Exploratory analysis of the relationship between home health agency engagement in a national campaign and reduction in acute care hospitalization in US home care patients.

RATIONALE, AIMS AND OBJECTIVES: To determine whether US home health agencies that intensively engaged with the 2010 Home Health Quality Improvement National Campaign were more likely to reduce acute care hospitalization (ACH) rates than less engaged agencies. METHOD: We included all Medicare-certified agencies that accessed Campaign resources in the first month of the Campaign and also responded to an online survey of resource utilization at month two. We used the survey data and item response theory to estimate a latent construct we called engagement with the campaign. ACH rates were calculated from the Centers for Medicare & Medicaid Services Outcome and Assessment Information Set for pre- and post-intervention periods (March-November 2009 and 2010, respectively). RESULTS: Staff from 1077 agencies accessed resources in the first month of the Campaign. Of these, 382 provided information about resource use and had 10 or more monthly discharges throughout the measurement periods. Dividing these agencies into quartiles based on engagement score, we found an association between engagement and reduction in ACH rates, P=0.049 (χ(2) for trend). Exploratory path analysis revealed the effect of engagement score on reduction in ACH rate to be partially mediated through reduction in average length of service rates. CONCLUSION: We found evidence that early intensity of engagement with the Campaign, as measured through use of activities and resources, was positively associated with improvement. To continue the investigation of this relationship, future work in this and other campaigns should focus on further development of engagement measures.

Bringing all the players to the table: the West Virginia Controlled Substance Advisory Board.

Abuse and diversion of controlled substances are well-known problems in West Virginia and nationally. The costs to our society in both dollars and human capital are substantial. These problems touch groups as diverse as law enforcement, medical professionals, government leaders, addiction specialists, pain specialists, social workers, educators and regulatory boards, among others. The issues these groups face are varied and often unique to each profession, often resulting in a lack of communication and collaboration. This problem has been compounded by the fact that each group often makes decisions based on independent data related to substance abuse and diversion, which historically have not been shared due to privacy and other concerns. The West Virginia Controlled Substance Advisory Board was created to address these and other issues involved in drug diversion and substance abuse in West Virginia.

Understanding the cultures of prescription drug abuse, misuse, addiction, and diversion.

Prescription drug abuse, misuse, addiction, and diversion have reached epidemic proportions in the United States. The elimination of the burden of these activities on the healthcare system, the criminal justice system and society as a whole requires a multifaceted approach. Before resolution of these issues around prescription drugs can occur, a clear understanding of the cultures leading to these activities is required.

Quality of ambulatory care for diabetes and lower-extremity amputation.

Lower extremity amputation (LEA) is a serious complication of diabetes. We sought to determine whether quality of ambulatory care affects risk of LEA. We conducted a claims-based case-control study of 409 Medicare beneficiaries younger than age 75 with diabetes and LEA between January 1, 2003, and December 31, 2005. They were matched with controls with diabetes without LEA, on age, gender, number of diabetes outpatient visits, and (for those with hospital admissions between January 1, 2000, and December 31, 2002) number of comorbid conditions, diabetes complications, and peripheral vascular disease. Quality-of-care measures for cases and controls covered the period April 1, 1999, through March 31, 2001. LEA patients were less likely to have had lipid screening than controls (odds ratio = 0.73; 95% confidence interval = 0.53-0.99), and controls were more likely to use physicians with high performance in lipid screening (chi(2) = 6.631, P = .012) and hemoglobin A1c testing (chi(2) = 6.079, P = .014).

Impact of the 2004 influenza vaccine shortage on repeat immunization rates.

PURPOSE: We assessed the impact of the severe influenza vaccine shortage of 2004 on individual physicians' immunization performance. METHODS: Using 1998-2004 Medicare claims data, we monitored the physician continuity rate (proportion of patients receiving influenza immunization from a physician in 1 year who received a subsequent immunization from the same physician the subsequent year) and other clinician rate (proportion of patients with claims from 1 physician in 1 year with a claim from another clinician the subsequent year) in West Virginia Medicare beneficiaries from 2000-2004. We examined vaccine claim trends by clinician and surveys of self-reported immunization to determine whether patients received vaccine from nonphysician clinicians or went without immunization each year. RESULTS: Claims-based influenza vaccination rates increased from 35.5% to 41.3% from 2000-2003, reflecting historical trends, before declining 14.1% in 2004. Median continuity rates among the 723 to 849 physicians claiming 25 or more influenza immunizations from 2000-2003 increased from 47% in 2000-2001 to 54% in 2002-2003; then fell to 3% in 2003-2004. The number of physicians filing 100 or more claims declined from 337 in 2003 to 130 in 2004. More than 25% of physicians had no repeat vaccinations of the same beneficiaries in 2004. Trends in clinician type and survey data indicated a shift of many beneficiaries to mass vaccinators and institutional providers; however, compared with previous years, there was an estimated 8% increase in 2004 in the number of West Virginia beneficiaries who did not receive vaccine. CONCLUSIONS: The 2004 vaccine shortage had a severe impact on influenza immunization rates in private physician's offices, disrupting continuity of care.

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.