The relationship of hospital quality and cost per case in Hawaii.

One of the leading questions of our time is whether high-quality care leads to lower health care costs. Using data from Hawaii hospitals, this paper addresses the relationship of overall cost per case to a composite measure of the quality of inpatient care and a 30-day readmission rate. We found that low-cost hospitals tend to have the highest quality but the worst readmission performance. Change in quality and change in cost were also negatively correlated, but not statistically significant. We conclude that high-quality hospital care does not have to cost more, but that the dynamics of the readmission rate differ substantially from other quality dimensions.

Investigating approaches to improving appropriate antibiotic use among higher risk ethnic groups.

A field study with follow up investigations sought to: 1. determine whether cold packs (over-the-counter symptomtic treatments), coupled with in-office education, improve antibiotic-related knowledge, attitudes and behaviors more than in-office education alone in patient populations with high percentages of Asian Americans and Hawaiian/Pacific Islanders; 2. identify possible reasons for intervention outcomes as described by physicians who participated in the field study; and 3. explore potential future directions based on a large sample survey of physicians in the field study's highly ethnic county. The intervention resulted in a pre- to post-consultation decrease in perceived need for and an increase in knowledge about antibiotic risks but had no impact on frequency of reported receipt of an antibiotic prescription. Unexpectedly, in-office education alone was more effective in increasing knowledge than in-office education plus the cold pack. In-depth interviews of field study physicians and a large scale physician survey suggest that cold pack interventions targeting patient populations with high percentages of Asian Americans and Hawaiian/Pacific Islanders may be more likely to succeed if accompanied by mass public education regarding risks and physician training regarding effective ways to talk to patients. Use of in-office education with cold packs alone may not achieve desired results.

A managed care organization's use of integrated health management to improve secondary prevention of coronary artery disease.

OBJECTIVE: To evaluate the effect of a managed care organization's multifactorial intervention program in optimizing secondary prevention of coronary artery disease (CAD). STUDY DESIGN: Retrospective observational analysis of claims-based data of health plan members with CAD receiving 1 or more prescriptions per year of any of the following classes of medications used for secondary prevention of CAD: lipid-lowering agents, angiotensin-converting enzyme (ACE) inhibitors, or angiotensin receptor blockers (ARBs) and beta-blockers. METHODS: Claims-based data of members from 2000 to 2004 were analyzed to discover trends in the use of medications for secondary prevention of CAD. chi(2) Test of proportion was used to determine whether the changes in the annual medication use rates were statistically significant. RESULTS: The annual medication use rates improved consistently throughout each year of the study period. From 2000 to 2004, the medication use rates increased for lipid-lowering agents (from 55% to 71%), ACE inhibitors or ARBs (from 44% to 55%), and beta-blockers (from 36% to 47%). Changes in all 3 indicators were statistically significant at P < .001. CONCLUSIONS: An integrated multifactorial approach is essential in addressing the underutilization of therapies available for secondary prevention of CAD. Managed care organizations are in a unique position to optimize the use of evidence-based pharmacological and behavioral therapies to effectively prevent and treat the underlying pathophysiology of CAD in member populations.

Aligning financial incentives with quality of care in the hospital setting.

This article describes the structure, implementation, and early results of a performance-based hospital incentive program designed by a large nonprofit health plan. The Hospital Quality Service and Recognition program, developed by the Hawaii Medical Service Association, was launched in 2001 to reward high-quality medical care at the hospital level. This pay-for-performance program used administrative claims data, survey data, and hospital-reported information to assess hospital performance in risk-adjusted complications and risk-adjusted length of stay (LOS), patient satisfaction, and hospital processes of care measures. Financial incentives were provided to participating hospitals based on their performance on these measures. Preliminary outcomes of the program evaluated over a 4-year period after implementation revealed improvements in aggregated rates of risk-adjusted surgical complications and efficiency of care as evidenced by a substantial decrease in risk-adjusted average LOS for several surgical procedures. Quality improvement was demonstrated in several other program components including emergency department satisfaction. This quality incentive program offers an innovative approach for encouraging delivery of high-quality and service-oriented care in a statewide network of participating hospitals.

Antibiotics and upper respiratory infections: the impact of Asian and Pacific Island ethnicity on knowledge, perceived need, and use.

The threat of microbial resistance to antibiotics grows increasingly serious each year. Despite the severity of the problem, little is known about ways that ethnicity and culture influence antibiotic knowledge, attitudes, and use. Based on a random sample of residents from a multicultural metropolitan county in the western United States, this study finds that Filipinos have lower levels of antibiotic knowledge, express higher perceived need, and report more frequent use. Whites in this sample are at the opposite end on all of these measures; other Asian Americans and Hawaiians/Pacific Islanders are in between. The results also suggest that preference for a "paternalistic" interaction/decision-making style between Filipino patients and their physicians may increase the challenge of designing an effective intervention promoting appropriate antibiotic use; a social marketing approach may be one possible alternative. Implications and future research directions are discussed for other multicultural urban environments that experience inappropriate use of antibiotics.

Aligning financial incentives with "Get With The Guidelines" to improve cardiovascular care.

OBJECTIVE: To describe the impact of a commercial insurer's financial incentives to hospitals in conjunction with collaboration with the American Heart Association (AHA) to accelerate implementation of Get With The Guidelines-Coronary Artery Disease (GWTG-CAD), a quality improvement program to rapidly improve cardiovascular secondary prevention in hospitalized patients. STUDY DESIGN: Observational assessment of quality improvement program participation and implementation in response to financial incentives. METHODS: The study population included all hospitals that participated with the Hawaii Medical Service Association (HMSA, Blue Cross Blue Shield of Hawaii) Hospital Quality and Service Recognition Program and had more than 30 annual admissions for acute coronary artery disease. These 13 hospitals were given encouragement and financial incentives to implement GWTG-CAD. Financial incentives were determined by a prorated amount of the total HMSA hospital reimbursement for all acute services, as part of a more comprehensive hospital "pay for performance" program. RESULTS: Incentives to 10 of 13 eligible hospitals included reimbursement for half the annual cost of the AHA Patient Management Tool. In addition, HMSA's pay for performance program--the Hospital Quality and Service Recognition Program--distributed monetary awards totaling 354,883 dollars, based on points awarded for GWTG-CAD workshop attendance documentation (10 hospitals), recognition by the AHA as a GWTG-CAD hospital, and attainment of 85% adherence to the GWTG-CAD performance measures (4 hospitals). CONCLUSIONS: Community-based promotion of GWTG-CAD and financial incentives provided by a commercial insurer resulted in the rapid implementation of a secondary prevention program for coronary artery disease in most hospitals in the State of Hawaii within a single year.