Medicare quality of care show plenty of room for improvement
November 1, 2000 4 minutes read
Data on Medicare quality of care show plenty of room for improvement
HCFA finds 24 new process improvement projects
Hospitals looking for a new set of performance improvement and benchmarking projects in the coming year don’t need to look further than a new study by the Health Care Financing Administration (HCFA). The study, on the quality of care received by Medicare beneficiaries, measured 24 process-of-care measures related to primary prevention, secondary prevention, and/or treatment of six medical conditions.
HCFA reported that "overall marks were high." However, there were some very low marks, too. For instance, in Arkansas, only 4% of Medicare patients in the hospital for pneumonia treatment were screened for a pneumococcal vaccine, and the median was 11%. "It is clear that screening for immunizations isn’t seen in many hospitals as a part of inpatient care, even for people who are at very high risk for certain diseases," says Stephen F. Jencks, MD, director of quality improvement at HCFA and the lead author of the study. "That needs to change, and I think there is a consensus among the medical establishment that it needs to change."
Jencks says there is unlikely to be a hospital, health system, or provider that could look at all 24 indicators and not find some room to improve its own practice. "The message is to look at your numbers, see how you compare, and note where you can improve." The study was published in the Oct. 4 issue of the Journal of the American Medical Association.1
If all patients received all of the items of care, the health care indicator rate or process-of-care measurement would be 100%. However, the national median for all process-of-care measures was about 70% of Medicare fee-for-service beneficiaries and varies widely from state to state and region to region.
The six conditions monitored for quality of care include acute myocardial infarction, breast cancer, diabetes, congestive heart failure, pneumonia, and stroke. For example, one process-of-care measure is whether a heart attack victim was given aspirin and a beta-blocker within 24 hours of being hospitalized and prescribed aspirin or a beta-blocker at discharge.
A measure of quality care for breast cancer is whether a woman receives a screening mammogram every two years. Indicators for diabetes include whether the patient was given a hemoglobin A1c test at least once a year and an eye exam every two years. For heart failure, the items checked include evaluation of the patient’s cardiac ejection fraction and prescribing ACE inhibitors when the patient is discharged.
For stroke, researchers checked for prescribing a blood thinner for a patient with acute stroke and atrial fibrillation. Pneumonia measures included whether physicians prescribe antibiotics within eight hours of hospitalization and if they determined whether the patient needs a pneumococcal and/or influenza immunization.
Despite the negatives in the report, there were some very positive results. For example, nationwide, 83.9% of patients who had a heart attack received aspirin within 24 hours of being admitted to a hospital. That included a range of 97.2% in one state to 66.7% in another. Nationally, 88% of patients with pneumonia received antibiotics within eight hours of being admitted to a hospital. The state range was 92.6% to 37.5%.
Opportunities for improvement
Jencks says he wasn’t surprised by any of the data presented in the report. "The numbers didn’t shock us. We have had a lot of individual reports in various forms that indicated those kinds of figures were expected." What is surprising is the regional variations, which Jencks says are "unexpected. We don’t understand it, and it suggests that there may be factors involved that we can learn about."Less populous states and those in the Northeast consistently rank high in relative performance, while others, particularly in the more populous states and those in the Southeast, consistently rank low. "We have substantial work to do to figure out the source of these variations," he says. "We have not yet been able to explore the many possibilities."
But just because HCFA doesn’t understand why there are variations is no excuse for not acting on the data. "If you look at the data — and you should, whether you are a hospital administrator, chief medical officer, or a provider — then there are plenty of opportunities to improve. I want to move to someplace where there is a hospital that says it doesn’t need to work on any of these areas."
Jencks says it doesn’t matter if you use a formal or informal process to check your data. Look at the information, and take advantage of the help state peer review organizations (PROs) offer. "Tell them you have an area where you think you want to improve. Ask them if they can assist you in doing your measurements and if there are cooperative efforts going on in specific areas."
The baseline data produced by the study represent the first step of a three-year, $240 million Medicare effort to improve the health care Medi-care beneficiaries receive, and required the review of thousands of documents.
The next step is a cooperative campaign with HCFA, its PROs, health care providers, and other concerned groups to use the data to improve beneficiary health care.
In 2002, HCFA will repeat the survey to measure progress on the 24 indicators, and the information will be used to plan steps for further improvement.
HCFA, the PROs, the American Medical Association, the American Hospital Association, and others have pledged to use the new baseline data to find ways to improve the quality of care provided to Medicare beneficiaries. These quality improvement efforts also will be directed toward the care provided by nursing homes, home health agencies, managed care organizations, and other providers.
[For more information, contact: Stephen F. Jencks, MD, Director of Quality Improvement, Health Care Financing Administration, Baltimore. Telephone: (202) 690-6145.]
Reference
1. Jencks SF, et al. Quality of medical care delivered to Medicare beneficiaries: A profile at state and national levels. JAMA 2000; 284:1,670-1,676.
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