Measuring Preventable Outcomes: Global Cardiovascular Risk (GCVR).

The National Committee for Quality Assurance (NCQA) piloted a new approach to quality measurement meant to reduce avoidable cardiac events and improve overall population health. In this pilot, we investigated whether a standardized technical specification could sufficiently define a process to reliably generate predicted outcome scores from heterogeneous electronic clinical data systems (ECDS) [1]. Patient data were electronically extracted from four health care organizations and processed by the Archimedes, Inc. Global Outcomes calculator, generating scores indicating future cardiovascular event probability for each provider's patient population. These Global Cardiovascular Risk (GCVR) scores represent the gap between current level of care achieved and optimal care for each clinician's patients, with a greater score indicating better performance. As GCVR requires more patient data than do traditional quality measures, we addressed feasibility and data completeness questions in order to understand the prospects of a wholly new quality concept. This pilot successfully produced GCVR scores for 2,251 clinicians, representing approximately 60 percent of the total patient population under study. To our knowledge, this is the first time predictive models have been proposed for quality measurement, and our pilot successfully demonstrated that a predicted outcome measure is feasible using electronic patient data. However, new specification standards are required before this approach is fully scalable to a national quality reporting program.

Field test results of a new ambulatory care Medication Error and Adverse Drug Event Reporting System--MEADERS.

PURPOSE: In this study, we developed and field tested the Medication Error and Adverse Drug Event Reporting System (MEADERS)-an easy-to-use, Web-based reporting system designed for busy office practices. METHODS: We conducted a 10-week field test of MEADERS in which 220 physicians and office staff from 24 practices reported medication errors and adverse drug events they observed during usual clinical care. The main outcomes were (1) use and acceptability of MEADERS measured with a postreporting survey and interviews with office managers and lead physicians, and (2) distributions of characteristics of the medication event reports. RESULTS: A total of 507 anonymous event reports were submitted. The mean reporting time was 4.3 minutes. Of these reports, 357 (70%) included medication errors only, 138 (27%) involved adverse drug events only, and 12 (2.4%) included both. Medication errors were roughly equally divided among ordering medications, implementing prescription orders, errors by patients receiving the medications, and documentation errors. The most frequent contributors to the medication errors and adverse drug events were communication problems (41%) and knowledge deficits (22%). Eight (1.6%) of the reported events led to hospitalization. Reporting raised staff and physician awareness of the kinds of errors that occur in office medication management; however, 36% agreed or strongly agreed that the event reporting "has increased the fear of repercussion in the practice." Time pressure was the main barrier to reporting. CONCLUSIONS: It is feasible for primary care clinicians and office staff to report medication errors and adverse drug events to a Web-based reporting system. Time pressures and a punitive culture are barriers to event reporting that must be overcome. Further testing of MEADERS as a quality improvement tool is warranted.

Rural public health financing: implications for community health promotion initiatives.

BACKGROUND: Public health in rural areas has distinctive features, often shaped by state-level infrastructure and organization and financing of public health activities. Variation in the way funds are distributed can influence the ability of local health departments and nongovernmental organizations serving rural communities to conduct public health functions. PURPOSE: The purpose of this article was to describe how federal funds for selected chronic disease prevention and health promotion activities are distributed through states to the local level and identify infrastructure-related barriers that local health departments and nongovernmental organizations may face in securing these funds. METHODS: Thirty semistructured interviews were conducted with individuals at the state and local levels responsible for managing funds and implementing initiatives in selected disease areas across six states, using a standardized protocol through which select funds were followed from the state to the local level. RESULTS: Respondents report that states do not get sufficient Centers for Disease Control and Prevention funding for diabetes, cancer, and injury prevention to distribute effectively to the local level. Local funding, when provided, tends to be allocated through competitive mini-grant processes that are often difficult for rural communities to access because of infrastructural challenges. Mini-grant amounts are often too limited to build local program capacities and often awarded to communities with existing capacities.