. It is unclear if she will survive, and the costs of her medical care will be in the millions.

Ms K’s complication is tragic—and largely preventable. For the type of surgery she had, there is a strong volume-outcome relationship: Those hospitals that perform more than 12 cases a year have significantly lower mortality. This finding, based on significant research, is made transparent by the Leapfrog Group and several insurers, who use a performance measure that combines the number of cases performed with the mortality rate. Hopkins Hospital performs more than 100 of these procedures a year, and across town, the University of Maryland tallies about 60. The hospital where Ms. K had her surgery did one last year. One. While the exact relationship between volume and outcome is imprecise, it is no wonder she had a complication.

Ms. K is not alone. Of the 45 Maryland hospitals that perform this surgery, 56 percent had fewer than 12 cases last year and 38 percent had fewer than six.

The Supreme Court May Have Saved Lives … by Keeping People Off Medicaid

Jul 30, 2012• 15

By John Goodman

Here’s the most underreported story of the summer. When the Supreme Court ruled on the Affordable Care Act (ObamaCare) it inadvertently liberated millions of people who were going to be forced into Medicaid. Now they will have the opportunity to have private health insurance instead. What difference does that make? It could be the difference between life and death.

A Congressional Budget Office (CBO) report this week says there are 3 million such people. The actual number could be several times that size. But first things first.

Imagine that you are the head of a family of three, struggling to get by on an income, say, of $25,000 a year. You’ve signed up for your employer’s health plan because you want your family to get good health care when they need it. But that takes a big bite out of your paycheck — $250 a month.

When you first heard about the president’s health plan, you heard him say that if you like the plan you’re in you can keep it. That was good news. You also believed the whole point of the reform was to help families like yours get health insurance if for some reason you had to seek insurance on your own.

Have Management Papers Ever Changed Practice in Healthcare?

May 25, 2012• 3

By Trish Greenhalgh

Sir Muir Gray, of evidence-based medicine fame, is a man who speaks his mind – often in 140 characters or fewer. “Show me a paper by a management academic,” he Tweeted, “that has changed the way we deliver health services” [and, implicitly, improved patient outcomes].

Part of me agreed with him, but I’m married to a management academic (“Oops sorry, better man than me,” Muir backpedalled), who helped me rise to Muir’s challenge.

We kicked off with a paper almost every clinician has heard of:

Kaplan and Norton’s ‘balanced scorecard’, published in Harvard Business Review in 1992 and cited over 8000 times since [1]. The scorecard was aimed at company directors who wanted some quick (and, one is tempted to suggest, dirty) metrics to monitor what their customers thought of them and where they should direct their efforts for the future. It has certainly changed practice (many healthcare organisations use it), but we were not overly sold on its transferability to the healthcare setting.

Fast Science: The Uncertainty Paradox

May 13, 2012• 9

By Marya Zilberberg, MD

Reading Barbara Ehrenreich’s “Bright-Sided” has been liberating in that is has given me permission to let my pessimistic nature out of the closet.

Well, it’s not exactly that I am pessimistic, but certainly I am not given over to brightness and cheer all the time. My poison is worry. Yes, I am a worrier, in case you had not noticed. So, imagine how satisfying it is for me to find new things to worry about. As if climate change were not enough, lately I started to worry about science.

No, my anxiety about how we do clinical science overall is not new; this blog is overrun with it. However, the new branch of that anxiety relates to something I have termed “fast science.” Like fast food it fills us up, but the calories are at best empty and at worst detrimental. What I mean is that science is a process more than it is a result, and this process cannot and should not be microwaved. Don’t believe me? Let me give you a couple of instances where slow science may be the answer to our woes.

1. Lies and damned lies

Remember this story in the Atlantic that rattled us with its incendiary message? Researcher John Ioannidis has been making headlines with his assertion that most, if not all, of what we know in medicine is in doubt, given how we do and publish research. And how we do and publish research has everything to do with the speed of “progress.” Academic careers are made with positive results, to sell news the media demand positive results, and to respond to this demand academic journals prefer only to publish positive results (this last phenomenon is referred to as “publication bias,” and is something Ben Goldacre rails against at length). A further manifestation of this fast science is that “no replicators need apply.” I am, of course, referring to an extension of the publications bias, whereby journals are not interested in publishing even a positive study that replicates a previous finding — this is simply not sexy. Thus, results have to be quick and positive to grab a share of our attention and sell academic prestige, journals and news.Continue reading…

Help Shape the Future of Patient-Centered Outcomes Research

Mar 12, 2012• 5

By Bill Silberg

The Patient-Centered Outcomes Research Institute (PCORI) is an independent, non-profit organization created by Congress in 2010. Our mission is to fund research that will provide patients, their caregivers and clinicians with the evidence-based information needed to make better-informed health care decisions.

We’re committed to continuously seeking input from a broad range of stakeholders to guide our work. So as part of that effort, we’re asking for public comment on our first draft National Priorities for Research and initial Research Agenda, which provide a framework for and identify the broad questions that must be addressed so that patients can make better and more personalized decisions in partnership with their clinicians.

We released the draft priorities and agenda on January 23 for a public comment period that runs through 11:59 pm EST on March 15. You can read the draft priorities and agenda, answer 10 questions about them and provide general comments, here

We encourage you to provide comment through our website, but we’ll also accept input by mail. Responses received through pcori.org will be displayed for public view on the site.

After reviewing public comments and other feedback, PCORI will publish a report summarizing the input and explaining how it led to changes in the draft priorities and agenda. PCORI’s Board of Governors then must adopt the priorities and agenda before primary funding announcements can be issued.

PCORI is counting on you and your colleagues to you to help shape our national priorities and research agenda. Your feedback and perspective will help insure that our work is responsive to the needs of patients and those who care for them.

So please visit pcori.org today to provide comment. And to receive regular updates and funding announcements from PCORI, please subscribe to our mailing list.

Bill Silberg is the Director of Communications at PCORI. Reach Bill at bsilberg@pcori.org.

Reports of the Death of Disease Management Are Greatly Exaggerated

Jan 19, 2012• 17

By AL LEWIS

There have been unsavory rumors flying around the internet that disease management as practiced today may not be all that effective. I’m not going to reveal who started these rumors but her name rhymes with Archelle Georgiou. This person says disease management is “dead.” Since there are still many disease management departments operating around the country apparently oblivious to their demise (and disease management departments are people too, you know), I suspect this commentator was using the word “dead” figuratively, as in: “The second he forgot the third cabinet department, Rick Perry was dead.” (Another example of presumably figurative speech in the death category would be: “After he denounced gays while wearing the Brokeback Mountain jacket, you could stick a fork in him.”)

And if the rhymes-with-Archelle commentator intends “dead” as a synonym for “not in very good shape,” she certainly has a point. Not only does she have a point, but I would add more items to her list of reasons for the field’s current troubles:

(1) The interval between diagnosis (the point where readiness to change is usually greatest) and successful patient contact can exceed three months;

(2) Predictive modeling “risk scores” that tell you only how sick someone was, dressed up as a “risk score,” not how sick they will be, even though they aren’t already high utilizers;

(3) Some interventions are so expensive that they exceed the cost of the disease;

The Cleveland Experiment

Sep 6, 2011• 8

By JOHN MOORE

There have been a number of research studies published that question the value of Electronic Health Records (EHRs), particularly as it pertains to improving quality of care and ultimately outcomes. Chilmark has always viewed these reports with a certain amount of skepticism. Simple logic leads us to conclude that a properly installed (including attention to workflow and thorough training) of an enterprise software system such as an EHR will lead to a certain level of standardization in overall process flow, contribute to efficiencies and quality in care delivery and ultimately lead to better outcomes. But to date, there has been a dearth of evidence to support this logic, that is until this week.

Last week the New England Journal of Medicine published the research paper: Electronic Health Records and Quality of Diabetes Care, which provides clear evidence, albeit a little fuzzy around the edges, that physician use of an EHR significantly improves quality metrics over physicians who rely on paper-based medical record keeping processes.

The research effort took place in Cleveland as part of Better Health Greater Cleveland from July 2009 till June 2010 and included 46 practices representing some 569 providers and over 27K adults with diabetes who visited their physician at least twice during the study period. Several common quality and outcome measures were used to assess and compare EHR-based care to paper-based. On composite standards of quality, EHR-based practices performed a whooping 35% better than their paper-based counterparts. On outcome measures, which are arguably more difficult for physicians as patients’ actions or lack thereof are more integral to final outcomes, EHR-based practices still outperformed their paper-based peers by some 15%. The Table below gives a more detailed breakout.

2010 Unplugged

Jan 4, 2011• 4

By BOB WACHTER, MD

For people like me, who, perversely enough, get a certain thrill from studying healthcare policy, there’s never been a more exciting, if also dizzying, year than 2010. Passage of the reform bill last March was only the start – and in some ways merely a marker – of the Shifting of the Paradigms: from provider to system; from pen to keyboard; from pay-for-piecework to pay-for-performance; from secrecy to transparency; from patient as passive actor to patient as star of our show.

I’ve been catching up on my reading during the holidays, so bear with me as I devote this blog – lengthier than usual – to a handful of articles, talks, and experiences that, while seeming unrelated, helped me better understand some of the threads of this vibrant healthcare tapestry we’re now weaving.

For decades, one of the defining characteristics of the American healthcare enterprise has been the remarkably poor value – quality divided by cost – it produces. Most of the changes afoot represent a push by a variety of stakeholders, using the tools at their disposal, to improve this value equation. And much of the push-back can be seen as the predictable acts of those who benefited from the old order. As the late William Safire once observed, when you zap a sacred cow, you need to brace yourself for the ensuing mooing. Welcome to Old MacDonald’s Farm.