Exceptions to outpatient quality measures for coronary artery disease in electronic health records.

BACKGROUND: Physicians report outpatient quality measures from data in electronic health records to facilitate care improvement and qualify for incentive payments. OBJECTIVE: To determine the frequency and validity of exceptions to quality measures and to test a system for classifying the reasons for these exceptions. DESIGN: Cross-sectional observational study. SETTING: 5 internal medicine or cardiology practices. PARTICIPANTS: 47,075 patients with coronary artery disease between 2006 and 2007. MEASUREMENTS: Counts of adherence with and exceptions to 4 quality measures, on the basis of automatic reports of recommended drug therapy by computer software and separate manual reviews of electronic health records. RESULTS: 3.5% of patients who had a drug recommended had an exception to the drug and were not prescribed it (95% CI, 3.4% to 3.7%). Clinicians did prescribe the recommended drug for many other patients with exceptions. In 538 randomly selected records, 92.6% (CI, 90.3% to 94.9%) of the exceptions reported automatically by computer software were also exceptions during manual review. Most medical exceptions were clinical contraindications, drug allergies, or drug intolerances. In 592 randomly selected records, an unreported exception or a drug prescription was found during manual review for 74.6% (CI, 71.1% to 78.1%) of patients for whom automatic reporting recorded a quality failure. LIMITATION: The study used a convenience sample of practices, nonstandardized data extraction methods, only drug-related quality measures, and no financial incentives. CONCLUSION: Exceptions to recommended therapy occur infrequently and are usually valid. Physicians frequently prescribed drugs even when exceptions were present. Automated reports of quality failure often miss critical information. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

The relationship between quality and utilization in managed care.

OBJECTIVE: To examine correlations of commercial health plan performance on Health Plan Employer Data and Information Set (HEDIS) effectiveness-of-care measures with utilization rates, as a proxy for cost. STUDY DESIGN: Cross-sectional study of 254 commercial health plans. METHODS: This report used data reported by commercial managed care plans in the 2003 HEDIS dataset. Utilization measures included access to care (the proportion of adults with at least 1 primary care or preventive visit), outpatient use (the number of outpatient visits per 1000 members per year), inpatient discharges (the number of inpatient discharges for medical conditions per 1000 members per year), and inpatient days (inpatient hospital days for medical conditions per 1000 members per year). A composite quality score was calculated from HEDIS indicators. Estimates of health plan membership demographics were identified from Consumer Assessment of Health Plans (CAHPS) survey data. Of 316 reporting plans, 254 reported sufficient data to be included in this analysis. Bivariate correlations and multivariate regressions (controlling for health plan and membership characteristics) were conducted. RESULTS: Quality was positively correlated with access to outpatient care (r = 0.46, P < .001), negatively associated with inpatient days (r = -0.30, P < .001), and not associated with total outpatient visits (r = 0.04, not significant). Regression results controlling for selected plan and member characteristics demonstrated similar findings. CONCLUSIONS: Although the mechanism of this cross-sectional association is unclear, these data provide important starting points for further research on the interrelationships of quality and resource use.

Screening for colorectal cancer: the business case.

Colorectal cancer screening is advocated by expert groups based on strong evidence of effectiveness, yet only approximately 1 in 3 Americans are screened. For a screening program to be effective, it is necessary for providers to offer and patients to accept screening, insurers to pay for screening, and provider groups to have monitoring and reminder systems and the expertise and facilities to perform the tests well. Whether and when such screening programs become successful depends on the priorities of healthcare decision makers as much as on the efforts of individual physicians and patients. There are strong arguments for decision makers giving colorectal cancer screening programs high priority: it saves as many lives as other services now in common use; it is a good use of scarce resources, costing less than $20,000 per year of life saved; and members of insurance programs increasingly expect screening benefits and programs, and failure to offer them might lead to member dissatisfaction and malpractice claims. Screening is costly, however, taking into account the cost of screening, follow-up tests, and treatments, and the costs occur many years before the benefits. Programs that are promoted to members but not fully implemented could create disappointment and backlash. Also, this screening can cause medical complications. Nevertheless, successful programs have been developed, proving that they are feasible in today's cost-conscious environment. We believe that colorectal cancer screening programs are integral to any organization purporting to provide high-quality care. Organizations without such programs should give them high priority for implementation.