Alternative pay-for-performance scoring methods: implications for quality improvement and patient outcomes.

BACKGROUND: Pay-for-performance programs typically rate hospitals using a composite summary score in which process measures are weighted by the total number of treatment opportunities. Alternative methods that weight process measures according to how hospitals organize care and the range for possible improvement may be more closely related to patient outcomes. OBJECTIVES: To develop a hospital-level summary process measure adherence score that reflects how hospitals organize cardiac care and the range for possible improvement; and to compare associations of hospital adherence to this score and adherence to a composite score based on the Centers for Medicare and Medicaid Services scoring system with inpatient mortality. RESEARCH DESIGN AND SUBJECTS: Hospital-level analysis of 7 process measures for acute myocardial infarction (AMI) and 4 process measures for heart failure at 4226 hospitals, and inpatient mortality after AMI at 1351 hospitals in the United States. Data are from the Hospital Compare and Joint Commission Core Measures databases for October 2004 through September 2006. MEASURES: Associations between composite scores based on Centers for Medicare and Medicaid Services methodology and alternative adherence scores with inpatient survival after AMI. RESULTS: In principal components analysis, hospital cardiac care varied between hospitals largely along the lines of "clinical" (ie, pharmacologic interventions) and "administrative" (ie, patient instructions or counseling) activities. A scoring system reflecting this organization was strongly associated with inpatient survival and fit the mortality data better than the composite score. Higher administrative activities scores, holding the clinical activities score fixed, were associated with lower survival. CONCLUSIONS: In-hospital cardiac care is organized by clinical and administrative processes of care. Pay-for-performance schemes that incentivize hospitals to focus on administrative process measures may be associated with decreased adherence to clinical processes. A pay-for-performance scheme that acknowledges these factors may be associated with improved inpatient mortality.

A framework for quality improvement: an analysis of factors responsible for improvement at hospitals participating in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) quality improvement initiative.

BACKGROUND: Hospitals are under increasing pressure to improve their quality of care. However, a key question remains: how can hospitals best design and implement successful quality improvement (QI) programs? Hospitals currently employ a variety of QI initiatives but have little empirical evidence on which to base their quality efforts. METHODS: We designed and applied a hospital cross-sectional survey to 212 hospitals participating in CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines), a voluntary QI initiative of patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS). We factor analysis and an ordinary least squares regression model to determine the key hospital factors most associated with unexpected improvements in institutional QI in the treatment of NSTE ACS. RESULTS: From 2002 to 2004, the following factors had a significant association with unexpected increases in the 2004 QI in NSTE ACS treatment: the use of CRUSADE QI tools, clinical commitment to quality by a cardiology coadvocate, institutional financial commitment to quality, and barriers to QI related to resource availability and cultural resistance to change (all P < .10). Of these factors, optimal use of CRUSADE QI tools was associated with the highest absolute improvement in process adherence score relative to other factors. CONCLUSIONS: We identified several institutional factors associated with improved quality of care in the treatment of high-risk NSTE ACS. We hope that this evidence-based framework will help guide the development and implementation of future QI programs in order to improve the institutional quality of care for NSTE ACS.

Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days.

OBJECTIVES: To determine whether hospitals where patients report higher overall satisfaction with their interactions among the hospital and staff and specifically their experience with the discharge process are more likely to have lower 30-day readmission rates after adjustment for hospital clinical performance. STUDY DESIGN: Among patients 18 years or older, an observational analysis was conducted using Hospital Compare data on clinical performance, patient satisfaction, and 30-day risk-standardized readmission rates for acute myocardial infarction, heart failure, and pneumonia for the period July 2005 through June 2008. METHODS: A hospital-level multivariable logistic regression analysis was performed for each of 3 clinical conditions to determine the relationship between patient-reported measures of their satisfaction with the hospital stay and staff and the discharge process and 30-day readmission rates, while controlling for clinical performance. RESULTS: In samples ranging from 1798 hospitals for acute myocardial infarction to 2562 hospitals for pneumonia, higher hospital-level patient satisfaction scores (overall and for discharge planning) were independently associated with lower 30-day readmission rates for acute myocardial infarction (odds ratio [OR] for readmission per interquartile improvement in hospital score, 0.97; 95% confidence interval [CI], 0.94-0.99), heart failure (OR, 0.96; 95% CI, 0.95-0.97), and pneumonia (OR, 0.97; 95% CI, 0.96-0.99). These improvements were between 1.6 and 4.9 times higher than those for the 3 clinical performance measures. CONCLUSIONS: Higher overall patient satisfaction and satisfaction with discharge planning are associated with lower 30-day risk-standardized hospital readmission rates after adjusting for clinical quality. This finding suggests that patient-centered information can have an important role in the evaluation and management of hospital performance.

Patient satisfaction and its relationship with clinical quality and inpatient mortality in acute myocardial infarction.

BACKGROUND: Hospitals use patient satisfaction surveys to assess their quality of care. A key question is whether these data provide valid information about the medically related quality of hospital care. The objective of this study was to determine whether patient satisfaction is associated with adherence to practice guidelines and outcomes for acute myocardial infarction and to identify the key drivers of patient satisfaction. METHODS AND RESULTS: We examined clinical data on 6467 patients with acute myocardial infarction treated at 25 US hospitals participating in the CRUSADE initiative from 2001 to 2006. Press Ganey patient satisfaction surveys for cardiac admissions were also available from 3562 patients treated at these same 25 centers over this period. Patient satisfaction was positively correlated with 13 of 14 acute myocardial infarction performance measures. After controlling for a hospital's overall guideline adherence score, higher patient satisfaction scores were associated with lower risk-adjusted inpatient mortality (P=0.025). One-quartile changes in both patient satisfaction and guideline adherence scores produced similar changes in predicted survival. For example, a 1-quartile change (75th to 100th) in either the patient satisfaction score or the guideline adherence score yielded the same change in predicted survival (odds ratio, 1.24; 95% CI, 1.02 to 1.49; and odds ratio, 1.24; 95% CI, 1.08 to 1.41, respectively). Satisfaction with nursing care was the most important determinant of overall patient satisfaction (P<0.001). CONCLUSIONS: Higher patient satisfaction is associated with improved guideline adherence and lower inpatient mortality rates, suggesting that patients are good discriminators of the type of care they receive. Thus, patients' satisfaction with their care provides important incremental information on the quality of acute myocardial infarction care.