Reporting and using health plan performance information in Massachusetts.

BACKGROUND: In 1993, 27 corporate and government health care purchasers formed the Massachusetts Healthcare Purchaser Group (MHPG). Sixteen health plans submitted 1992 data on six clinical indicators-mental health inpatient days per patient and inpatient readmission, blood pressure screening, prenatal care, mammography screening, cesarean section (C-section) rates, and asthma admission rates-developed in an earlier pilot effort in response to the quality portion of MHPG's "Cost/Quality Challenge." DATA COLLECTION AND ANALYSIS: Detailed data specifications developed in the pilot to ensure uniform data collection were used, with a requested sample size for chart-reviewed measures of 220. A "clinically significant average range" was defined. Health plan performance was summarized for each indicator in a report released in March 1994. REPORTING OF CLINICAL INDICATOR RESULTS: For the six indicators, each plan had a unique pattern of variation from the average range. For prenatal care, mammography, and hypertension, many plans had opportunities for improvement. SURVEY OF PURCHASERS: Most of the purchasers MHPG surveyed in October 1994 about their assessment and use of the Cost/Quality Challenge Report found it useful. RESPONSES TO THE REPORT: To promote quality improvement activities among health plans, MHPG showed purchasers how to pursue performance issues with health plans, held a Best Practice Forum on C-section, and created a follow-up endeavor, the Coordinated Purchasing Initiative. SUMMARY AND CONCLUSIONS: In spite of potential problems posed by technical deficiencies, costs of data acquisition and quality efforts, and unintended effects of public reporting, purchaser/plan initiatives such as the Cost/Quality Challenge can provide valuable information to purchasers.

Assessing the needs of women and clinicians for the management of menopause in an HMO.

OBJECTIVE: To determine the perceived needs of perimenopausal women regarding the management of menopause and the resource needs of the clinicians who treat them. SETTING: A large staff and group network model health maintenance organization (HMO) in New England. PARTICIPANTS: A random sample of 790 perimenopausal women aged 45-60 years who were members of the HMO in 1991, and a random sample of 180 clinicians in internal medicine, family practice, and obstetrics/gynecology practicing in the HMO during 1991. METHOD: Mailed surveys of women and clinicians were designed to assess possible needs and attitudes that could lead to the improvement of care for menopausal women. The chi-square test was used to determine differences in perceived needs and satisfaction levels among women with differences in self-reported menopausal status. The Kruskal-Wallis one-way analysis of variance and the Mann-Whitney U test were used in the clinician survey to test for differences among specialties and between genders. RESULTS: The key findings include that: 1) most (81%) of the women wanted to see a woman clinician, 2) many (50%) were interested in a menopause support group, 3) 30% reported that their care for menopause had been fair to poor, 4) only 55% of the primary care specialists (including internal medicine and family practice) reported high confidence in their abilities to treat menopause, compared with 68% of the obstetric/gynecology clinicians, and 5) 56% of the clinicians surveyed said that support from the HMO to their practices for the treatment of menopause was fair to poor. CONCLUSIONS: There is an opportunity for better care for perimenopausal women as reported by two sources, HMO clinicians and members. To provide this care, clinicians may need explicit guidelines as well as administrative supports such as educational materials and specialty access. Since the capability for menopausal care from clinicians in obstetrics/gynecology is perceived to be higher than that from primary care clinicians, an opportunity for cross-specialty collaboration and training may exist.

Development of clinical indicators for performance measurement and improvement: an HMO/purchaser collaborative effort.

This article describes a collaborative effort between a major health care purchaser, three area health maintenance organizations, and a state Medicaid agency to develop clinical indicators as the basis for a comparison database. Some of the difficulties in developing a "common yardstick" of quality and value are candidly discussed.

Detecting semen antisperm antibodies in the clinical laboratory.

Although antisperm antibodies are associated with infertility, many hospital laboratories do not test for these antibodies. This study included 520 males who were referred for infertility evaluation. Semen samples from all patients were tested for antisperm antibodies by using the mixed antiglobulin reaction and immunobead binding tests. These results were correlated with the findings of semen analyses, postcoital tests, and sperm penetration assays. Eighty-eight men (16.9%) tested positive for IgG, IgA, or IgM antisperm antibodies. More samples tested positive for IgG antibodies by the mixed antiglobulin reaction than by the immunobead test (n = 71 vs n = 42); 57 samples tested IgA positive. Both methods showed good reproducibility (97.6%). Antibody-positive males had a higher incidence of abnormal semen analyses (92% vs 74%) and other immune-related fertility test results (94.2% vs 38.4%). The presence of antisperm antibodies correlates with other abnormal semen parameters. Testing for these antibodies should be included in an infertility evaluation and could be readily implemented in a clinical laboratory.

Strategic planning applied to quality in asthma management for children.

This strategic plan translates the HCHP vision statement into a working plan for one major clinical condition--asthma in children. It is a working plan for clinicians and managers across specialties and levels. The results of the projects will improve in a measurable way significant clinical practice and outcomes, in keeping with the FY 1993 strategic goals.

Is QA antiquated, or was it at the right place at the wrong time?

Much has been written about the strengths and weaknesses of quality assurance (QA) and continuous quality improvement (CQI) as approaches to achieving optimal quality and value in health care. In the past, the motivation behind QA was largely regulatory. Today, the driving force for CQI is corporate America, whose clout has key provider constituencies ready to cooperate as never before. This article argues that many of the functions of traditional QA will remain an integral component of quality management strategies for health care organizations and that the success of these efforts will depend on a coordinated effort by professionals from QA, quality management, and health services research. Furthermore, quality engineering concepts from other industries provide a useful framework to enable coordination among these three fields.

Analyzing in-hospital mortality and morbidity with adjustment for admission severity.

Recognition of the need for measuring quality has increasingly permeated the thinking of leaders in industry. Until relatively recently, however, measuring health care quality was a novel concept. For many reasons a variety of constituencies have begun to see the need for information about the quality of health care. Here, we describe a particular model for quality measurement in the inpatient setting and present an approach for preliminary screening of data to identify potential areas for effectiveness review. For purchasers of health care, this type of information would be helpful as a first screen for identifying areas for more in-depth review by hospitals. Some caveats relating to the approach are also discussed.

Diffusion of innovations in burn care: selected findings.

Large sums of money are spent to support biomedical research, but relatively little effort is directed toward getting results to the clinical setting. Understanding the process underlying the diffusion of innovations would promote more efficient conversion of new knowledge into practice. This study examines the diffusion of innovations in burn care that were discussed at the United States National Institutes of Health 1978 Consensus Development Conference on Supportive Therapy in Burn Care. The study traces the awareness and use of innovations in burn care, the source and timing of new information to physicians and the ways in which characteristics of both innovations and physicians are related to the diffusion process. The principal basis for the study is a survey in five New England States of physicians who treat burn patients. The data suggested that between 56 and 97 per cent of physicians were aware of eight major advances. Physicians were more aware of high than low consensus treatments and the adoption rate and adoption level were higher for high consensus treatments. The three most important sources of information about the advances were staff conferences, journals and medical school.