Facility characteristics and quality of lung cancer care in an integrated health care system.

INTRODUCTION: In a national, integrated health care system, we sought to identify facility-level attributes associated with better quality of lung cancer care. METHODS: Adherence to 23 quality indicators across four domains (Diagnosis and Staging, Treatment, Supportive Care, End-of-Life Care) was assessed through abstraction of electronic records from 4804 lung cancer patients diagnosed in 2007 at 131 Veterans Health Administration facilities. Performance was reported as proportions of eligible patients fulfilling adherence criteria. With stratification of patients by stage, generalized estimating equations identified facility-level characteristics associated with performance by domain. RESULTS: Overall performance was high for the older (mean age 67.7 years, SD 9.4 years), predominantly male (98%) veterans. However, no facility did well on every measure, and range of adherence across facilities was large; 9% of facilities were in the highest quartile for one or more domain of care, more than 30% for two, and 65% for three. No facility performed consistently well across all domains. Less than 1% performed in the lowest quartile for all. Few facility-level characteristics were associated with care quality. For End-of-Life Care, diagnosis and treatment within the same facility, availability of cancer psychiatry/psychology consultation services, and availability of both inpatient and outpatient palliative care consultation services were associated with better adherence. CONCLUSIONS: Quality of Veterans Health Administration lung cancer care is generally high, though substantial variation exists across facilities. With the exception of the salutary impact of palliative care consultation services on end-of-life quality of care, observed facility-level characteristics did not consistently predict adherence to indicators, suggesting quality may be determined by complex local factors that are difficult to measure.

Quality of supportive care for patients with advanced lung cancer in the Veterans Health Administration.

BACKGROUND: Morbidity related to cancer and its treatment remains a significant source of human suffering and a challenge to the delivery of high-quality care. OBJECTIVES: To develop and apply quality indicators to evaluate quality of supportive care for advanced lung cancer in the Veterans Health Administration (VHA) and examine facility-level predictors of quality. METHODS: We evaluated supportive care quality using 12 quality indicators. Data were taken from VHA electronic health records for incident lung cancer cases occurring during 2007. Organizational characteristics of 111 VHA facilities were examined for association with receipt of care. LIMITATIONS: Not all supportive care was evaluated. Care processes identified as present at facilities may not have been applied to cohort patients. Facility-level results may be influenced by errors in attributing a patient's care to the correct facility. CONCLUSIONS: Quality indicators for supportive cancer care can be developed and applied in large evaluations using electronic health record review. This study confirmed high-quality supportive care, while identifying significant facility-level variation in VHA.

Patient preference and contraindications in measuring quality of care: what do administrative data miss?

PURPOSE: Prior studies report that half of patients with lung cancer do not receive guideline-concordant care. With data from a national Veterans Health Administration (VHA) study on quality of care, we sought to determine what proportion of patients refused or had a contraindication to recommended lung cancer therapy. PATIENTS AND METHODS: Through medical record abstraction, we evaluated adherence to six quality indicators addressing lung cancer-directed therapy for patients diagnosed within the VHA during 2007 and calculated the proportion of patients receiving, refusing, or having contraindications to recommended treatment. RESULTS: Mean age of the predominantly male population was 67.7 years (standard deviation, 9.4 years), and 15% were black. Adherence to quality indicators ranged from 81% for adjuvant chemotherapy to 98% for curative resection; however, many patients met quality indicator criteria without actually receiving recommended therapy by having a refusal (0% to 14%) or contraindication (1% to 30%) documented. Less than 1% of patients refused palliative chemotherapy. Black patients were more likely to refuse or bear a contraindication to surgery even when controlling for comorbidity; race was not associated with refusals or contraindications to other treatments. CONCLUSION: Refusals and contraindications are common and may account for previously demonstrated low rates of recommended lung cancer therapy performance at the VHA. Racial disparities in treatment may be explained, in part, by such factors. These results sound a cautionary note for quality measurement that depends on data that do not reflect patient preference or contraindications in conditions where such considerations are important.

Using NCCN clinical practice guidelines in oncology to measure the quality of colorectal cancer care in the veterans health administration.

Clinical practice guidelines can be used to help develop measures of quality of cancer care. This article describes the use of a Cancer Care Quality Measurement System (CCQMS) to monitor these measures for colorectal cancer in the Veterans Health Administration (VHA). The CCQMS assessed practice guideline concordance primarily based on colon (14 indicators) and rectal (11 indicators) cancer care guidelines of the NCCN. Indicators were developed with input from VHA stakeholders with the goal of examining the continuum of diagnosis, neoadjuvant therapy, surgery, adjuvant therapy, and survivorship surveillance and/or end-of-life care. In addition, 9 measures of timeliness of cancer care were developed. The measures/indicators formed the basis of a computerized data abstraction tool that produced reports on quality of care in real-time as data were entered. The tool was developed for a 28-facility learning collaborative, the Colorectal Cancer Care Collaborative (C4), aimed at improving colorectal cancer (CRC) care quality. Data on 1373 incident stage I-IV CRC cases were entered over approximately 18 months and were used to target and monitor quality improvement activities. The primary opportunity for improvement involved surveillance colonoscopy and services in patients after curative-intent treatment. NCCN Clinical Practice Guidelines in Oncology were successfully used to develop a measurement system for a VHA research-operations quality improvement partnership.

Colorectal cancer diagnosis improvement project evaluation demonstrates the importance of using multiple measures to track progress toward timeliness goals.

Using data from an improvement collaborative, we examined whether facility-specific conclusions regarding the success of efforts to improve timely access could vary depending on the type of measure used. The sample was drawn from 21 Veterans Health Administration (VHA) medical facilities participating in a collaborative on timely diagnostic evaluation following positive fecal occult blood tests (FOBT+). We identified FOBT+ cases from participating facilities between September 2004 and August 2005 (precollaborative), and September 2006-August 2007 (postcollaborative). Dates of FOBT+ results, colonoscopy, and death were extracted from VHA medical records. We estimated the cumulative proportion receiving colonoscopy within 2 months of the FOBT+ (target measure established by collaborative), and compared facility-specific results regarding improvement on this measure to results from measures of the cumulative proportion receiving colonoscopy within 12 months, and average time-to-colonoscopy. In 12 facilities (57%), all measures suggested consistent results regarding pre-post collaborative changes in colonoscopy rates. In four facilities (19%), the target measure suggested less favorable change, and in five (24%), more favorable change than one or both other measures. Because conclusions drawn about the success of QI efforts can vary by the measure used, multiple measures should be employed to track progress toward timeliness goals.

Lower use of carotid artery imaging at minority-serving hospitals.

OBJECTIVE: We determined whether site of care explains a previously identified racial disparity in carotid artery imaging. METHODS: In this retrospective cohort study, data were obtained from a chart review of veterans hospitalized with ischemic stroke at 127 Veterans Administration hospitals in 2007. Extensive exclusion criteria were applied to obtain a sample who should have received carotid artery imaging. Minority-serving hospitals were defined as the top 10% of hospitals ranked by the proportion of stroke patients who were black. Population level multivariate logistic regression models with adjustment for correlation of patients in hospitals were used to calculate predictive probabilities of carotid artery imaging by race and minority-service hospital status. Bootstrapping was used to obtain 95% confidence intervals (CIs). RESULTS: The sample consisted of 1,534 white patients and 628 black patients. Nearly 40% of all black patients were admitted to 1 of 13 minority-serving hospitals. No racial disparity in receipt of carotid artery imaging was detected within nonminority serving hospitals. However, the predicted probability of receiving carotid artery imaging for white patients at nonminority-serving hospitals (89.7%, 95% CI [87.3%, 92.1%]) was significantly higher than both white patients (78.0% [68.3%, 87.8%] and black patients (70.5% [59.3%, 81.6%]) at minority-serving hospitals. CONCLUSIONS: Underuse of carotid artery imaging occurred most often among patients hospitalized at minority-serving hospitals. Further work is required to explore why site of care is a mechanism for racial disparities in this clinically important diagnostic test.

The use and misuse of thrombolytic therapy within the Veterans Health Administration.

BACKGROUND: Within the Veterans Health Administration (VHA), approximately 6000 veterans are hospitalized with acute ischemic stroke annually. We examined the use and misuse of thrombolytic therapy with tissue plasminogen activator (tPA) in a national sample of veterans who were admitted to a VHA Medical Center (VAMC) with acute ischemic stroke. METHODS: Medical record reviews were conducted on 5000 acute stroke patients who were admitted to a VAMC in 2007. Patients were defined as eligible to receive tPA if they arrived at the hospital within 3 hours of stroke symptom onset and had no contraindications to tPA. We compared eligible patients who received tPA to those who did not and examined the distribution of eligible patients across the 129 VAMCs included in this study. RESULTS: Among the 3931 ischemic stroke patients, 174 (4.4%) were eligible for tPA. Among the 135 patients who arrived within 2 hours of symptom onset which allowed adequate time for testing and evaluation, 19 (14.1%) received tPA. An additional 11 patients received tPA but did not meet eligibility criteria. Eligible patients receiving tPA were similar to eligible patients not receiving tPA in terms of clinical conditions and time to brain imaging. Among the 30 patients that received tPA, 5 (16.6%) received the wrong dose. Among the 85 VAMCs that received ≥1 eligible patient, on average 2.3 patients were eligible for tPA annually. CONCLUSIONS: Relatively few eligible veterans receive thrombolysis across the VHA system. Strategies to improve thrombolysis delivery will have to account for the low annual volume of eligible stroke patients cared for at individual VAMCs.

Estimating and reporting on the quality of inpatient stroke care by Veterans Health Administration Medical Centers.

BACKGROUND: Reporting of quality indicators (QIs) in Veterans Health Administration Medical Centers is complicated by estimation error caused by small numbers of eligible patients per facility. We applied multilevel modeling and empirical Bayes (EB) estimation in addressing this issue in performance reporting of stroke care quality in the Medical Centers. METHODS AND RESULTS: We studied a retrospective cohort of 3812 veterans admitted to 106 Medical Centers with ischemic stroke during fiscal year 2007. The median number of study patients per facility was 34 (range, 12-105). Inpatient stroke care quality was measured with 13 evidence-based QIs. Eligible patients could either pass or fail each indicator. Multilevel modeling of a patient's pass/fail on individual QIs was used to produce facility-level EB-estimated QI pass rates and confidence intervals. The EB estimation reduced interfacility variation in QI rates. Small facilities and those with exceptionally high or low rates were most affected. We recommended 8 of the 13 QIs for performance reporting: dysphagia screening, National Institutes of Health Stroke Scale documentation, early ambulation, fall risk assessment, pressure ulcer risk assessment, Functional Independence Measure documentation, lipid management, and deep vein thrombosis prophylaxis. These QIs displayed sufficient variation across facilities, had room for improvement, and identified sites with performance that was significantly above or below the population average. The remaining 5 QIs were not recommended because of too few eligible patients or high pass rates with little variation. CONCLUSIONS: Considerations of statistical uncertainty should inform the choice of QIs and their application to performance reporting.

Correlation of inpatient and outpatient measures of stroke care quality within veterans health administration hospitals.

BACKGROUND AND PURPOSE: Quality of care delivered in the inpatient and ambulatory settings may be correlated within an integrated health system such as the Veterans Health Administration. We examined the correlation between stroke care quality at hospital discharge and within 6 months postdischarge. METHODS: We conducted a cross-sectional hospital-level correlation analyses of chart-abstracted data for 3467 veterans discharged alive after an acute ischemic stroke from 108 Veterans Health Administration medical centers and 2380 veterans with postdischarge follow-up within 6 months in fiscal year 2007. Four risk-standardized processes of care represented discharge care quality: prescription of antithrombotic and antilipidmic therapy, anticoagulation for atrial fibrillation, and tobacco cessation counseling along with a composite measure of defect-free care. Five risk-standardized intermediate outcomes represented postdischarge care quality: achievement of blood pressure, low-density lipoprotein, international normalized ratio, and glycosylated hemoglobin target levels, and delivery of appropriate treatment for poststroke depression along with a composite measure of achieved outcomes. RESULTS: Median risk-standardized composite rate of defect-free care at discharge was 79%. Median risk-standardized postdischarge rates of achieving goal were 56% for blood pressure, 36% for low-density lipoprotein, 41% for international normalized ratio, 40% for glycosylated hemoglobin, and 39% for depression management and the median risk-standardized composite 6-month outcome rate was 44%. The hospital composite rate of defect-free care at discharge was correlated with meeting the low-density lipoprotein goal (r=0.31; P=0.007) and depression management (r=0.27; P=0.03) goal but was not correlated with blood pressure, international normalized ratio, glycosylated hemoglobin goals, nor with the composite measure of achieved postdischarge outcomes (probability values >0.13). CONCLUSIONS: Hospital discharge care quality was not consistently correlated with ambulatory care quality.

Evaluation of a VHA collaborative to improve follow-up after a positive colorectal cancer screening test.

BACKGROUND: In 2005, the Veterans Health Administration initiated a yearlong Colorectal Cancer Care Collaborative (C4) to improve timely follow-up after positive fecal occult blood tests. METHODS: Twenty-one facilities formed local quality improvement (QI) teams. Teams received QI training, created process flow maps, implemented process changes, and shared learning through 2 face-to-face meetings, conference calls, and a discussion board. We evaluated pre-post change in the timeliness of follow-up among C4 facilities and 3 control facilities. Outcome measures included the proportion of patients receiving a follow-up colonoscopy within 1 year, the proportion receiving 60-day follow-up (the focus of C4 teams), and average days to colonoscopy. Survey data from C4 team members was analyzed to identify predictors of facility-level improvement. RESULTS: Both C4 and control facilities improved on 1-year follow-up (10% and 9% increases, respectively, both P's<0.001). There was a statistically significant increase in the proportion receiving 60-day follow-up among C4 facilities (27% pre-C4 vs. 39% post-C4, P=0.008) but a nonsignificant decrease among control facilities (45% pre-C4 vs. 29% post-C4, P=0.14). Average days to colonoscopy decreased significantly among C4 facilities (129 pre-C4 vs. 103 post-C4, P=0.004) but increased significantly among control facilities (81 pre-C4 vs. 103 post-C4, P=0.04). Teams with the most improvement established clear roles/goals, had previous QI training, made more use of QI tools, and incorporated primary care education into their improvement work. CONCLUSIONS: A Veterans Health Administration improvement collaborative modestly decreased time to colonoscopy after a positive colorectal cancer screening test but significant room for improvement remains and benefits of participation were not realized by all facilities.

Prevalence of inadequate blood pressure control among veterans after acute ischemic stroke hospitalization: a retrospective cohort.

BACKGROUND: Reducing blood pressure (BP) after stroke reduces risk for recurrent events. Our aim was to describe hypertension care among veterans with ischemic stroke including BP control by discharge and over the 6 months after the stroke event. METHODS AND RESULTS: The Office of Quality and Performance Stroke Special Study included a systematic sample of veterans hospitalized for ischemic stroke in 2007. We examined BP control (<140/90 mm Hg) at discharge excluding those who died, enrolled in hospice, or had unknown discharge disposition (n=3640, n=3382 adjusted analysis). The second outcome was BP control (<140/90 mm Hg) within 6-months after stroke, excluding patients who died/readmitted within 30 days, were lost to follow-up, or did not have a BP recorded (n=2054, n=1915 adjusted analysis). The population was 62.7% white and 97.7% men; 46.9% were <65 years of age; and 29% and 37% had a history of cerebrovascular or cardiovascular disease, respectively. Among the 3640 stroke patients, 1573 (43%) had their last documented BP before discharge as >140/90 mm Hg. Black race (adjusted odds ratio, 0.77; 95% confidence interval, 0.65 to 0.91), diabetes (odds ratio, 0.73; 95% confidence interval, 0.62 to 0.86), and hypertension history (odds ratio, 0.51; 95% confidence interval, 0.42 to 0.63) were associated with lower odds for controlled BP at discharge. Of the 2054 stroke patients seen within 6 months from their index event, 673 (32.8%) remained uncontrolled. By 6 months after the event, neither race nor diabetes was associated with BP control, whereas history of hypertension continued to have lower odds of BP control. For each 10-point increase in systolic BP >140 mm Hg at discharge, odds of BP control within 6 months after discharge decreased by 12% (95% confidence interval [8%, 18%]). CONCLUSIONS: BP values in excess of national guidelines are common after stroke. Forty-three percent of patients were discharged with an elevated BP, and 33% remained uncontrolled by 6 months.

Quality of nonmetastatic colorectal cancer care in the Department of Veterans Affairs.

PURPOSE: The Veterans Affairs (VA) healthcare system treats approximately 3% of patients with cancer in the United States each year. We measured the quality of nonmetastatic colorectal cancer (CRC) care in VA as indicated by concordance with National Comprehensive Cancer Network practice guidelines (six indicators) and timeliness of care (three indicators). PATIENTS AND METHODS: A retrospective medical record abstraction was done for 2,492 patients with incident stages I to III CRC diagnosed between October 1, 2003, and March 31, 2006, who underwent definitive CRC surgery. Patients were treated at one or more of 128 VA medical centers. The proportion of patients receiving guideline-concordant care and time intervals between care processes were calculated. RESULTS: More than 80% of patients had preoperative carcinoembryonic antigen determination (ie, stages II to III disease) and documented clear surgical margins (ie, stages II to III disease). Between 72% and 80% of patients had appropriate referral to a medical oncologist (ie, stages II to III disease), preoperative computed tomography scan of the abdomen and pelvis (ie, stages II to III disease), and adjuvant fluorouracil-based chemotherapy (ie, stage III disease). Less than half of patients with stages I to III CRC (43.5%) had a follow-up colonoscopy 7 to 18 months after surgery. The mean number of days between major treatment events included the following: 26.6 days (standard deviation [SD], 38.2; median, 20 days) between diagnosis and initiation of treatment (in stages II to III disease); 64.8 [corrected] days (SD, 54.9; median, 50 days) between definitive surgery and start of adjuvant chemotherapy (in stages II to III disease); and 444.2 [corrected] days (SD, 182.1; median, 393 days) between definitive surgery and follow-up colonoscopies (in stages I to III disease). CONCLUSION: Although there is opportunity for improvement in the area of cancer surveillance, the VA performs well in meeting established guidelines for diagnosis and treatment of CRC.

Developing and sustaining quality improvement partnerships in the VA: the Colorectal Cancer Care Collaborative.

OBJECTIVE: The Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) seeks to develop partnerships between VA health services researchers and clinical managers, with the goal of designing and evaluating interventions to improve the quality of VA health care. METHODS: In the present report we describe one such initiative aimed at enhancing the continuum of colorectal cancer (CRC) care, including diagnosis, treatment and surveillance-the Colorectal Cancer Care Collaborative (C4). RESULTS: We describe the process and thinking that led to two parallel quality improvement "collaboratives" that addressed (1) CRC screening and diagnostic follow-up and (2) the guideline concordance and timeliness of CRC treatment. Additionally, we discuss ongoing effort to spread lessons learned during the first stages of the project, which initially occurred at only a subset of VA facilities, throughout the VA health care system. The description of this initiative is organized around key questions that must be answered when developing, sustaining and spreading multi-component quality improvement interventions. CONCLUSION: We conclude with a discussion of lessons learned that we believe would apply to similar initiatives elsewhere, even if they address different clinical issues in health care settings with different organizational structures.

Timely follow-up of positive fecal occult blood tests strategies associated with improvement.

BACKGROUND: In light of previous research indicating that many patients fail to receive timely diagnostic follow-up of positive colorectal cancer (CRC) screening tests, the Veterans Health Administration (VA) initiated a national CRC diagnosis quality-improvement (QI) effort. PURPOSE: This article documents the percent of patients receiving follow-up within 60 days of a positive CRC screening fecal occult blood test (FOBT) and identifies improvement strategies that predict timely follow-up. METHODS: In 2007, VA facilities completed a survey in which they indicated the degree to which they had implemented a series of improvement strategies and described barriers to improvement. Three types of strategies were assessed: developing QI infrastructure, improving care delivery processes, and building gastroenterology capacity. Survey data were merged with a measure of 60-day positive-FOBT follow-up. Facility-level predictors of timely follow-up were identified and relationships among categories of improvement strategies were assessed. Data were analyzed in 2008. RESULTS: The median facility-reported 60-day follow-up rate for positive screening FOBTs was 24.5%. Several strategies were associated with timeliness of follow-up. The relationship between the implementation of QI infrastructure strategies and timely follow-up was mediated by the implementation of process-change strategies. Although constraints on gastroenterology capacity were often sited as a key barrier, implementation of strategies to address this issue was unassociated with timely follow-up. CONCLUSIONS: Developing QI infrastructure appears to be an effective strategy for improving FOBT follow-up when this work is followed by process improvements. Increasing gastroenterology capacity may be more difficult than improving processes of care.

Hospital characteristics associated with timeliness of care in veterans with lung cancer.

RATIONALE: Timeliness is one of six important dimensions of health care quality recognized by the Institute of Medicine. OBJECTIVES: To evaluate timeliness of lung cancer care and identify institutional characteristics associated with timely care within the Veterans Affairs (VA) health care system. METHODS: We used data from a VA nation-wide retrospective chart review and an independent audit of VA cancer programs to examine the association between time to first treatment and potentially explanatory institutional characteristics (e.g., volume of lung cancer patients) for 2,372 veterans diagnosed with lung cancer between 1 January 2002 and 1 September 2005 at 127 VA medical centers. We developed linear mixed effects models to control for clustering of patients within hospitals and we stratified analyses by stage. MEASUREMENTS AND MAIN RESULTS: Median time to treatment varied widely between (23 to 182 d) and within facilities. Median time to treatment was 90 days in patients with stage I or II cancer and 52 days in those with more advanced disease (P < 0.0001). Factors associated with shorter times to treatment included a nonacademic setting and the existence of a specialized diagnostic clinic (in patients with limited-stage disease), performing a patient flow analysis (in patients with advanced disease), and leadership beliefs about providing timely care (in both groups). However, institutional characteristics explained less than 1% of the observed variation in treatment times. CONCLUSIONS: Time to lung cancer treatment in U.S. veterans is highly variable. The numerous institutional characteristics we examined explained relatively little of this variability, suggesting that patient, clinician, and/or unmeasured institutional characteristics may be more important determinants of timely care.

Timeliness across the continuum of care in veterans with lung cancer.

INTRODUCTION: By providing timely care at all steps along the continuum of lung cancer care, providers may be able to limit disease progression before treatment and possibly improve clinical outcomes. This study examines the timeliness of key events in the process of care between initial radiograph and first treatment. METHODS: Dates of key events were extracted from the medical records of 2463 veterans receiving lung cancer care at 133 Department of Veterans Affairs (VA) facilities. After reviewing their site's abstraction results, facility leaders completed a survey on their perceptions of their local processes of lung cancer care. RESULTS: Median time from first radiography to first treatment was 71 days. The longest intermediate time interval examined was between first treatment referral and first treatment (median = 12 days). Time from first to last diagnostic test was most variable (interquartile range = 0-27 days). We found a significant trend indicating that the time interval from first radiograph to treatment was shorter for patients with more advanced disease. This effect was also significant within six of the seven intermediate time intervals we examined. Survey responses indicated that the chart review process stimulated improvement activity. CONCLUSIONS: Although patients with earlier stage disease benefit more from treatment, they do not proceed as quickly through the continuum of care as patients with more advanced disease. By measuring variability in timeliness of care at multiple steps in the lung cancer care process, facilities may identify opportunities for improvement.

Timely administration of prophylactic antibiotics for major surgical procedures.

BACKGROUND: Prophylactic antibiotics (PA) given within 60 minutes before surgical incision decrease risk of subsequent surgical site infection. Nationwide quality improvement initiatives have focused on improving the proportion of patients who receive timely prophylactic antibiotics. STUDY DESIGN: This is a cohort study of major surgical procedures performed in 108 Veterans Affairs hospitals between January and December 2005. Using data from the External Peer Review Program and the National Surgical Quality Improvement Program, we examined factors associated with timely PA administration. Univariate and multivariable analyses were performed. RESULTS: There were 8,137 major surgical procedures: cardiac (2,664), hip and knee arthroplasty (3,603), colon (1,142), arterial vascular (606), and hysterectomy (122). Timely PA occurred in 76.2% of patients, 18.2% received them too early, and 5.4% received them too late. Early administration accounted for 79% of untimely PA. Differences in timeliness were seen by procedure type (68% to 87%; p < 0.0001), admission status (67% to 80%; p < 0.0001), and antibiotic class (65% to 89%; p < 0.0001). PA administration occurred in the operating room for 63.5% of patients. When PA administration occurred in the operating room, they were timely in 89% of patients, compared with 54% of patients where administration was outside the operating room (odds ratio, 7.74; 95% CI = 6.49 to 9.22). CONCLUSIONS: Early PA administration accounted for the majority of inappropriately timed PA. Efforts to improve performance on this measure should focus on administering antibiotics in the operating room.

Sex, quality of care, and outcomes of elderly patients hospitalized with heart failure: findings from the National Heart Failure Project.

BACKGROUND: Previous studies have demonstrated that women hospitalized for heart failure receive poorer quality of care and have worse outcomes than men. However, these studies were based upon selected patient populations and lacked quality of care measures. METHODS: We used data from the National Heart Failure Project, a national sample of fee-for-service Medicare patients hospitalized with heart failure in the United States in 1998-1999, to evaluate differences in quality of care and patient outcomes between men and women. Multivariable hierarchical logistic regression models and chi2 analyses were used to examine sex differences in the documentation of left ventricular systolic function (LVSF), prescription of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) for patients with left ventricular dysfunction, and mortality within 30 days and 1 year of admission in the study cohort (n = 30,996). RESULTS: Women had lower overall rates of LVSF assessment than men (64.9% vs 69.5%, P < .001). Among patients classified as candidates for ACE inhibitor prescription, women had lower crude rates of ACE inhibitor prescription than men (70.1% vs 74.2%, P = .015), but treatment rates were similar when evaluating the prescription of ACE inhibitors or ARBs (78.9% women vs 81.3% men, P = .11). Despite lower rates of treatment, women had lower mortality rates than men at 30 days (9.2% vs 11.4%, P < .001) and 1 year (36.2% vs 43.0%, P < .001) after admission. Results were similar after multivariable adjustment. CONCLUSIONS: There were small sex differences in the quality of care provided to fee-for-service Medicare patients hospitalized with heart failure, although women had higher rates of survival than men up to 1 year after hospitalization.

Provider and hospital characteristics associated with geographic variation in the evaluation and management of elderly patients with heart failure.

BACKGROUND: Rates of guideline-based care for elderly patients with heart failure vary by state, and overall are not optimal. Identifying factors associated with the lack of uniformly high-quality health care might aid efforts to improve care. We therefore sought to determine the extent to which provider and hospital characteristics contribute to small-area geographic variation in heart failure care after controlling for patient factors. METHODS: We studied 30 228 Medicare patients who were older than 65 years and hospitalized with heart failure. We mapped rates for 2 quality measures-documentation of left ventricular ejection fraction and appropriate prescription of angiotensin-converting enzyme inhibitors-across the United States, using a Bayesian technique that smooths rates and enhances assessment for significant patterns of small-area variation. We used nonlinear hierarchical models to assess for associations between the the quality indicators and provider and hospital characteristics independent of patient characteristics. RESULTS: Smoothed, unadjusted rates of left ventricular ejection fraction documentation ranged from 30.1% to 67.2% and of angiotensin-converting enzyme inhibitor prescription from 55.8% to 87.1% among hospital referral regions; regional patterns were apparent. After patient factors were controlled for, care at hospitals without a medical school affiliation, without invasive cardiac capabilities, or in a rural location, as well as not having a cardiologist as an attending physician, was significantly associated with lower rates of left ventricular ejection fraction documentation. Hospitalization at a nonteaching facility was significantly associated with failure to prescribe angiotensin-converting enzyme inhibitors. CONCLUSION: Characteristics of providers and hospitals explain in part the geographic variation in guideline-based care for elderly patients with heart failure.

Quality improvement for pressure ulcer care in the nursing home setting: the Northeast Pressure Ulcer Project.

OBJECTIVES: The objectives of this study were to evaluate the impact of a collaborative model of quality improvement in nursing homes on processes of care for the prevention and treatment of pressure ulcers. STUDY DESIGN: The study design was experimental. SETTING: We studied 29 nursing homes in New Jersey, Pennsylvania, and Rhode Island. PARTICIPANTS: Participants consisted of pressure ulcer quality improvement teams in 29 nursing homes. INTERVENTION: Quality improvement teams attended a series of workshops to review clinical guidelines and quality improvement principles and to share best practices, and worked one-on-one with mentors to implement quality improvement techniques and to collect data independently. MEASUREMENTS: We calculated process measures based on the Agency for Healthcare Research and Quality (AHRQ) guidelines. Process measures addressed each facility's processes of care for the prevention and treatment of pressure ulcers at baseline and after 12 months of intervention. Prevention measures focused on recent admissions and high-risk residents; treatment measures focused on patients newly diagnosed with pressure ulcers and all patients with pressure ulcers. RESULTS: Overall, 6 of 8 prevention process measures improved significantly, with percent difference between baseline and follow up ranging from 11.6% to 24.5%. Three of 4 treatment process measures improved significantly, with 5.0%, 8.9%, and 25.9% difference between baseline and follow up. For each process measure, between 5 and 12 facilities demonstrated significant improvement between baseline and follow up, and only 2 or fewer declined for each process measure. CONCLUSION: Improvement in processes of care after the use of a structured collaborative quality improvement approach is possible in the nursing home setting.