Vermont targets inconsistent practice patterns in state
Inconsistent patterns in Vermont
February 28, 1998
Vermont targets inconsistent practice patterns in state
Vermont is not alone in having inconsistent practice patterns across the state for middle ear infections, congestive heart failure, complicated pregnancies or other conditions. While significant variations in practice patterns have been documented in virtually all states, Vermont is unique in having a private, non-profit organization working with providers to reduce those variations.
The Vermont Program for Quality in Health Care (VPQHC), an unusual alliance of providers, insurers, employers, consumers and state regulators, analyzes differences in practice patterns and helps hospitals and other providers in the state improve quality of care.
To get people together to commit to a mutual goal like this is really extraordinary. Riley
Similar efforts in other states are often carried out by health plans, academic organizations or health systems. One health policy expert says Vermont's collaborative venture in sharing data and using practice guidelines could serve as a model for other states.
"To get people together to commit to a mutual goal like this is really extraordinary," said Trish Riley, executive director of the National Academy for State Health Policy. "Again, all eyes are on Vermont."
VPQHC operates with a staff of six and a budget of $466,000. In its early years, VPQHC relied on hospitals for most of its funding, and providers dominated its board of directors. VPQHC now gets 70% of its funding from a state-imposed tax on health insurers and hospitals and its board now includes employers, state officials and consumers, along with doctors, hospital executives and insurance company representatives.
With an expanded board and a reliable funding source, VPQHC has become bolder -- more willing to publicize its data.
Each year, VPQHC publishes the Vermont Health Care Quality Report, which uses maps and charts and plain English to show practice variations for everything from C-section rates to cardiac catheterization. The report also details VPQHC's own efforts to improve health care quality, and, where appropriate, compares Vermont's progress against HEDIS measures, goals for the national Healthy People 2000 initiative and its companion initiative in the state, Healthy Vermonters 2000.
When the legislature considered a bill mandating insurance reimbursement for chiropractic care, the state insurance department contracted with VPQHC to bring chiropractors and MDs to the table to examine appropriate scope of services for chiropractic care in Vermont.
When VPQHC conducts a study, it assembles a steering committee of medical experts in the field to guide the project, develop practice guidelines and offer assistance to other providers.
Anya Rader, VPQHC's executive director, admits the medical establishment isn't always comfortable with the scrutiny.
"I think there's a constant tension, and if there wasn't we probably wouldn't be doing our job right," she said. But overall, she said, doctors are willing, interested participants.
"To the extent they're able to fit it into their busy lives, they really do want to do this stuff," Ms. Rader said. "And intellectually, I think, they're interested in it. You might find exceptions to that rule, but by and large these are people who want to do good work, are smart, are interested in the latest knowledge and want to find ways to incorporate that in what they do."
Ear Infections
In reviewing claims data, VPQHC found that surgery on Vermont children with chronic ear infections varied depending on their health insurer. Children covered by Medicaid had the highest rates of surgery, while children insured with Blue Cross and Blue Shield of Vermont were far less likely to undergo the same procedure. Although there could be any number of explanations for the disparity in surgical rates, VPQHC concluded some children were getting unnecessary surgery while others were not getting treatment they needed.
Acknowledging the controversy in the scientific literature about the best treatment, VPQHC convened a 12-member study group of Vermont providers and insurers to establish guidelines.
Key elements of the guidelines, said Cyrus Jordan, VPQHC's medical director, include emphasizing use of pneumatic otoscopy to confirm presence of fluid in the middle ear and use of the narrowest spectrum antibiotic so that organisms won't develop resistance to agents. The guidelines have clear recommendations for when children need evaluation for surgery. VPQHC also produced a brochure for parents on ear infections.
Cesarean sections
VPQHC found that too many Vermont babies were being delivered by Cesarean section. A woman having a baby at Southwestern Vermont Medical Center in Bennington, VT, for example, was more than twice as likely to deliver by C-section than a woman giving birth at Porter Hospital in Middlebury.
VPQHC holds regular conferences for Vermont doctors and national experts to share their knowledge about how to reduce C-section rates. Local physicians and nurses sometimes visit hospitals with high rates to offer their expertise. VPQHC sends hospitals quarterly reports on C-sections so that they can compare their performance to those of other hospitals.
Vermont's overall C-section rate was16.5% in the first half of 1997, which is well below the national average of 20.8% reported by the National Center for Health Statistics for 1995 (the preliminary figure for 1996 is 20.6%). The goal is to have a Cesarean-section rate of 15% of all births by the year 2000, VPQHC reports.
Congestive heart failure
VPQHC found that Vermonters were being hospitalized for congestive heart failure at wildly differing rates.
Vermonters age 65 and older living in the northwest corner of the state, for example, were nearly three times as likely to be hospitalized for congestive heart failure in 1995 than Vermonters of the same age living in the upper Connecticut River Valley along the New Hampshire border.
The project's steering committee, which includes some of the state's most respected cardiologists, reviewed the literature and developed a consensus on standards of care and sent it to every cardiologist in the state.
Karen Meyer, executive vice president at the Vermont Medical Society, said physicians are far more receptive to quality improvement efforts when they come from VPQHC rather than a health plan. "It's educational and it's about improvement of patient care," she said. "A health plan always feels like it's about money."
The Medical Society strongly supports VPQHC not only because it provides physicians with data and guidelines to help them improve, but also because it fosters collegiality among Vermont doctors, many of whom work in rural areas far from large medical centers, Ms. Meyer said.
In the past, VPQHC concerned itself largely with cost and clinical practices: Did the surgery work and what did it cost? But the congestive heart failure project will add a new dimension to VPQHC's work: patient satisfaction. VPQHC can get a better measure of value in the health care system once it examines the patient's sense of satisfaction with the service and his or her physical and mental well-being after surgery or hospitalization, Ms. Rader said.
Can a heart patient go shopping for groceries or play with grandchildren without feeling weak? Was the medical staff nice to family members? How is the patient's mental health?
The state Division of Health Care Administration is a partner in VPQHC's efforts. The Division itself has begun a data-collection initiative, and plans to share information with VPQHC and consumers.
Theresa Alberghini, who heads the division, said the state will provide information to consumers about insurance-company practices and making choices in health care, while VPQHC continues to work in its area of expertise -- with medical professionals on quality improvement.
"We're not just collecting data because we like to collect data," she said. "We're collecting it because it's going to help us protect consumers."
ÑBryan Pfeiffer
Vermont targets inconsistent practice patterns in state
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