Characterization of adverse events detected in a large health care delivery system using an enhanced global trigger tool over a five-year interval.

OBJECTIVE: To report 5 years of adverse events (AEs) identified using an enhanced Global Trigger Tool (GTT) in a large health care system. STUDY SETTING: Records from monthly random samples of adults admitted to eight acute care hospitals from 2007 to 2011 with lengths of stay ≥3 days were reviewed. STUDY DESIGN: We examined AE incidence overall and by presence on admission, severity, stemming from care provided versus omitted, preventability, and category; and the overlap with commonly used AE-detection systems. DATA COLLECTION: Professional nurse reviewers abstracted 9,017 records using the enhanced GTT, recording triggers and AEs. Medical record/account numbers were matched to identify overlapping voluntary reports or AHRQ Patient Safety Indicators (PSIs). PRINCIPAL FINDINGS: Estimated AE rates were as follows: 61.4 AEs/1,000 patient-days, 38.1 AEs/100 discharges, and 32.1 percent of patients with ≥1 AE. Of 1,300 present-on-admission AEs (37.9 percent of total), 78.5 percent showed NCC-MERP level F harm and 87.6 percent were "preventable/possibly preventable." Of 2,129 hospital-acquired AEs, 63.3 percent had level E harm, 70.8 percent were "preventable/possibly preventable"; the most common category was "surgical/procedural" (40.5 percent). Voluntary reports and PSIs captured <5 percent of encounters with hospital-acquired AEs. CONCLUSIONS: AEs are common and potentially amenable to prevention. GTT-identified AEs are seldom caught by commonly used AE-detection systems.

Description and evaluation of adaptations to the global trigger tool to enhance value to adverse event reduction efforts.

OBJECTIVE: To adapt the Global Trigger Tool (GTT) as a sustainable monitoring tool able to characterize adverse events (AEs) for organizational learning, within the context of limited resources. METHODS: Baylor Health Care System (BHCS) expanded the AE data collected to include judgments of preventability, presence on admission, relation to care provided or not provided, and narrative descriptions. To reduce costs, we focused on patients with length of stay (LOS) of 3 days or more, suspecting greater likelihood they had experienced an AE; adapted the sample size and frequency of review; and used a single nurse reviewer followed by quality assurance review within the Office of Patient Safety. We compared AE rates in patients with LOS of less than 3 days versus 3 days or greater, assessed trigger yields and interrater reliability, and submitted identified AEs to each hospital for validation as event types targeted for reduction. RESULTS: In 2008, 91% of identified AEs were in patients with LOS of 3 days or greater; there were 6.4 AEs per 100 discharges with LOS of less than 3 days versus 27.1 AEs per 100 discharges with LOS of 3 days or greater. Over 4 years, we reviewed 16,172 medical records; 14,184 had positive triggers, 17.1% of which were associated with an AE. Most AEs were identified via the "surgical" (36.3%) and "patient care" (36.0%) trigger modules. Reviewers showed fair to good agreement (κ = 0.62), and hospital clinical leaders strongly agreed that the identified events were AEs. CONCLUSIONS: The GTT can be adapted to health-care organizations' goals and resource limitations. This flexibility was essential in crossing our organization's "value threshold."

The effectiveness of implementing an electronic health record on diabetes care and outcomes.

OBJECTIVE: To assess the impact of electronic health record (EHR) implementation on primary care diabetes care. DATA SOURCES: Charts were abstracted semi-annually for 14,051 diabetes patients seen in 34 primary care practices in a large, fee-for-service network from January 1, 2005 to December 31, 2010. The study sample was limited to patients aged 40 years or older. STUDY DESIGN: A naturalistic experiment in which GE Centricity Physician Office-EMR 2005 was rolled out over a staggered 3-year schedule. DATA COLLECTION: Chart audits were conducted using the AMA/Physician Consortium Adult Diabetes Measure set. The primary outcome was the HealthPartners' "optimal care" measure: HbA1c ≤ 8 percent; LDL cholesterol < 100 mg/dl; blood pressure < 130/80 mmHg; not smoking; and documented aspirin use in patients ≥ 40 years of age. PRINCIPAL FINDINGS: After adjusting for patient age, sex, and insulin use, patients exposed to the EHR were significantly more likely to receive "optimal care" when compared with unexposed patients (p < .001), with an estimated difference of 9.20 percent (95% CI: 6.08, 12.33) in the final year between exposed patients and patients never exposed. Components of the optimal care bundle showing positive improvement after adjustment were systolic blood pressure <80 mmHg, diastolic blood pressure <130 mmHg, aspirin prescription, and smoking cessation. Among patients exposed to EHR, all process and outcome measures except HbA1c and lipid control showed significant improvement. CONCLUSION: Implementation of a commercially available EHR in primary care practice may improve diabetes care and clinical outcomes.

Changes over six years in administration of aspirin and beta blockers on arrival and timely reperfusion and in in-hospital and 30-day postadmission mortality in patients with acute myocardial infarction.

There is conflicting evidence regarding the impact of improving quality-of-care measures on patient outcomes. From July 2002 through June 2008, compliance with 3 in-hospital acute myocardial infarction quality-of-care measures (administration of aspirin and ß blockers on arrival, timely reperfusion) and mortality were assessed in consecutive patients eligible for ≥1 of the measures at 8 hospitals (n = 6,826). Adjusted odds ratios for in-hospital and 30-day postadmission mortality and rate ratios for compliance with the 3 quality-of-care measures were calculated using marginal structural models to assess differences over time. Compliance with the 3 in-hospital quality-of-care measures improved significantly over the 6-year period. Adjusted odds ratios (95% confidence intervals) revealed significant decreases in in-hospital mortality in cohorts eligible for aspirin at arrival (year 6 vs baseline 0.37, 0.22 to 0.65), ß blockers at arrival (year 6 vs baseline 0.24, 0.11 to 0.52), and an "all-eligible" measure comprising aspirin at arrival, ß blockers at arrival, and timely reperfusion (year 6 vs baseline 0.41, 0.24 to 0.69). Significant decreases in 30-day postadmission mortality followed the same pattern (aspirin at arrival 0.53, 0.35 to 0.80; ß blockers at arrival 0.43, 0.26 to 0.73; all-eligible measure 0.54, 0.36 to 0.81). In conclusion, over the 6-year study period, the health care system's compliance with the 3 in-hospital quality-of-care measures and 30-day mortality improved significantly.

Health care reform at trauma centers--mortality, complications, and length of stay.

OBJECTIVE: The Trauma Quality Improvement Program has demonstrated existence of significant variations in risk-adjusted mortality across trauma centers. However, it is unknown whether centers with lower mortality rates also have reduced length of stay (LOS), with associated cost savings. We hypothesized that LOS is not primarily determined by unmodifiable factors, such as age and injury severity, but is primarily dependent on the development of potentially preventable complications. METHODS: The National Trauma Data Bank (2002-2006) was used to include patients (older than 16 years) with at least one severe injury (Abbreviated Injury Scale score ≥ 3) from Level I and II trauma centers (217,610 patients, 151 centers). A previously validated risk-adjustment algorithm was used to calculate observed-to-expected mortality ratios for each center. Poisson regression was used to determine the relationship between LOS, observed-to-expected mortality ratios, and complications while controlling for confounding factors, such as age, gender, mechanism, insurance status, comorbidities, and injuries and their severity. RESULTS: Large variations in LOS (median, 4-8 days) were observed across trauma centers. There was no relationship between mortality and LOS. The most important predictor of LOS was complications, which were associated with a 62% increase. Injury severity score, shock, gunshot wounds, brain injuries, intensive care unit admission, and comorbidities were less important predictors of LOS. CONCLUSION: Quality improvement programs focusing on mortality alone may not be associated with reduced LOS. Hence, the Trauma Quality Improvement Program should also focus on processes of care that reduce complications, thereby shortening LOS, which may lead to significant cost savings at trauma centers.

Clinical quality is independently associated with favorable bond ratings.

The relation between clinical quality and bond rating for nonprofit hospitals has been proposed but never fully studied. We analyzed the relation between bond rating, clinical quality measures (The Joint Commission/Centers for Medicare and Medicaid Services [CMS] core measures), and balance sheet and income statement financial measures of 236 hospitals across the United States that are rated by Moody's Investors Service and that reported clinical quality measures to CMS during the study period. We found a statistically significant relation between higher quality measures and more favorable bond ratings. This association remained significant after controlling for traditional financial parameters.

Prophylaxis for venous thromboembolism during rehabilitation for traumatic brain injury: a multicenter observational study.

BACKGROUND: Deep venous thrombosis (DVT) is a major cause of mortality and morbidity after traumatic brain injury (TBI). There is no consensus regarding appropriate screening, prophylaxis, or treatment during acute rehabilitation. METHODS: This prospective observational study evaluated prophylactic anticoagulation during rehabilitation in patients with TBI aged 16 years or older admitted to 12 TBI Model Systems rehabilitation centers (July 2004-December 2007). After propensity score stratification within center, the odds ratio associated with incidence of symptomatic DVT or pulmonary embolism (PE) for patients who did and did not receive prophylactic anticoagulation was estimated using conditional logistic regression in patients who were not screened for DVT on rehabilitation admission or who screened negative; the analysis was repeated in these two subgroups. RESULTS: Patients with identified DVTs at rehabilitation admission (n = 266) were excluded, leaving 1,897 patients: 1,002 screened negative, 895 unscreened; 932 received prophylactic anticoagulation, and 965 did not. Symptomatic DVT/PE was detected in 32 patients (15 of 932 [1.6%] with prophylaxis, 17 of 965 [1.8%] without). After propensity score adjustment, the odds ratio (95% confidence interval) for symptomatic DVT/PE with prophylaxis versus no prophylaxis was 0.80 (0.33-1.94) in the full analytic population and 0.46 (0.12-1.84) in the screened-negative subgroup. The only probable venous thromboembolism-related death occurred in the prophylactic anticoagulation group. Fewer new/expanded intracranial hemorrhages occurred among patients who received prophylactic anticoagulation. CONCLUSIONS: Prophylactic anticoagulation during rehabilitation seemed safe for TBI patients whose physicians deemed it appropriate, but did not conclusively reduce venous thromboembolism. Given the number of DVTs present before rehabilitation, screening and prophylaxis during acute care may be more important.

A High Level of Patient Activation Is Observed But Unrelated to Glycemic Control Among Adults With Type 2 Diabetes.

OBJECTIVE: To measure patient activation and its relationship to glycemic control among adults with type 2 diabetes who had not participated in a formal diabetes self-management education program as a baseline assessment for tailoring diabetes education in a primary care setting. RESEARCH DESIGN AND METHODS: Patient activation was assessed in a stratified, cross-sectional study of adults with controlled (n = 21) and uncontrolled (n = 27) type 2 diabetes, who were receiving primary care at a unique family practice center of Baylor Health Care System in Dallas, Tex. RESULTS: The mean patient activation was 66.0 (95% confidence interval [CI] 60.8-71.2) among patients with uncontrolled diabetes and 63.7 (55.9-71.5) among those with controlled diabetes (P = 0.607). A significant association was observed between the self-management behavior score and activation among patients whose glycemia was under control (ρ = 0.73, P = 0.01) as well as among patients with uncontrolled glycemia (ρ = 0.48, P < 0.001). CONCLUSIONS: Although activation is correlated with self-management and may be important in tailored patient-centered approaches to improving diabetes care outcomes, the highest stage of activation may be necessary to achieve glycemic control. These findings reinforce the importance of conducting prerequisite needs assessments so diabetes educators are able to tailor their educational interventions to individual patients' needs and readiness to take action.

A hospital-randomized controlled trial of a formal quality improvement educational program in rural and small community Texas hospitals: one year results.

OBJECTIVE: To investigate the effectiveness of a quality improvement educational program in rural hospitals. DESIGN: Hospital-randomized controlled trial. PARTICIPANTS: A total of 47 rural and small community hospitals in Texas that had previously received a web-based benchmarking and case-review tool. INTERVENTION: The 47 hospitals were randomized either to receive formal quality improvement educational program or to a control group. The educational program consisted of two 2-day didactic sessions on continuous quality improvement techniques, followed by the design, implementation and reporting of a local quality improvement project, with monthly coaching conference calls and annual follow-up conclaves. MAIN OUTCOME MEASURES: Performance on core measures for community-acquired pneumonia and congestive heart failure were compared between study groups to evaluate the impact of the educational program. RESULTS: No significant differences were observed between the study groups on any measures. Of the 23 hospitals in the intervention group, only 16 completed the didactic program and 6 the full training program. Similar results were obtained when these groups were compared with the control group. CONCLUSIONS: While the observed results suggest no incremental benefit of the quality improvement educational program following implementation of a web-based benchmarking and case-review tool in rural hospitals, given the small number of hospitals that completed the program, it is not conclusive that such programs are ineffective. Further research incorporating supporting infrastructure, such as physician champions, financial incentives and greater involvement of senior leadership, is needed to assess the value of quality improvement educational programs in rural hospitals.

Challenges in conducting a hospital-randomized trial of an educational quality improvement intervention in rural and small community hospitals.

The study design for this hospital-randomized controlled trial of an educational quality improvement intervention in rural and small community hospitals, following the implementation of a Web-based quality benchmarking and case review tool, specified a control group and a rapid-cycle quality improvement education group of >or= 30 hospitals each. Of the 64 hospitals initially interested in participating, 7 could not produce the required quality data and 10 refused consent to randomization. Of the 23 hospitals randomized to the educational intervention, 16 completed the educational program, 1 attended the didactic sessions but did not complete the required quality improvement project, 3 enrolled in "make-up" sessions, and 3 were unable to attend. Of the 42 individuals who attended educational sessions, 5 (12%) have left their positions. Quality improvement interventions require several different approaches to engage participating organizations and should include plans to train new staff given the high turnover of health care quality improvement personnel.

The effect of health care system administrator pay-for-performance on quality of care.

BACKGROUND: The effectiveness of pay-for-performance (P4P) programs for health care administrators has received little attention. In 2001, Baylor Health Care System (BHCS) began linking supervisor compensation to performance on the Joint Commission core measures. METHODS: The effect of the P4P program was assessed on the basis of seven core measures for eligible patients discharged from the five BHCS acute care facilities from July 2001 to June 2005 using core measure-specific random effects logistic models. The time trends in performance were compared for BHCS and other hospitals nationwide reporting data on core measures to the Joint Commission. RESULTS: Improved performance for 13,673 patients (17,114 admissions; 4,035 admissions before the intervention and 13,079 after) was associated with exposure to administrator P4P for all individual core measures. This effect persisted following adjustment for age and gender (all p values < .0001) but weakened following adjustment for calendar time. Aspirin at discharge and pneumococcal vaccination performance remained significant following adjustment for calendar time. BHCS hospitals exposed to P4P increased performance on all P4P core measures more rapidly than a random sample of hospitals reporting the same measures, with increases in three of the measures significantly faster. DISCUSSION: The evidence provided by the study would have been stronger if it had it been possible to randomize exposure to the quality portion of the P4P program. In addition, BHCS engaged in several quality improvement initiatives that could have affected performance on the core measures. Still, linking administrator compensation to performance on specific clinical quality indicators may help improve health care quality. Further research is needed to clarify the impact of administrator P4P.

The effects of interdisciplinary outpatient geriatrics on the use, costs and quality of health services in the fee-for-service environment.

BACKGROUND AND AIMS: To evaluate the effect of interdisciplinary outpatient geriatrics on the use, cost, and quality of health services in a fee-for-service (FFS) environment of two networks of primary care clinics operated by a not-for-profit provider organization in Dallas County, Texas. METHODS: The Senior Health Network (SHN) provides interdisciplinary primary care to patients aged 55 years or older; the Health Texas Provider Network (HTPN) provides "usual" primary care to patients of all ages. We conducted a two-year retrospective cohort study of 13,098 fee-for-service Medicare beneficiaries who had 2+ visits to one of the networks in 2000. In the SHN, interdisciplinary teams supplemented primary care with social services, specialized clinics, and health education. We compared the use, cost and quality of health services, as reflected by paid Medicare claims, provided to eligible patients in the SHN vs the HTPN. RESULTS: Medicare payments for hospital, skilled nursing facility, and home health care services were lower for SHN patients than HTPN patients (-32.7%, -19.8%, and -23.8%, respectively, p

Improving quality and reducing inequities: a challenge in achieving best care.

The health care quality chasm is better described as a gulf for certain segments of the population, such as racial and ethnic minority groups, given the gap between actual care received and ideal or best care quality. The landmark Institute of Medicine report Crossing the Quality Chasm: A New Health System for the 21st Century challenges all health care organizations to pursue six major aims of health care improvement: safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness. "Equity" aims to ensure that quality care is available to all and that the quality of care provided does not differ by race, ethnicity, or other personal characteristics unrelated to a patient's reason for seeking care. Baylor Health Care System is in the unique position of being able to examine the current state of equity in a typical health care delivery system and to lead the way in health equity research. Its organizational vision, "culture of quality," and involved leadership bode well for achieving equitable best care. However, inequities in access, use, and outcomes of health care must be scrutinized; the moral, ethical, and economic issues they raise and the critical injustice they create must be remedied if this goal is to be achieved. Eliminating any observed inequities in health care must be synergistically integrated with quality improvement. Quality performance indicators currently collected and evaluated indicate that Baylor Health Care System often performs better than the national average. However, there are significant variations in care by age, gender, race/ethnicity, and socioeconomic status that indicate the many remaining challenges in achieving "best care" for all.

A hospital-randomized controlled trial of an educational quality improvement intervention in rural and small community hospitals in Texas following implementation of information technology.

Rural and small community hospitals typically have few resources and little experience with quality improvement (QI) and, on average, demonstrate poorer quality of care than larger facilities. Formalized QI education shows promise in improving quality, but little is known about its effect in rural and small community hospitals. The authors describe a randomized controlled trial assigning 47 rural and small community Texas hospitals to such a program (n = 23) or to the control group (n = 24), following provision of a Web-based quality benchmarking and case review tool. Centers for Medicare and Medicaid Services Core Measures composite scores for congestive heart failure (CHF) and community-acquired pneumonia (CAP), using Texas Medical Foundation data collected via the QualityNet Exchange system, are compared for the groups, for 2 years postintervention. Given the estimated baseline rates for the CHF (68%) and CAP (66%) composites, the cohort enables the detection of 14% and 11% differences (alpha = .05; power = 0.8), respectively.

Improving delivery of clinical preventive services: a multi-year journey.

BACKGROUND: Adults in the United States typically do not receive all recommended clinical preventive services (CPS) for which they are eligible, missing opportunities for prevention and/or early detection. A multi-year quality improvement initiative targeting CPS delivery in a fee-for-service ambulatory care network is described. METHODS: Since 1999, HealthTexas Provider Network (HTPN) has implemented multiple initiatives to increase CPS delivery, including a flowsheet, a physician champion model, physician- and practice-level audit and feedback, and rapid-cycle quality improvement training. RESULTS: From 2000 to 2006, "recommended or done" CPS delivery increased from 68% to 92%, and "done" from 70% to 86% (2001 to 2006). "Perfect care" composite performance increased from 0.19 to 0.51 (2001 to 2006). CONCLUSIONS: Long-term, multistrategy approaches can achieve substantial sustained improvement in CPS delivery throughout a large ambulatory care provider network.

Cost and effects of performance feedback and nurse case management for medicare beneficiaries with diabetes: a randomized controlled trial.

Nurse case management has been shown to improve the quality of diabetes care in closed model health maintenance organizations and Veterans Affairs medical clinics. A randomized controlled trial of a similar intervention within HealthTexas Provider Network, a fee-for-service primary care network in North Texas, demonstrated no benefit in processes of care or clinical outcomes for Medicare diabetes patients. To investigate whether the case management model impacted the cost of diabetes care from the Medicare perspective, we compared the average payments and charges incurred between intervention arms: claims-based audit and feedback; claims- and medical-record-based audit and feedback; and claims- and medical-record-based audit and feedback plus a practice-based diabetes resource nurse. Following adjustment for baseline differences between groups, no significant differences were observed. Thus, within this setting, it appears the nurse case management model produced no improvement in either clinical quality or in costs associated with diabetes from a Medicare perspective.

Improving quality and reducing inequities: a challenge in achieving best care.

The health care quality chasm is better described as a gulf for certain segments of the population, such as racial and ethnic minority groups, given the gap between actual care received and ideal or best care quality. The landmark Institute of Medicine report Crossing the Quality Chasm: A New Health System for the 21st Century challenges all health care organizations to pursue six major aims of health care improvement: safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness. "Equity" aims to ensure that quality care is available to all and that the quality of care provided does not differ by race, ethnicity, or other personal characteristics unrelated to a patient's reason for seeking care. Baylor Health Care System is in the unique position of being able to examine the current state of equity in a typical health care delivery system and to lead the way in health equity research. Its organizational vision, "culture of quality," and involved leadership bode well for achieving equitable best care. However, inequities in access, use, and outcomes of health care must be scrutinized; the moral, ethical, and economic issues they raise and the critical injustice they create must be remedied if this goal is to be achieved. Eliminating any observed inequities in health care must be synergistically integrated with quality improvement. Quality performance indicators currently collected and evaluated indicate that Baylor Health Care System often performs better than the national average. However, there are significant variations in care by age, gender, race/ethnicity, and socioeconomic status that indicate the many remaining challenges in achieving "best care" for all.

Effectiveness of diabetes resource nurse case management and physician profiling in a fee-for-service setting: a cluster randomized trial.

Nurses with advanced training-diabetes resource nurses (DRNs)-can improve care for people with diabetes in capitated payment settings. Their effectiveness in fee-for-service settings has not been investigated. We conducted a 12-month practice-randomized trial involving 22 practices in a fee-for-service metropolitan network with 92 primary care physicians caring for 1891 Medicare patients ≥65 years with diabetes mellitus. Each practice was randomized to one of three intervention groups: physician feedback on process measures using Medicare claims data; Medicare claims feedback plus feedback on clinical measures from medical record (MR) abstraction; or both types of feedback plus a practice-based DRN. The primary endpoint investigated was hemoglobin A(1c) level. Other measures were low-density lipoprotein (LDL) cholesterol level, blood pressure, annual hemoglobin A(1c) testing, annual LDL screening, annual eye exam, annual foot exam, and annual renal assessment. Data were collected from medical chart abstraction and Medicare claims. The number of patients with hemoglobin A(1c) <9% increased by 4 (0.9%) in the Claims group; 9 (2.1%) in the Claims + MR group (comparison with Claims: P = 0.97); and 16 (3.8%) in the DRN group (comparison with Claims: P = 0.31). Results were similar for the other clinical outcomes, with no differences significant at P = 0.10. For process of care measures, decreases were seen in all groups, with no significant differences in change scores. Quality improvement strategies must be evaluated in the appropriate setting. Initiatives that have been effective in capitated systems may not be effective in fee-for-service environments.

Quality of care of Medicare patients with diabetes in a metropolitan fee-for-service primary care integrated delivery system.

Diabetes care in the United States is suboptimal. Although closed-panel health maintenance organizations (HMOs) and the Department of Veterans Affairs (VA) report performance superior to national norms, fee-for-service performance is uncertain. To address this issue, 3 outcome and 5 process indicators were measured for 2010 Medicare diabetes patients across 22 sites in a large, fee-for-service primary care group practice. American Diabetes Association standards for glycemic control, low-density lipoprotein cholesterol, and blood pressure were met by 53%, 46%, and 19% of patients, respectively. Diabetes Quality Improvement Project/Alliance poor control markers for the same measures were exceeded by 9%, 20%, and 54% of patients. Chart abstraction demonstrated annual eye examination, foot examination, and nephropathy screening rates of 16%, 49%, and 38%, while Medicare claims showed an annual eye examination rate of 63%. Observed processes and outcomes in this fee-for-service setting were superior to reported national performance and similar to the best performance in staff-model HMOs and the VA.