RESUMO
This column is the fourth in a series describing Health Care Financing Administration initiatives to improve care for Medicare beneficiaries with heart failure. The first three papers addressed the background, design, and baseline results of the Health Care Financing Administration national initiative to improve quality of inpatient care for heart failure through the activities of each state's Health Care Financing Administration contractor Peer Review Organization. This paper describes a smaller-scale but equally important endeavor: the Heart Failure Practice Improvement Effort, a pilot project to test the feasibility of assessing and improving heart failure care in the outpatient setting. (c)2001 by CHF, Inc.
RESUMO
CONTEXT: Despite condition-specific and managed care-specific reports, no systematic program has been developed for monitoring the quality of medical care provided to Medicare beneficiaries. OBJECTIVE: To create a monitoring system for a range of measures of clinical performance that supports quality improvement and provides repeated, reliable estimates at the national and state levels for fee-for-service (FFS) Medicare beneficiaries. DESIGN, SETTING, AND PARTICIPANTS: National study of repeated, cross-sectional observational data collected in 1997-1999 on all Medicare FFS beneficiaries or on a representative sample of beneficiaries with a particular condition. Data were collected using medical record abstraction for inpatient care, analysis of Medicare claims for some ambulatory services, and surveys for immunization rates. Separate samples were drawn for each topic for each state. MAIN OUTCOME MEASURES: Beneficiary patients' receipt of 24 process-of-care measures related to primary prevention, secondary prevention, or treatment of 6 medical conditions (acute myocardial infarction, breast cancer, diabetes mellitus, heart failure, pneumonia, and stroke) for which there is strong scientific evidence and professional consensus that the process of care either directly improves outcomes or is a necessary step in a chain of care that does so. RESULTS: Across all states for all measures, the percentage of patients receiving appropriate care in the median state ranged from a high of 95% (avoidance of sublingual nifedipine for patients with acute stroke) to a low of 11% (patients with pneumonia screened for pneumococcal immunization status before discharge). The median performance on an indicator is 69% (patients discharged with heart failure diagnosis who received angiotensin-converting enzyme inhibitors; diabetic patients having an eye examination in the last 2 years). Some states (particularly less populous states and those in the Northeast) consistently ranked high in relative performance while others (particularly more populous states and those in the Southeast) consistently ranked low. CONCLUSIONS: It is possible to assemble information on a diverse set of clinical performance measures that represent performance on the range of services in a health insurance program. These findings indicate substantial opportunities to improve the care delivered to Medicare beneficiaries and urgently invite a partnership among practitioners, hospitals, health plans, and purchasers to achieve that improvement. JAMA. 2000;284:1670-1676.
Assuntos
Medicare/normas , Garantia da Qualidade dos Cuidados de Saúde/métodos , Indicadores de Qualidade em Assistência à Saúde , Neoplasias da Mama/terapia , Estudos Transversais , Diabetes Mellitus/terapia , Planos de Pagamento por Serviço Prestado/normas , Cardiopatias/terapia , Humanos , Auditoria Médica , Infarto do Miocárdio/terapia , Pneumonia/terapia , Garantia da Qualidade dos Cuidados de Saúde/estatística & dados numéricos , Acidente Vascular Cerebral/terapia , Estados UnidosAssuntos
Insuficiência Cardíaca/terapia , Qualidade da Assistência à Saúde/organização & administração , Antagonistas Adrenérgicos beta/uso terapêutico , Idoso , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Anticoagulantes/uso terapêutico , Aspirina/uso terapêutico , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Coleta de Dados , Digoxina/uso terapêutico , Terapia por Exercício , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/diagnóstico , Humanos , Serviços de Informação/organização & administração , Tempo de Internação/estatística & dados numéricos , Avaliação de Processos e Resultados em Cuidados de Saúde/métodos , Educação de Pacientes como Assunto/organização & administração , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/normas , Qualidade da Assistência à Saúde/economia , Encaminhamento e Consulta/organização & administração , Volume Sistólico , Estados Unidos , Disfunção Ventricular Esquerda/complicações , Disfunção Ventricular Esquerda/diagnóstico , Disfunção Ventricular Esquerda/tratamento farmacológicoRESUMO
This is the second in a series describing Health Care Financing Administration (HCFA) initiatives to improve care for Medicare beneficiaries with heart failure. The first article outlined the history of HCFA quality-improvement projects and current initiatives to improve care in six priority areas: heart failure, acute myocardial infarction, stroke, pneumonia, diabetes, and breast cancer. This article details the objectives and design of the Medicare National Heart Failure Quality Improvement Project (NHF), which has as its goal the improvement of inpatient heart failure care. (c)2000 by CHF, Inc.