An asthma and diabetes quality improvement project: enhancing care in clinics and community health centers.

Asthma and diabetes are major chronic conditions in the United States, particularly in the Medicaid population. The majority of care for these diseases occurs at ambulatory practice sites. The New York State Department of Health Office of Health Insurance Programs (OHIP) worked with IPRO, the New York State Medicare quality improvement organization, to develop and implement a quality improvement project (QIP) for these conditions. The approach was based upon the Chronic Care Model and used an iterative academic-detailing methodology. Clinics and community health centers volunteered to participate and used IPRO-collected data with audit and feedback to improve their practices. Several metrics significantly improved for asthma (e.g., use of anti-inflammatory long term controller agents, assessment of asthma severity, use of asthma action plans) and for diabetes (e.g., lipid testing and control, A1c testing). Key organizational elements of success included senior medical leadership commitment and practice site quality improvement team meetings. OHIP has used the QIP experience to begin patient-centered medical home implementation in New York State.

Transforming the mortality review conference to assess palliative care in the acute care setting: a feasibility study.

OBJECTIVE: This project sought to evaluate the impact of a hospital-based Palliative Care Consultation (PCC) service utilizing a common practice: the resident mortality review conference. METHOD: Internal Medicine residents used a revised chart audit tool during the mortality review conference, which included domains described in the Clinical Practice Guidelines for Quality Palliative Care (2004). This study attempted to transform the common practice into a methodology for collecting data that could be used as a platform to assess the quality of hospital care near the end of life. In this review, the residents were asked not only "what care was delivered appropriately?" but "what could we have done?" to relieve the patient's and family's suffering. RESULTS: The results showed that the mortality review process could be used to assess care at the end of life. It also showed that those patients who received a PCC received better care. Symptoms were addressed at a significantly higher rate for those patients who received a PCC than for those who did not. Specifically, these were symptoms of pain (75% vs. 51%, p < .0001), dyspnea (75% vs. 59%, p < 0.0001), nausea (28% vs. 18%, p < 0.0001), and agitation (53% vs. 33%, p < 0.0001). SIGNIFICANCE OF RESULTS: The mortality review process was found to be valuable in assessing care delivery for patients near the end of life. The tool yielded results that were consistent with findings of other studies looking at pain and symptom management, advance care planning, and the rate of palliative care consults across major diagnostic categories, supporting the face validity of the mortality review process.

Comparison of processes and outcomes of pneumonia care between hospitalists and community-based primary care physicians.

OBJECTIVE: To compare medical care provided by hospitalists and primary care physicians to patients with community-acquired pneumonia in order to identify specific practices that might explain the improved efficiency of care provided by hospitalists. PATIENTS AND METHODS: We retrospectively reviewed the medical charts of 455 patients hospitalized with pneumonia at a community-based tertiary care center between January 1, 1998, and January 1, 1999. Exclusion criteria included human immunodeficiency virus infection, lung cancer, active tuberculosis, hospitalization within 7 days, length of stay (LOS) more than 14 days, and requirement of mechanical ventilation. All patients were cared for by either a full-time hospitalist or a primary care physician. Data collected included patient insurance status, variables to calculate each patient's Pneumonia Severity Index score, initial antibiotic selection, door-to-needle time, time to patient stability for switch to oral antibiotics, time to actual switch, unstable variables at discharge, and subspecialty consultation rate. Each patient's initial chest x-ray film was reviewed and classified as diagnostic of pneumonia, indeterminate, or clear. Outcomes measured via administrative database were mortality, LOS, costs, and readmission rate. RESULTS: Primary care physicians cared for 270 patients, and hospitalists cared for 185. Primary care physician patients were older, and this group had a higher proportion of the highest-risk patients. The mean time to stability was 3.2 days for hospitalists and 3.3 days for primary care physicians, and the mean time from stability to actual switch from intravenous to oral antibiotics was 1.6 days and 23 days, respectively (P=.003). The mean adjusted LOS was 5.6 days for hospitalists and 6.5 days for primary care physicians. Similarly adjusted costs were $594 less per patient treated by hospitalists. A difference in door-to-needle time of 0.9 hour favoring primary care physicians did not contribute to LOS. No significant differences were noted in adjusted inpatient mortality or the appropriateness of initial antibiotics used. Primary care physicians were more likely to prescribe clindamycin and ceftazidime, and they requested infectious disease consultations more often. At discharge, 14% of hospitalist patients and 7% of primary care physician patients had at least 1 unstable variable. Differences in hospital readmission rates at 15 and 30 days were not statistically significant in combined or risk-stratified analyses. CONCLUSIONS: Inpatients with community-acquired pneumonia cared for by hospitalists had a shorter adjusted LOS than those seen by primary care physicians primarily because of earlier recognition of stability and more rapid conversion from intravenous to oral antibiotics. Adjusted costs were likewise reduced. However, patients seen by hospitalists were discharged with an unstable clinical variable more often. Other than earlier switch to oral antibiotics, less use of clindamycin and ceftazidime, and fewer infectious disease consultations, hospitalists' processes of care were similar to those of primary care physicians.

Limited impact of a multicenter intervention to improve the quality and efficiency of pneumonia care.

STUDY OBJECTIVES: To evaluate the impact of a multifactorial intervention to improve the quality, efficiency, and patient understanding of care for community-acquired pneumonia. DESIGN: Times series cohort study. SETTING: Four academic health centers in the New York City metropolitan area. PATIENTS OR PARTICIPANTS: All consecutive adults hospitalized for pneumonia during a 5-month period before (n = 1,013) and after (n = 1,081) implementation of an inpatient quality improvement (QI) initiative. INTERVENTIONS: A multidisciplinary team of opinion leaders developed evidence-based treatment guidelines and critical pathways, conducted educational sessions with physicians, distributed pocket reminder cards, promoted standardized orders, and developed bilingual patient education materials. MEASUREMENTS AND RESULTS: The average age was 71.4 years, and 44.1% of cases were low risk, 36.8% were moderate risk, and 19.2% were high risk. The preintervention and postintervention groups were well matched on age, sex, race, nursing home residence, pneumonia severity, initial presentation, and most major comorbidities. The intervention increased the use of guideline-recommended antimicrobial therapy from 78.1 to 83.4% (p = 0.003). There was also a borderline decrease in the proportion of patients being discharged prior to becoming clinically stable, from 27.0 to 23.5% (p = 0.06). However, there were no improvements in the other targeted indicators, including time to first dose of antibiotics, proportion receiving antibiotics within 8 h, timely switch to oral antibiotics, timely discharge, length of stay, or patient education outcomes. CONCLUSIONS: This real-world QI program was able to improve modestly on some quality indicators, but not effect resource use or patient knowledge of their disease. Changing physician and organizational behavior in academic health centers will require the development and implementation of more intensive, system-oriented strategies.

The relationship between organizational systems and clinical quality in diabetes care.

OBJECTIVE: To assess the clinical quality of diabetes care and the systems of care in place in Medicare managed care organizations (MCOs) to determine which systems are associated with the quality of care. STUDY DESIGN: Cross-sectional, observational study that included a retrospective review of 2001 diabetes Health Plan Employer and Data Information Set (HEDIS) measures and a mailed survey to MCOs. METHODS: One hundred and thirty-four plans received systems surveys. Data on clinical quality were obtained from HEDIS reports of diabetes measures. RESULTS: Ninety plans returned the survey. Composite diabetes quality scores (CDSs) were based on averaging scores for the 6 HEDIS diabetes measures. For the upper quartile of responding plans, the average score was 77.6. The average score for the bottom quartile was 53.9 (P < .001). The mean number of systems or interventions for the upper-quartile group and the bottom-quartile group was 17.5 and 12.5 (P < .01), respectively. There were significant differences in the 2 groups in the following areas: computer-generated reminders, physician champions, practitioner quality-improvement work groups, clinical guidelines, academic detailing, self-management education, availability of laboratory results, and registry use. After adjusting for structural and geographic variables, practitioner input and use of clinical-guidelines software remained as independent predictors of CDS. Structural variables that were independent predictors were nonprofit status and increasing number of Medicare beneficiaries in the MCO. CONCLUSIONS: MCO structure and greater use of systems/interventions are associated with higher-quality diabetes care. These relationships require further exploration.

The impact of do-not-resuscitate order on triage decisions to a medical intensive care unit.

PURPOSE: To determine whether the presence of a do-not-resuscitate (DNR) order impacts on triage decisions to a medical intensive care unit (MICU) of an academic medical center. METHODS: Data were collected on 179 patients in whom MICU consultation was sought and included demographic, clinical information, diagnoses, ICU admission decision, Acute Physiological and Chronic Health Evaluation II (APACHE II) score, and the presence of DNR order. Functional status was determined retrospectively using the Modified Rankin Score. RESULTS: The only factor that influenced MICU admission was the presence of DNR order at the time of MICU consultation (odds ratio, 0.25; 95% confidence interval, 0.09-0.71, P < .006). There was no difference between the age, APACHE II scores, or functional status between admitted or refused. Medical intensive care unit admission was associated with increased length of stay without difference in mortality. CONCLUSION: The presence of a DNR order at the time of MICU consultation was significantly associated with the decision to refuse a patient to the MICU.