Hospital Quality Improvement Interventions, Statewide Policy Initiatives, and Rates of Cesarean Delivery for Nulliparous, Term, Singleton, Vertex Births in California.

Importance: Safe reduction of the cesarean delivery rate is a national priority. Objective: To evaluate the rates of cesarean delivery for nulliparous, term, singleton, vertex (NTSV) births in California in the context of a statewide multifaceted intervention designed to reduce the rates of cesarean delivery. Design, Setting, and Participants: Observational study of cesarean delivery rates from 2014 to 2019 among 7 574 889 NTSV births in the US and at 238 nonmilitary hospitals providing maternity services in California. From 2016 to 2019, California Maternal Quality Care Collaborative partnered with Smart Care California to implement multiple approaches to decrease the rates of cesarean delivery. Hospitals with rates of cesarean delivery greater than 23.9% for NTSV births were invited to join 1 of 3 cohorts for an 18-month quality improvement collaborative between July 2016 and June 2019. Exposures: Within the collaborative, multidisciplinary teams implemented multiple strategies supported by mentorship, shared learning, and rapid-cycle data feedback. Partnerships among nonprofit organizations, state governmental agencies, purchasers, and health plans addressed the external environment through transparency, award programs, and incentives. Main Outcomes and Measures: The primary outcome was the change in cesarean delivery rates for NTSV births in California and a difference-in-differences analysis was performed to compare cesarean delivery rates for NTSV births in California vs the rates in the rest of the US. A mixed multivariable logistic regression model that adjusted for patient-level and hospital-level confounders also was used to assess the collaborative and the external statewide actions. The cesarean delivery rates for NTSV births at hospitals participating in the collaborative were compared with the rates from the nonparticipating hospitals and the rates in the participating hospitals prior to participation in the collaborative. Results: A total of 7 574 889 NTSV births occurred in the US from 2014 to 2019, of which 914 283 were at 238 hospitals in California. All California hospitals were exposed to the statewide actions to reduce the rates of cesarean delivery, including the 149 hospitals that had baseline rates of cesarean delivery greater than 23.9% for NTSV births, of which 91 (61%) participated in the quality improvement collaborative. The rate of cesarean delivery for NTSV births in California decreased from 26.0% (95% CI, 25.8%-26.2%) in 2014 to 22.8% (95% CI, 22.6%-23.1%) in 2019 (relative risk, 0.88; 95% CI, 0.87-0.89). The rate of cesarean delivery for NTSV births in the US (excluding California births) was 26.0% in both 2014 and 2019 (relative risk, 1.00; 95% CI, 0.996-1.005). The difference-in-differences analysis revealed that the reduction in the rate of cesarean delivery for NTSV births in California was 3.2% (95% CI, 1.7%-3.5%) higher than in the US (excluding California). Compared with the hospitals and the periods not exposed to the collaborative activities, and after adjusting for patient characteristics and time using a modified stepped-wedge analysis, exposure to collaborative activities was associated with a lower odds of cesarean delivery for NTSV births (24.4% vs 24.6%; adjusted odds ratio, 0.87 [95% CI, 0.85-0.89]). Conclusions and Relevance: In this observational study of NTSV births in California from 2014 to 2019, the rates of cesarean delivery decreased over time in the setting of the implementation of a coordinated hospital-level collaborative and statewide initiatives designed to support vaginal birth.

Public Reporting of Hospital-Level Cancer Surgical Volumes in California: An Opportunity to Inform Decision Making and Improve Quality.

PURPOSE: Most patients, providers, and payers make decisions about cancer hospitals without any objective data regarding quality or outcomes. We developed two online resources allowing users to search and compare timely data regarding hospital cancer surgery volumes. METHODS: Hospital cancer surgery volumes for all California hospitals were calculated using ICD-9 coded hospital discharge summary data. Cancer surgeries included (bladder, brain, breast, colon, esophagus, liver, lung, pancreas, prostate, rectum, and stomach) were selected on the basis of a rigorous literature review to confirm sufficient evidence of a positive association between volume and mortality. The literature could not identify threshold numbers of surgeries associated with better or worse outcomes. A multidisciplinary working group oversaw the project and ensured sound methodology. RESULTS: In California in 2014, about 60% of surgeries were performed at top-quintile-volume hospitals, but the per-hospital median numbers of surgeries for esophageal, pancreatic, stomach, liver, or bladder cancer surgeries were four or fewer. At least 670 patients received cancer surgery at hospitals that performed only one or two surgeries for a particular cancer type; 72% of those patients lived within 50 miles of a top-quintile-volume hospital. CONCLUSION: There is clear potential for more readily available information about hospital volumes to help patient, providers, and payers choose cancer surgery hospitals. Our successful public reporting of hospital volumes in California represents an important first step toward making publicly available even more provider-specific data regarding cancer care quality, costs, and outcomes, so those data can inform decision-making and encourage quality improvement.

Collecting Patient-Reported Outcomes: Lessons from the California Joint Replacement Registry.

CONTEXT: While patient-reported outcomes (PROs) have long been used for research, recent technology advancements make it easier to collect patient feedback and use it for patient care. Despite the promise and appeal of PROs, substantial barriers to widespread adoption remain-including challenges in interpreting privacy regulations, educating patients and physicians about the power that PRO collection can provide to patient-centered care. CASE DESCRIPTION: This article describes lessons learned from the California Joint Replacement Registry's (CJRR) five-year effort to collect PROs from patients undergoing total hip and total knee replacement surgeries. CJRR is a voluntary, multi-institutional registry in California that collects clinical and device information, as well as PROs from patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) surgeries. PROPOSED SOLUTIONS: The CJRR encountered and developed solutions to overcome several key issues: (1) limitations of electronic PRO collection, (2) challenges in patient recruitment and tracking, (3) challenges in encouraging patients to complete PRO surveys, (4) real and perceived administrative burden to clinic and hospital staff, (5) surgeon engagement, and (6) survey costs. CONCLUSION: The CJRR's field experience can inform growing numbers of providers and researchers who seek to more fully understand the impact of care from the patient's perspective. In addition, the authors believe that these challenges can best be addressed through a combination of policy changes and increased incentives.

A field experiment on the impact of physician-level performance data on consumers' choice of physician.

BACKGROUND: In 2008, HealthPlus of Michigan introduced an online primary care provider (PCP) report that displays clinical quality data and patients' ratings of their experiences with PCPs on a public web site. DESIGN AND PROCEDURE: A randomized encouragement design was used to examine the impact of HealthPlus's online physician-quality report on new plan members' choice of a PCP. This study evaluated the impact of an added encouragement to utilize the report by randomizing half of new adult plan members in 2009-2010, who were required to select a PCP (N=1347), to receive a 1-page letter signed by the health plan's chief medical officer emphasizing the importance of the online report and a brief phone call reminder. We examined the use of the report and the quality of PCPs selected by participants. RESULTS: Twenty-eight percent of participants in the encouragement condition versus 22% in the control condition looked at the online report before selecting a PCP. Although participants in the encouragement condition selected PCPs with higher patient experience ratings than did control participants, this difference was not explained by their increased likelihood of accessing the online report. CONCLUSIONS: Health plan members can be encouraged successfully to access physician-level quality data using an inexpensive letter and automated phone call. However, a large proportion of missing data in HealthPlus's online report may have limited the influence of the physician-quality report on consumer choice.

Patient experience of care in the safety net: current efforts and challenges.

Measuring patient experience of care fosters the delivery of patient-centered services and increases health care quality. Most pay-for-performance and public reporting programs focus on care provided to insured populations, excluding the uninsured. Using qualitative research methods, we interviewed leaders of California safety-net practices to assess how they measure patient experience of care and the measurement barriers they encounter. Most had unmet needs for assistance with data collection and quality improvement strategies for their patient population. Tailored measurement and quality improvement resources, coupled with policy mandates to give all patients a voice, would improve the quality of patient-centered care in safety-net organizations.

The current state of quality of care measurement in the California Department of Corrections and Rehabilitation.

The quality of health care in prisons is lacking in many states. In particular, the California Department of Corrections and Rehabilitation (CDCR) is in the midst of an extreme legal remedy to address problems related to access to and quality of care; it now operates under the direction of a federally appointed receiver for medical care. To understand the current state of access and quality measurement and to assess strengths and weaknesses of current activities, the RAND Corporation conducted a series of interviews and site visits in the CDCR and related offices as well as document reviews (December 2008 to February 2009). Findings supported RAND's larger project goals to identify measures for use in a sustainable quality measurement system.

A review of quality measures used by state and federal prisons.

In response to deficiencies in the delivery of health care in prisons, a number of state correctional systems and the Federal Bureau of Prisons (BOP) have established quality of care monitoring systems. In 2009, the California Department of Corrections and Rehabilitation and the federal receiver overseeing the system asked the RAND Corporation to identify existing indicators of quality performance and to recommend a set of indicators applicable to the prison population. An environmental scan of quality measures being used by other state correctional systems and the BOP found substantial variation in the number and type of measures being used and the underlying data systems used to construct measures. Explicit quality measures were being used, as were measures of disease prevalence and standards.

Selecting performance indicators for prison health care.

Improving prison health care requires a robust measurement dashboard that addresses multiple domains of care. We sought to identify tested indicators of clinical quality and access that prison health managers could use to ascertain gaps in performance and guide quality improvement. We used the RAND/UCLA modified Delphi method to select the best indicators for correctional health. An expert panel rated 111 indicators on validity and feasibility. They voted to retain 79 indicators in areas such as access, cardiac conditions, geriatrics, infectious diseases, medication monitoring, metabolic diseases, obstetrics/gynecology, screening/prevention, psychiatric disorders/substance abuse, pulmonary conditions, and urgent conditions. Prison health institutions, like all other large health institutions, need robust measurement systems. The indicators presented here provide a basic library for prison health managers developing such systems.

Are electronic health records ready for genomic medicine?

PURPOSE: The goal of this project was to assess genetic/genomic content in electronic health records. METHODS: Semistructured interviews were conducted with key informants. Questions addressed documentation, organization, display, decision support and security of family history and genetic test information, and challenges and opportunities relating to integrating genetic/genomics content in electronic health records. RESULTS: There were 56 participants: 10 electronic health record specialists, 18 primary care clinicians, 16 medical geneticists, and 12 genetic counselors. Few clinicians felt their electronic record met their current genetic/genomic medicine needs. Barriers to integration were mostly related to problems with family history data collection, documentation, and organization. Lack of demand for genetics content and privacy concerns were also mentioned as challenges. Data elements and functionality requirements that clinicians see include: pedigree drawing; clinical decision support for familial risk assessment and genetic testing indications; a patient portal for patient-entered data; and standards for data elements, terminology, structure, interoperability, and clinical decision support rules. Although most said that there is little impact of genetics/genomics on electronic records today, many stated genetics/genomics would be a driver of content in the next 5-10 years. CONCLUSIONS: Electronic health records have the potential to enable clinical integration of genetic/genomic medicine and improve delivery of personalized health care; however, structured and standardized data elements and functionality requirements are needed.

Taking stock of pay-for-performance: a candid assessment from the front lines.

Pay-for-performance (P4P) has been widely adopted, but it remains unclear how providers are responding and whether results are meeting expectations. Physician organizations involved in the California Integrated Healthcare Association's (IHA) P4P program reported having increased physician-level performance feedback and accountability, speeded up information technology adoption, and sharpened their organizational focus and support for improvement in response to P4P; however, after three years of investment, these changes had not translated into breakthrough quality improvements. Continued monitoring is required to determine whether early investments made by physician organizations provide a basis for greater improvements in the future.

Pay for performance in the hospital setting: what is the state of the evidence?

More than 40 private sector hospital pay-for-performance (P4P) programs now exist, and Congress is considering initiating a Medicare hospital P4P program. Given the growing interest in hospital P4P, this systematic review of the literature examines the current state of knowledge about the effect of P4P on clinical process measures, patient outcomes and experience, safety, and resource utilization. Little formal evaluation of hospital P4P has occurred, and most of the 8 published studies have methodological flaws. The most rigorous studies focus on clinical process measures and demonstrate that hospitals participating in the Centers for Medicare and Medicaid Services-Premier Hospital Quality Incentive Demonstration, a P4P program, had a 2- to 4-percentage point greater improvement than the improvement observed in control hospitals. There is a need for more systematic evaluation of hospital P4P to understand its effect and whether the benefits of investing in P4P outweigh the associated costs.

Experiences of Agency for Healthcare Research and Quality-funded projects that implemented practices for safer patient care.

OBJECTIVES: To synthesize lessons learned from the experiences of Agency for Healthcare Research and Quality-funded patient safety projects in implementing safe practices. DATA SOURCES: Self-reported data from individual and group interviews with Original, Challenge, and Partnerships in Implementing Patient Safety (PIPS) grantees, from 2003 to 2006. STUDY DESIGN: Interviews with three grantee groups (n=60 total) implementing safe practice projects, with comparisons on factors influencing project implementation and sustainability. DATA COLLECTION: Semi-structured protocols contained open-ended questions on lessons learned and more structured questions on factors associated with project implementation and sustainability. PRINCIPAL FINDINGS: The grantees shared common experiences, frequently identifying lessons learned regarding structural components needing to be in place before implementation, components of the implementation process, components of interventions' results needed for sustainability, changes in timelines or activities, unanticipated issues, and staff acceptance/adoption. Also, fewer Original grants had many of the factors related project to implementation/sustainability than the PIPS or Challenge grantees had. CONCLUSIONS: Although much of what was reported seemed like common sense, surprisingly few projects actually planned for or expected many of the barriers or facilitators they experienced during their project implementation. Others implementing practice improvements likely will share the experiences and issues identified by these implementation projects and can learn from their lessons.

Training a patient safety work force: the patient safety improvement corps.

OBJECTIVE: Evaluate short-term effects of the Patient Safety Improvement Corps (PSIC), an Agency for Healthcare Research and Quality­sponsored program to train state teams in patient safety skills/tools, to assess its contribution to building a national infrastructure supporting effective patient safety practices. DATA SOURCE: Self-reported information gathered from (1) group interviews at the end of each year; (2) individual telephone interviews 1 year later; (3) faxed information forms 2 years later. STUDY DESIGN: Program evaluation of immediate and short-term process and impact (use of skills/tools, information sharing, changes in practice). DATA COLLECTION: Semistructured interviews; faxed forms. PRINCIPAL FINDINGS: One year after training, approximately half of Year 1 and 2 state agency representatives reported they had initiated or modified legislation to strengthen safe practices, and modified adverse event oversight procedures. Approximately three-quarters of hospital representatives said training contributed to modifications to adverse event oversight procedures and promotion of patient safety culture. Two years posttraining, approximately three-quarters of Year 1 trainees said they continued to use many skills/tools. CONCLUSIONS: The PSIC contributed to building a national infrastructure supporting effective patient safety practices. Expanded training is needed to reach a larger fraction of the population for which this training is important.

Understanding the reporting practices of CAHPS sponsors.

This article examines the reporting of Consumer Assessment of Healthcare Providers and Systems (CAHPSO) consumer experience data by sponsors, those that fund data collection and decide how information is summarized and disseminated. We found that sponsors typically publicly reported comparative data to consumers, employers, and/or purchasers. They presented health plan-level data in print and online at least annually, usually in combination with non-CAHPS information. Many provided trend data, comparisons to individual plans, and summary scores. Most shared information consistent with known successful reporting practices. Areas meriting attention include: tailoring reports to specific audiences, assessing literacy, planning dissemination, educating vendors, and evaluating products and programs.

Will financial incentives stimulate quality improvement? Reactions from frontline physicians.

Pay-for-performance is being applied at the physician level to stimulate improvements in quality of care and cost efficiency; however, little is known about how physicians will respond. We interviewed physicians exposed to a financial incentive program in California to identify possible barriers to the successful application of financial incentives by exploring physicians' opinions of and experiences with pay-for-performance programs. Reasons physicians cited for quality deficiencies included insurance coverage limitations and lack of patient compliance, time, and proper physician oversight. Physicians believe that they play a significant role and have a moderate to high degree of control over quality of care and that it is important to self-monitor. Physicians expressed the need for accurate and timely data, peer comparisons, and more patient time, staff support, and consultations with colleagues to successfully monitor and deliver quality care. Many support increased pay for delivering high-quality care but question measurement accuracy, bonus payment financing, and health plan involvement.

Direct-to-consumer advertising of COX-2 inhibitors: effect on appropriateness of prescribing.

Spending on direct-to-consumer advertising (DTCA) of prescription drugs has increased dramatically in the past several years. An unresolved question is whether such advertising leads to inappropriate prescribing. In this study, the authors use survey and administrative data to determine the association of DTCA with the appropriate prescribing of cyclooxygenase-2 (COX-2) inhibitors for 1,382 patients. Treatment with either a COX-2 or a traditional nonsteroidal anti-inflammatory drug (NSAID) was defined as appropriate or not according to three different definitions of gastrointestinal risk. Patients who saw or heard a COX-2 advertisement and asked their physician about the advertised drug were significantly more likely to be prescribed a COX-2 (versus a NSAID, as recommended by evidence-based guidelines) than all other patients. Findings also suggest that some patients may benefit from DTCA. The authors discuss the need for balanced drug information for consumers, increased physician vigilance in prescribing appropriately, and further study of DTCA.

Access to medical care for low-income persons: how do communities make a difference?

This paper considers the impact of community-level variables over and above the effects of individual characteristics on healthcare access of low-income children and adults residing in large metropolitan statistical areas (MSAs). Further, we rank MSAs' performance in promoting healthcare access for their low-income populations. The individual-level data come from the 1995 and 1996 National Health Interview Survey (NHIS). The community-level variables are derived from multiple public-use data sources. The outcome variable is whether low-income individuals received a physician visit in the past twelve months. The proportion receiving a visit by MSA varied from 63% to 99% for children and from 62% to 83% for adults. Access was better for individuals with health insurance and a regular source of care and for those living in communities with more federally-funded health centers. Children residing in MSA.