A qualitative analysis of hospital leaders' opinions about publicly reported measures of health care quality.

BACKGROUND: Hospital leaders play an important role in the success of quality improvement (QI) initiatives, yet little is known about how leaders engaged in QI currently view quality performance measures. In a follow-up to a quantitative study conducted in 2012, a study employing qualitative content analysis was conducted to (1) describe leaders' opinions about the quality measures reported on the Centers for Medicare & Medicaid Services (CMS) Hospital Compare website, (2) to generate hypotheses about barriers/facilitators to improving hospitals' performance, and (3) to elicit recommendations about how to improve publicly reported quality measures. METHODS: The opinions of leaders from a stratified sample of 630 hospitals across the United States regarding quality measures were assessed with an open-ended prompt that was part of a 21-item questionnaire about quality measures publicly reported by CMS. Their responses were qualitatively analyzed in an iterative process, resulting in the identification of the presence and frequency of major themes and subthemes. RESULTS: Participants from 131 (21%) of the 630 hospitals surveyed replied to the open-ended prompt; 15% were from hospitals with higher-than-average performance scores, and 52% were from hospitals with lower-than-average scores. Major themes included (1) concerns regarding quality measurement (measure validity, importance, and fairness) and/or public reporting; 76%); (2) positive views of quality measurement (stimulate improvement, focus efforts; 13%); and (3) recommendations for improving quality measurement. CONCLUSIONS: Among hospital leaders responding to an open-ended survey prompt, some supported the concept of measuring quality, but the majority criticized the validity and utility of current quality measures. Although quality measures are frequently being reevaluated and new measures developed, the ability of such measures to stimulate improvement may be limited without greater buy-in from hospital leaders.

The impact of hospital-onset Clostridium difficile infection on outcomes of hospitalized patients with sepsis.

OBJECTIVE: To examine the impact of hospital-onset Clostridium difficile infection (HOCDI) on the outcomes of patients with sepsis. BACKGROUND: Most prior studies that have addressed this issue lacked adequate matching to controls, suffered from small sample size, or failed to consider time to infection. DESIGN: Retrospective cohort study. SETTING AND PATIENTS: We identified adults with a principal or secondary diagnosis of sepsis who received care at 1 of the institutions that participated in a large multihospital database between July 1, 2004 and December 31, 2010. Among eligible patients with sepsis, we identified patients who developed HOCDI during their hospital stay. MEASUREMENTS: We used propensity matching and date of diagnosis to match cases to patients without Clostridium difficile infections and compared outcomes between the 2 groups. MAIN RESULTS: Of 218,915 sepsis patients, 2368 (1.08%) developed HOCDI. Unadjusted in-hospital mortality was significantly higher in HOCDI patients than controls (25% vs 10%, P < 0.001). After multivariate adjustment, in-hospital mortality rate was 24% in cases vs. 15% in controls. In an analysis limited to survivors, adjusted length of stay (LOS) among cases with Clostridium difficile infections was 5.1 days longer than controls (95% confidence interval: 4.4-5.8) and the median-adjusted cost increase was $4916 (P < 0.001). CONCLUSIONS: After rigorous adjustment for time to diagnosis and presenting severity, hospital-acquired Clostridium difficile infection was associated with increased mortality, LOS, and cost. Our results can be used to assess the cost-effectiveness of prevention programs and suggest that efforts directed toward high-risk patient populations are needed.

Access to subspecialty care for patients with mobility impairment: a survey.

BACKGROUND: Adults who use wheelchairs have difficulty accessing physicians and receive less preventive care than their able-bodied counterparts. OBJECTIVE: To learn about the accessibility of medical and surgical subspecialist practices for patients with mobility impairment. DESIGN: A telephone survey was used to try to make an appointment for a fictional patient who was obese and hemiparetic, used a wheelchair, and could not self-transfer from chair to examination table. SETTING: 256 endocrinology, gynecology, orthopedic surgery, rheumatology, urology, ophthalmology, otolaryngology, and psychiatry practices in 4 U.S. cities. PATIENTS: None. MEASUREMENTS: Accessibility of the practice, reasons for lack of accessibility, and planned method of transfer of the patient to an examination table. RESULTS: Of 256 practices, 56 (22%) reported that they could not accommodate the patient, 9 (4%) reported that the building was inaccessible, 47 (18%) reported inability to transfer a patient from a wheelchair to an examination table, and 22 (9%) reported use of height-adjustable tables or a lift for transfer. Gynecology was the subspecialty with the highest rate of inaccessible practices (44%). LIMITATION: Small numbers of practices in 8 subspecialties in 4 cities and use of a fictional patient with obesity and hemiparesis limit generalizability. CONCLUSION: Many subspecialists could not accommodate a patient with mobility impairment because they could not transfer the patient to an examination table. Better awareness among providers about the requirements of the Americans with Disabilities Act and the standards of care for patients in wheelchairs is needed. PRIMARY FUNDING SOURCE: None.

A mixed-methods analysis of patient reviews of hospital care in England: implications for public reporting of health care quality data in the United States.

BACKGROUND: In the United States patients have limited opportunities to read and write narrative reviews about hospitals. In contrast, the National Health Service (NHS) in England encourages patients to provide feedback to hospitals on their quality-reporting website, NHS Choices. The scope and content of the narrative feedback was studied. METHODS: All NHS hospitals with more than 10 reviews posted on NHS Choices were included in a cross-sectional mixed-methods (qualitative and quantitative) analysis of patients' reviews of 20 randomly selected hospitals. RESULTS: The final sample consisted of 264 hospitals and 2,640 patient responses to structured questions. All 200 reviews from the 20 hospitals randomly selected were subjected to further quantitative and qualitative analysis. Comments about clinicians and staff were common (179 [90%]) and overwhelmingly positive, with 149 (83%) favorable to workers. In 124 (62%) of the 200 reviews, patients commented on technical aspects of hospital care, including quality of care, injuries, errors, and incorrect medical record or discharge documentation. Perceived medical errors were described in 51 (26%) hospital reviews. Comments about the hospital facility appeared in half (52%) of reviews, describing hospital cleanliness, food, parking, and amenities. Hospitals replied to 56% of the patient reviews. DISCUSSION: NHS Choices represents the first government-run initiative that enables any patient to provide narrative feedback about hospital care. Reviews appear to have similar domains to those covered in existing satisfaction surveys but also include detailed feedback that would be unlikely to be revealed by such surveys. Online narrative reviews can therefore provide useful and complementary information to consumers (patients) and hospitals, particularly when combined with systematically collected patient experience data.

Mythmaking in medical education and medical practice.

BACKGROUND: Despite the emergence of evidence-based medicine, gaps in medical knowledge are filled by tradition, common sense, and experience, giving rise to medical myths. METHODS: We explored the origins of and evidence related to four medical myths: patients with shellfish allergies should not receive intravenous contrast, patients with atrial fibrillation of less than 48 hours' duration do not require anticoagulation before cardioversion, patients with suspected meningitis should have a computed tomography (CT) scan before a lumbar puncture, and patients with respiratory disease should not receive ß-blockers. We conducted a literature review to describe each myth's origins and the quality of supporting evidence. RESULTS: All patients with allergies, including but not limited to seafood allergies, are at an increased risk for anaphylactoid reactions to radiocontrast. No conclusive studies indicate that patients with atrial fibrillation of less than 48 hours' duration do not require anticoagulation before cardioversion. A CT scan before lumbar puncture in suspected acute bacterial meningitis is a clinically inefficient precaution. ß-blockers can be safely used in patients with respiratory disease and may even prevent cardiac events in these patients. CONCLUSIONS: These familiar myths have maintained prominent roles in medical thinking because they represent wisdom passed down from eminent sources, they teach physiology and medical skills, and they offer physicians a sense of control in the face of uncertainty. In addition to providing scientific evidence, changing physicians' practice requires acknowledging that even meticulous care cannot always avert bad outcomes.

Contributors to variation in hospital spending for critically ill patients with sepsis.

BACKGROUND: Costs of severe sepsis in the US exceeded $24 billion in 2007. Identifying the relative contributions of patient, hospital, and physician factors to the variation in hospital costs of sepsis could help target efforts to improve the value of care. METHODS: We identified adults with a principal or secondary diagnosis of sepsis who received care between June 1, 2004 and June 30, 2006 at one of the hospitals participating in a multi-institutional database. We constructed a regression model to predict mean hospital costs that included patient characteristics, hospital mission and environment (e.g., teaching status, percentage of low-income patients), hospital fixed costs, and risk-adjusted length of stay, which encompasses hospital throughput, the incidence of complications, and other aspects of physician practice. To determine the contribution to cost variance by each predictor, we calculated the R(2). RESULTS: At 189 hospitals, we identified 40,265 adults with sepsis who met inclusion criteria. The median cost of a hospitalization was $20,216. The model explained 69% of the hospital-level variation in the costs of hospitalization. Of explained variation, differences in patients' ages, comorbidities, and severity accounted for 20%; hospital mission and environment represented 16%; differences in hospital fixed costs, including acquisition costs and overhead, accounted for 19%; and wage index explained an additional 12%. Risk-adjusted length of stay comprised the final one-third of explained variation. CONCLUSION: A large proportion of variation in the cost of caring for critically ill patients with sepsis across hospitals is related to differences in patient characteristics and immutable hospital characteristics, while nearly one-third is the result of differences in risk-adjusted length of stay. IMPLICATIONS: Efforts to reduce spending on the critically ill should aim to understand determinants of practice style but should also focus on hospital throughput, overhead, acquisition, and labor costs.

Patients' evaluations of health care providers in the era of social networking: an analysis of physician-rating websites.

BACKGROUND: Internet-based social networking tools that allow users to share content have enabled a new form of public reporting of physician performance: the physician-rating website. OBJECTIVE: To describe the structure and content of physician-rating websites and to assess the extent to which a patient might find them valuable. METHODS: We searched Google for websites that allowed patients to review physicians in the US. We included websites that met predetermined criteria, identified common elements of these websites, and recorded website characteristics. We then searched the websites for reviews of a random sample of 300 Boston physicians. Finally, we separately analyzed quantitative and narrative reviews. RESULTS: We identified 33 physician-rating websites, which contained 190 reviews for 81 physicians. Most reviews were positive (88%). Six percent were negative, and six percent were neutral. Generalists and subspecialists did not significantly differ in number or nature of reviews. We identified several narrative reviews that appeared to be written by the physicians themselves. CONCLUSION: Physician-rating websites offer patients a novel way to provide feedback and obtain information about physician performance. Despite controversy surrounding these sites, their use by patients has been limited to date, and a majority of reviews appear to be positive.