Improving the home health acute-care hospitalization quality measure.

OBJECTIVES: (1) To demonstrate average length of service (ALOS) bias in the currently used acute-care hospitalization (ACH) home health quality measure, limiting comparability across agencies, and (2) to propose alternative ACH measures. DATA SOURCES/STUDY SETTING: Secondary analysis of Medicare home health service data 2004-2007; convenience sample of Medicare fee-for-service hospital discharges. STUDY DESIGN: Cross-sectional analysis and patient-level simulation. DATA COLLECTION/EXTRACTION METHODS: We aggregated outcome and ALOS data from 2,347 larger Medicare-certified home health agencies (HHAs) in the United States between 2004 and 2007, and calculated risk-adjusted monthly ACH rates. We used multiple regression to identify agency characteristics associated with ACH. We simulated ACH during and immediately after home health care using patient and agency characteristics similar to those in the actual data, comparing the existing measure with alternative fixed-interval measures. PRINCIPAL FINDINGS: Of agency characteristics studied, ALOS had by far the highest partial correlation with the current ACH measure (r(2)=0.218, p<.0001). We replicated the correlation between ACH and ALOS in the patient-level simulation. We found no correlation between ALOS and the alternative measures. CONCLUSIONS: Alternative measures do not exhibit ALOS bias and would be appropriate for comparing HHA ACH rates with one another or over time.

ACE inhibitor use and mortality reduction: do controlled trial results equal clinical practice?

Randomized trials have shown that angiotensin converting enzyme inhibitors (ACEIs) reduce mortality and morbidity and improve symptoms in many patients with heart failure. However, recent data show that the rate of ACEI prescriptions in West Virginia Medicare beneficiaries diagnosed with heart failure is not increasing. Data from the charts of patients who were discharged from 44 acute care hospitals during 2000 and 2001 were obtained, and these data were matched with current beneficiary data to determine if and when the patient died subsequent to the hospitalization of record. We examined data from 5,144 patients with heart failure for whom we had information on ACEI use, comorbidities, and contraindications, in addition to basic demographics. Patients who received angiotensin receptor blockers (ARBs) were excluded. Of these patients, 863 were eligible for ACEls, and 716 (83%) were discharged on an ACEI. Logistic regression showed that being discharged on an ACEI had a significant negative association with mortality one year later (P = .0009), reducing mortality in patients with heart failure by about one third.

Promoting influenza and pneumococcal immunization in older adults.

BACKGROUND: Reducing the risk of influenza and pneumococcal disease in older adults is a long-standing goal of Medicare's Quality Improvement Organization (QIO) program and parallels the Joint Commission's National Patient Safety Goal 10. ADDRESSING THE GOAL: Since 1999 the West Virginia Medical Institute has worked with a statewide partnership of health organizations on a program to improve influenza and pneumonia vaccination rates in hospitalized Medicare beneficiaries. Methods included education, audit and feedback, toolkits, and training meetings. RESULTS: During the first three years (1999-2001) of the effort, the rate of assessment for pneumococcal immunization at discharge increased from < 10% to 74.1% statewide and for influenza immunization from near zero to 63.4% statewide. Since 2002 pneumococcal immunization administration has increased from 16.1% to 41.1%, with similar improvement in influenza measures. LESSONS LEARNED/NEXT STEPS: Hospitals--and, by extension, long term care facilities--can make dramatic improvements in quality performance in a relatively short time when key staff receive feedback about the need to improve and the tools to assist in improving.

West Virginia Medical Institute: the Quality Improvement Organization for West Virginia.

The Federal Quality Improvement program, (QIO), charged with quality improvement and some case review activities is conducted under a contract with the Centers for Medicare and Medicaid Services (formerly HCFA), now CMS. Every state has one organization which handles this program and in West Virginia, the West Virginia Medical Institute has been responsible for this work for over 30 years. When case review is involved, the conclusions are communicated to individual physicians and hospitals. Occasionally, serious quality of care concerns are encountered. This article explains the case review process and why cases are selected, and also makes suggestions about how individual physicians may appeal or respond. It is designed to help enhance understanding of the program and its goals.

Beta blocker use in acute myocardial infarction in West Virginia.

This article describes our study of the use of beta blocker drugs in Medicare beneficiaries hospitalized for acute myocardial infarction in West Virginia between 1999 and 2000. We contrasted findings with the responses of practicing cardiologists in the state. The survey asked cardiologists to describe their recent patterns of beta blocker usage, to comment on the severity of generally recognized contraindications to beta blocker administration, and to speculate on reasons why West Virginia's rates of beta blocker use in AMI were lower than rates in most other states. Our study revealed that beta blocker use in AMI declined significantly with patient age, and that rates of use in larger hospitals exceeded those in smaller hospitals. There was little difference attributable to the specialty of the admitting physician. We also observed a positive association between the use of beta blockers in AMI and other appropriate interventions, such as the use of aspirin and revascularization. Cardiologists said they were using more beta blockers in AMI than five years ago, and speculated that high rates of chronic obstructive pulmonary disease and non-specialist physicians were responsible for low rates in West Virginia.