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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

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. [ABSTRACT FROM AUTHOR]

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., (© Health Research and Educational Trust.)

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."

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., (© Health Research and Educational Trust.)

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 β 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), β blockers at arrival (year 6 vs baseline 0.24, 0.11 to 0.52), and an "all-eligible" measure comprising aspirin at arrival, β 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; β 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., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: The Institute for Healthcare Improvement encourages use of the Global Trigger Tool to objectively determine and monitor adverse events (AEs)., Setting: Baylor Health Care System (BHCS) is an integrated healthcare delivery system in North Texas. The Global Trigger Tool was applied to BHCS's eight general acute care hospitals, two inpatient cardiovascular hospitals and two rehabilitation/long-term acute care hospitals., Strategy: Data were collected from a monthly random sample of charts for each facility for patients discharged between 1 July 2006 and 30 June 2007 by external professional nurse auditors using an MS Access Tool developed for this initiative. In addition to the data elements recommended by Institute for Healthcare Improvement, BHCS developed fields to permit further characterisation of AEs to identify learning opportunities. A structured narrative description of each identified AE facilitated text mining to further characterise AEs. INITIAL FINDINGS: Based on this sample, AE rates were found to be 68.1 per 1000 patient days, or 50.8 per 100 encounters, and 39.8% of admissions were found to have ≥1 AE. Of all AEs identified, 61.2% were hospital-acquired, 10.1% of which were associated with a National Coordinating Council - Medical Error Reporting and Prevention harm score of "H or I" (near death or death)., Future Direction: To enhance learning opportunities and guide quality improvement, BHCS collected data-such as preventability and AE source-to characterise the nature of AEs. Data are provided regularly to hospital teams to direct quality initiatives, moving from a general focus on reducing AEs to more specific programmes based on patterns of harm and preventability.

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.

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.

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.

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 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.

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.

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.

Objective: To determine baseline levels of medication errors and their root causes so as to highlight areas of potential process improvements and serve as a ruler against which to measure future improvements., Design: A prospective pharmacist intervention study determining errors in 1014 medication orders at Baylor University Medical Center. Only errors in the process of medication ordering were documented; errors in drug administration were not considered. Root causes of errors were examined., Results: The baseline medication error rate was 111.4 per 1000 orders (n = 1014). Most common were dosing errors (43.4 per 1000 orders), followed by frequency errors (19.7 per 1000 orders) and unavailable drug errors (12.8 per 1000 orders). Of the 113 total errors found, 52 (46%) had a transcription-based cause, i.e., an error in inputting the handwritten physician order into a computer system. System- or process-related root causes (such as duplicate orders or lack of crossover from one information system to another) accounted for 35.4% of the errors, and prescribing based causes (such as wrong dosage or nonformulary drugs) accounted for 18.6% of errors., Conclusions: Implementing a computerized physician order entry (CPOE) system would eliminate order-entry transcription-based errors. Its ability to resolve system/process-based and prescribing-based root causes of error is not as clear. Furthermore, the modification of processes due to implementation of CPOE could lead to new types of errors. Present processes must be redesigned according to evidence-based medicine, and future processes must be anticipated as technological changes occur. Such efforts-rather than outright reliance on technology--are more likely to lead to an error-free environment after CPOE is implemented.

Background: This paper describes a collaborative Medicare claims data linkage and sharing effort between the Baylor Health Care System (BHCS) and Texas Medical Foundation (TMF, the Texas Quality Improvement Organization) designed to assess the effect of three quality improvement interventions on care delivered to elderly patients with diabetes. The randomized controlled trial is being conducted among a network of primary care physician practices owned by BHCS and focuses on measures of care process and outcome., Methods: Cohort definition and baseline measurement took place between January 1 and December 31, 2000. BHCS administrative data and TMF-supplied Medicare enrollment data were used to define the January 1, 2001 prevalence cohort of Medicare diabetic beneficiaries meeting study inclusion criteria. A total of 22 practices (with 92 physicians and 2,158 patients) were randomized to one of three interventions, each of which involved performance measurement feedback on three claims-based measures of care process. Physician profiles, generated by TMF using Medicare utilization files, were reported to study physicians via academic detailing sessions with a BHCS physician educator., Results: The January 1 - December 31, 2000 baseline Medicare claims for the January 1, 2001 prevalence cohort were provided to HTPN by TMF in October 2001, representing a ten-month lag in the ability of Quality Improvement Organizations to provide Part B data relative to a specific episode of care time frame. Overall baseline rates for the claims-based process measures were: annual HbA1c testing (86.1%), annual eye examination (60.8%), and annual lipid profile (72.5%). As anticipated, medical-record based rates of annual eye examination were significantly underrepresented. Agreement between claims-based and medical record-based measures was very close for annual HbA1c and annual lipid profile., Conclusions: The use of Medicare claims data, through collaboration with a QIO, can help health care providers overcome a significant barrier associated with quality improvement initiatives. Limitations associated with the use of Medicare claims can impact implementation of intervention strategies, but do not prevent them from being a practical tool for improving care.

Background: Peptic ulcer disease has well-defined causes, with most cases related to Helicobacter pylori infection and nonsteroidal anti-inflammatory drug use., Objectives: To report performance rates on measures of care related to peptic ulcer disease in hospitalized Medicare patients and to identify improvement opportunities., Methods: Retrospective study of 2267 Medicare beneficiaries hospitalized with peptic ulcer disease. Data were obtained from 2 sources: medical records (n = 1580) from 80 hospitals--16 hospitals in each of 5 states (Alabama, Florida, Louisiana, Tennessee, and Texas)-and a national random sample (n = 687). Three measures of care were evaluated: (1) rate of diagnostic screening or treatment for H. pylori infection, (2) rate of screening for nonsteroidal anti-inflammatory drug use on admission to the hospital, and (3) rate of assessment of risk factors for recurrence., Results: The rate of screening or treatment for H. pylori infection was 52.9% to 59.8% among the 5 states and 55.6% in the national random sample. The rate of screening for nonsteroidal anti-inflammatory drug use was 64.6% to 75.4% among the states and 73.4% in the national random sample. The rate of assessment at discharge from the hospital for additional risks for ulcer recurrence was 66.1% to 73.6% among the states and 70.9% in the national random sample., Conclusions: Based on hospital records, slightly more than half of the Medicare patients admitted with diagnoses studied are being considered for H. pylori eradication. If recurrence of this disease is to be reduced, physicians must adopt current screening and treatment recommendations.