Showing papers in "Health Affairs in 2011"

The Benefits Of Health Information Technology: A Review Of The Recent Literature Shows Predominantly Positive Results

Abstract: An unprecedented federal effort is under way to boost the adoption of electronic health records and spur innovation in health care delivery. We reviewed the recent literature on health information technology to determine its effect on outcomes, including quality, efficiency, and provider satisfaction. We found that 92 percent of the recent articles on health information technology reached conclusions that were positive overall. We also found that the benefits of the technology are beginning to emerge in smaller practices and organizations, as well as in large organizations that were early adopters. However, dissatisfaction with electronic health records among some providers remains a problem and a barrier to achieving the potential of health information technology. These realities highlight the need for studies that document the challenging aspects of implementing health information technology more specifically and how these challenges might be addressed.

‘Global Trigger Tool’ Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured

Abstract: Identification and measurement of adverse medical events is central to patient safety, forming a foundation for accountability, prioritizing problems to work on, generating ideas for safer care, and testing which interventions work. We compared three methods to detect adverse events in hospitalized patients, using the same patient sample set from three leading hospitals. We found that the adverse event detection methods commonly used to track patient safety in the United States today—voluntary reporting and the Agency for Healthcare Research and Quality's Patient Safety Indicators—fared very poorly compared to other methods and missed 90 percent of the adverse events. The Institute for Healthcare Improvement's Global Trigger Tool found at least ten times more confirmed, serious events than these other methods. Overall, adverse events occurred in one-third of hospital admissions. Reliance on voluntary reporting and the Patient Safety Indicators could produce misleading conclusions about the current safety of care in the US health care system and misdirect efforts to improve patient safety.

Nurses’ Widespread Job Dissatisfaction, Burnout, And Frustration With Health Benefits Signal Problems For Patient Care

Abstract: Job dissatisfaction among nurses contributes to costly labor disputes, turnover, and risk to patients. Examining survey data from 95,499 nurses, we found much higher job dissatisfaction and burnout among nurses who were directly caring for patients in hospitals and nursing homes than among nurses working in other jobs or settings, such as the pharmaceutical industry. Strikingly, nurses are particularly dissatisfied with their health benefits, which highlights the need for a benefits review to make nurses’ benefits more comparable to those of other white-collar employees. Patient satisfaction levels are lower in hospitals with more nurses who are dissatisfied or burned out—a finding that signals problems with quality of care. Improving nurses’ working conditions may improve both nurses’ and patients’ satisfaction as well as the quality of care.

The Importance Of Transitional Care In Achieving Health Reform

Abstract: Under the Affordable Care Act of 2010, a variety of transitional care programs and services have been established to improve quality and reduce costs. These programs help hospitalized patients with complex chronic conditions—often the most vulnerable—transfer in a safe and timely manner from one level of care to another or from one type of care setting to another. We conducted a systematic review of the research literature and summarized twenty-one randomized clinical trials of transitional care interventions targeting chronically ill adults. We identified nine interventions that demonstrated positive effects on measures related to hospital readmissions—a key focus of health reform. Most of the interventions led to reductions in readmissions through at least thirty days after discharge. Many of the successful interventions shared similar features, such as assigning a nurse as the clinical manager or leader of care and including in-person home visits to discharged patients. Based on these findings, we reco...

Palliative Care Consultation Teams Cut Hospital Costs For Medicaid Beneficiaries

Abstract: Patients facing serious or life-threatening illnesses account for a disproportionately large share of Medicaid spending. We examined 2004-07 data to determine the effect on hospital costs of palliative care team consultations for patients enrolled in Medicaid at four New York State hospitals. On average, patients who received palliative care incurred $6,900 less in hospital costs during a given admission than a matched group of patients who received usual care. These reductions included $4,098 in hospital costs per admission for patients discharged alive, and $7,563 for patients who died in the hospital. Consistent with the goals of a majority of patients and their families, palliative care recipients spent less time in intensive care, were less likely to die in intensive care units, and were more likely to receive hospice referrals than the matched usual care patients. We estimate that the reductions in Medicaid hospital spending in New York State could eventually range from $84 million to $252 million annually (assuming that 2 percent and 6 percent of Medicaid patients discharged from the hospital received palliative care, respectively), if every hospital with 150 or more beds had a fully operational palliative care consultation team.

Medication Adherence Leads To Lower Health Care Use And Costs Despite Increased Drug Spending

Abstract: Researchers have routinely found that improved medication adherence—getting people to take medicine prescribed for them—is associated with greatly reduced total health care use and costs. But previous studies do not provide strong evidence of a causal link. This article employs a more robust methodology to examine the relationship. Our results indicate that although improved medication adherence by people with four chronic vascular diseases increased pharmacy costs, it also produced substantial medical savings as a result of reductions in hospitalization and emergency department use. Our findings indicate that programs to improve medication adherence are worth consideration by insurers, government payers, and patients, as long as intervention costs do not exceed the estimated health care cost savings.

New 2011 Survey Of Patients With Complex Care Needs In Eleven Countries Finds That Care Is Often Poorly Coordinated

Abstract: Around the world, adults with serious illnesses or chronic conditions account for a disproportionate share of national health care spending. We surveyed patients with complex care needs in eleven countries (Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States) and found that in all of them, care is often poorly coordinated. However, adults seen at primary practices with attributes of a patient-centered medical home—where clinicians are accessible, know patients’ medical history, and help coordinate care—gave higher ratings to the care they received and were less likely to experience coordination gaps or report medical errors. Throughout the survey, patients in Switzerland and the United Kingdom reported significantly more positive experiences than did patients in the other countries surveyed. Reported improvements in the United Kingdom tracked with recent reforms there in health care delivery. Patients in the United States...

The Looming Expansion And Transformation Of Public Substance Abuse Treatment Under The Affordable Care Act

Abstract: Public substance abuse treatment services have largely operated as an independent part of the overall health care system, with unique methods of administration, funding, and service delivery. The Affordable Care Act of 2010 and other recent health care reforms, coupled with declines in state general revenue spending, will change this. Overall funding for these substance abuse services should increase, and they should be better integrated into the mainstream of general health care. Reform provisions are also likely to expand the variety of substance abuse treatment providers and shift services away from residential and stand-alone programs toward outpatient programs and more integrated programs or care systems. As a result, patients should have better access to care that is more medically based and person-centered.

Where Health Disparities Begin: The Role Of Social And Economic Determinants—And Why Current Policies May Make Matters Worse

Abstract: Health disparities by racial or ethnic group or by income or education are only partly explained by disparities in medical care. Inadequate education and living conditions—ranging from low income to the unhealthy characteristics of neighborhoods and communities—can harm health through complex pathways. Meaningful progress in narrowing health disparities is unlikely without addressing these root causes. Policies on education, child care, jobs, community and economic revitalization, housing, transportation, and land use bear on these root causes and have implications for health and medical spending. A shortsighted political focus on reducing spending in these areas could actually increase medical costs by magnifying disease burden and widening health disparities.

Understanding the cumulative impacts of inequalities in environmental health: implications for policy.

Abstract: Racial or ethnic minority groups and low-income communities have poorer health outcomes than others. They are more frequently exposed to multiple environmental hazards and social stressors, including poverty, poor housing quality, and social inequality. Researchers are grappling with how best to characterize the cumulative effects of these hazards and stressors in order to help regulators and decision makers craft more-effective policies to address health and environmental disparities. In this article we synthesize the existing scientific evidence regarding the cumulative health implications of higher rates of exposure to environmental hazards, along with individual biological susceptibility and social vulnerability. We conclude that current environmental policy, which is focused narrowly on pollutants and their sources, should be broadened to take into account the cumulative impact of exposures and vulnerabilities encountered by people who live in neighborhoods consisting largely of racial or ethnic minorities or people of low socioeconomic status.

The Ongoing Quality Improvement Journey: Next Stop, High Reliability

Abstract: Quality improvement in health care has a long history that includes such epic figures as Ignaz Semmelweis, the nineteenth-century obstetrician who introduced hand washing to medical care, and Florence Nightingale, the English nurse who determined that poor living conditions were a leading cause of the deaths of soldiers at army hospitals. Systematic and sustained improvement in clinical quality in particular has a more brief and less heroic trajectory. Over the past fifty years, a variety of approaches have been tried, with only limited success. More recently, some health care organizations began to adopt the lessons of high-reliability science, which studies organizations such as those in the commercial aviation industry, which manage great hazard extremely well. We review the evolution of quality improvement in US health care and propose a framework that hospitals and other organizations can use to move toward high reliability.

Confidence About Vaccines In The United States: Understanding Parents’ Perceptions

Abstract: The United States has made tremendous progress in using vaccines to prevent serious, often infectious, diseases. But concerns about such issues as vaccines’ safety and the increasing complexity of ...

Place, Not Race: Disparities Dissipate In Southwest Baltimore When Blacks And Whites Live Under Similar Conditions

Abstract: Much of the current health disparities literature fails to account for the fact that the nation is largely segregated, leaving racial groups exposed to different health risks and with variable access to health services based on where they live. We sought to determine if racial health disparities typically reported in national studies remain the same when black and white Americans live in integrated settings. Focusing on a racially integrated, low-income neighborhood of Southwest Baltimore, Maryland, we found that nationally reported disparities in hypertension, diabetes, obesity among women, and use of health services either vanished or substantially narrowed. The sole exception was smoking: We found that white residents were more likely than black residents to smoke, underscoring the higher rates of ill health in whites in the Baltimore sample than seen in national data. As a result, we concluded that racial differences in social environments explain a meaningful portion of disparities typically found in national data. We further concluded that when social factors are equalized, racial disparities are minimized. Policies aimed solely at health behavior change, biological differences among racial groups, or increased access to health care are limited in their ability to close racial disparities in health. Such policies must address the differing resources of neighborhoods and must aim to improve the underlying conditions of health for all.

How Intermountain Trimmed Health Care Costs Through Robust Quality Improvement Efforts

Abstract: It has been estimated that full implementation of the Affordable Care Act will extend coverage to thirty-two million previously uninsured Americans. However, rapidly rising health care costs could thwart that effort. Since 1988 Intermountain Healthcare has applied to health care delivery the insights of W. Edwards Deming's process management theory, which says that the best way to reduce costs is to improve quality. Intermountain achieved such quality-based savings through measuring, understanding, and managing variation among clinicians in providing care. Intermountain created data systems and management structures that increased accountability, drove improvement, and produced savings. For example, a new delivery protocol helped reduce rates of elective induced labor, unplanned cesarean sections, and admissions to newborn intensive care units. That one protocol saves an estimated $50 million in Utah each year. If applied nationally, it would save about $3.5 billion. "Organized care" along these lines may be central to the long-term success of health reform.

The $17.1 Billion Problem: The Annual Cost Of Measurable Medical Errors

Abstract: At a minimum, high-quality health care is care that does not harm patients, particularly through medical errors. The first step in reducing the large number of harmful medical errors that occur today is to analyze them. We used an actuarial approach to measure the frequency and costs of measurable US medical errors, identified through medical claims data. This method focuses on the analysis of comparative rates of illness, using mathematical models to assess the risk of occurrence and to project costs to the total population. We estimate that the annual cost of measurable medical errors that harm patients was $17.1 billion in 2008. Pressure ulcers were the most common measurable medical error, followed by postoperative infections and by postlaminectomy syndrome, a condition characterized by persistent pain following back surgery. A total of ten types of errors account for more than two-thirds of the total cost of errors, and these errors should be the first targets of prevention efforts.

Large Variations In Medicare Payments For Surgery Highlight Savings Potential From Bundled Payment Programs

Abstract: Payers are considering bundled payments for inpatient surgery, combining provider reimbursements into a single payment for the entire episode. We found that current Medicare episode payments for ce...

How A Regional Collaborative Of Hospitals And Physicians In Michigan Cut Costs And Improved The Quality Of Care

Abstract: There is evidence that collaborations between hospitals and physicians in particular regions of the country have led to improvements in the quality of care. Even so, there have not been many of these collaborations. We review one, the Michigan regional collaborative improvement program, which was paid for by a large private insurer, has yielded improvements for a range of clinical conditions, and has reduced costs in several important areas. In general and vascular surgery alone, complications from surgery dropped almost 2.6 percent among participating Michigan hospitals—a change that translates into 2,500 fewer Michigan patients with surgical complications each year. Estimated annual savings from this one collaborative are approximately $20 million, far exceeding the cost of administering the program. Regional collaborative improvement programs should become increasingly attractive to hospitals and physicians, as well as to national policy makers, as they seek to improve health care quality and reduce costs.

An Agenda For Improving Compassionate Care: A Survey Shows About Half Of Patients Say Such Care Is Missing

Abstract: As the US health care system undergoes restructuring and pressure to reduce costs intensifies, patients worry that they will receive less compassionate care. So do health care providers. Our survey of 800 recently hospitalized patients and 510 physicians found broad agreement that compassionate care is "very important" to successful medical treatment. However, only 53 percent of patients and 58 percent of physicians said that the health care system generally provides compassionate care. Given strong evidence that such care improves health outcomes and patients' care experiences, we recommend that national quality standards include measures of compassionate care; that such care be a priority for comparative effectiveness research to determine which aspects have the most influence on patients' care experiences, health outcomes, and perceptions of health-related quality of life; and that payers reward the provision of such care. We also recommend the development of systematic approaches to help health care professionals improve the skills required for compassionate care.

Transforming Physician Practices To Patient-Centered Medical Homes: Lessons From The National Demonstration Project

Abstract: Many commentators view the conversion of small, independent primary care practices into patient-centered medical homes as a vital step in creating a better-performing health care system. The country's first national medical home demonstration, which ran from June 1, 2006, to May 31, 2008, and involved thirty-six practices, showed that this transformation can be lengthy and complex. Among other features, the transformation process requires an internal capability for organizational learning and development; changes in the way primary care clinicians think about themselves and their relationships with patients as well as other clinicians on the care team; and awareness on the part of primary care clinicians that they will need to make long-term commitments to change that may require three to five years of external assistance. Additionally, transforming primary care requires synchronizing practice redesign with development of the health care "neighborhood," which is made up of a broad range of health and health care resources available to patients. It also requires payment reform that supports practice development and a policy environment that sets reasonable expectations and time frames for the adoption of appropriate innovations.

Evidence Links Increases In Public Health Spending To Declines In Preventable Deaths

Abstract: Public health encompasses a broad array of programs designed to prevent the occurrence of disease and injury within communities. But policy makers have little evidence to draw on when determining t...

Partnering Urban Academic Medical Centers And Rural Primary Care Clinicians To Provide Complex Chronic Disease Care

Abstract: Many of the estimated thirty-two million Americans expected to gain coverage under the Affordable Care Act are likely to have high levels of unmet need because of various chronic illnesses and to l...

Eliminating Health And Health Care Disparities Among The Growing Population Of People With Disabilities

Abstract: Fifty-four million people in the United States are now living with disabilities. That number will grow substantially in the next thirty years, as the “baby-boom” generation ages and many of today’s children and young adults mature and experience complications related to overweight and obesity. This reality poses a major challenge to the health care and policy communities. People with disabilities confront disadvantages from social and environmental determinants of health, including lower educational levels, lower incomes, and higher unemployment, than people without disabilities. Those with disabilities are also much more likely to report being in fair or poor health; to use tobacco; to forgo physical activity; and to be overweight or obese. People with disabilities also experience health care disparities, such as lower rates of screening and more difficulty accessing services, compared to people without disabilities. Eliminating these multifaceted disadvantages among people with disabilities should be a ...

The effect of pay-for-performance in hospitals: lessons for quality improvement.

Abstract: The payment approach known as “pay-for-performance” has been widely adopted with the aim of improving the quality of health care. Nonetheless, little is known about how to use the approach most effectively to improve care. We examined the effects in 260 hospitals of a pay-for-performance demonstration project carried out by the Centers for Medicare and Medicaid Services in partnership with Premier Inc., a nationwide hospital system. We compared these results to those of a control group of 780 hospitals not in the demonstration project. The performance of the hospitals in the project initially improved more than the performance of the control group: More than half of the pay-for-performance hospitals achieved high performance scores, compared to fewer than a third of the control hospitals. However, after five years, the two groups’ scores were virtually identical. Improvements were largest among hospitals that were eligible for larger bonuses, were well financed, or operated in less competitive markets. Th...

Clinical Decision Support Systems Could Be Modified To Reduce ‘Alert Fatigue’ While Still Minimizing The Risk Of Litigation

Abstract: Clinical decision support systems—interactive computer systems that help doctors make clinical choices—can reduce errors in drug prescribing by offering real-time alerts about possible adverse reactions. But physicians and other users often suffer “alert fatigue” caused by excessive numbers of warnings about items such as potentially dangerous drug interactions. As a result, they may pay less attention to or even ignore some vital alerts, thus limiting these systems’ effectiveness. Designers and vendors sharply limit the ability to modify alert systems because they fear being exposed to liability if they permit removal of a warning that could have prevented a harmful prescribing error. Our analysis of product liability principles and existing research into the use of clinical decision support systems, however, finds that more finely tailored or parsimonious warnings could ease alert fatigue without imparting a high risk of litigation for vendors, purchasers, and users. Even so, to limit liability in this ...

Children’s Vulnerability To Toxic Chemicals: A Challenge And Opportunity To Strengthen Health And Environmental Policy

Abstract: A key policy breakthrough occurred nearly twenty years ago with the discovery that children are far more sensitive than adults to toxic chemicals in the environment. This finding led to the recognition that chemical exposures early in life are significant and preventable causes of disease in children and adults. We review this knowledge and recommend a new policy to regulate industrial and consumer chemicals that will protect the health of children and all Americans, prevent disease, and reduce health care costs. The linchpins of a new US chemical policy will be: first, a legally mandated requirement to test the toxicity of chemicals already in commerce, prioritizing chemicals in the widest use, and incorporating new assessment technologies; second, a tiered approach to premarket evaluation of new chemicals; and third, epidemiologic monitoring and focused health studies of exposed populations.

Proportion Of Antidepressants Prescribed Without A Psychiatric Diagnosis Is Growing

Abstract: Over the past two decades, the use of antidepressant medications has grown to the point that they are now the third most commonly prescribed class of medications in the United States. Much of this growth has been driven by a substantial increase in antidepressant prescriptions by nonpsychiatrist providers without an accompanying psychiatric diagnosis. Our analysis found that between 1996 and 2007, the proportion of visits at which antidepressants were prescribed but no psychiatric diagnoses were noted increased from 59.5 percent to 72.7 percent. These results do not clearly indicate a rise in inappropriate antidepressant use, but they highlight the need to gain a deeper understanding of the factors driving this national trend and to develop effective policy responses. To the extent that antidepressants are being prescribed for uses not supported by clinical evidence, there may be a need to improve providers’ prescribing practices, revamp drug formularies, or vigorously pursue implementation of broad refor...

Air Pollution Around Schools Is Linked To Poorer Student Health And Academic Performance

Abstract: Exposing children to environmental pollutants during important times of physiological development can lead to long-lasting health problems, dysfunction, and disease. The location of children’s schools can increase their exposure. We examined the extent of air pollution from industrial sources around public schools in Michigan to find out whether air pollution jeopardizes children’s health and academic success. We found that schools located in areas with the highest air pollution levels had the lowest attendance rates—a potential indicator of poor health—and the highest proportions of students who failed to meet state educational testing standards. Michigan and many other states currently do not require officials considering a site for a new school to analyze its environmental quality. Our results show that such requirements are needed. For schools already in existence, we recommend that their environmental quality should be investigated and improved if necessary.

The $16,819 Pay Gap For Newly Trained Physicians: The Unexplained Trend Of Men Earning More Than Women

Abstract: Prior research has suggested that gender differences in physicians' salaries can be accounted for by the tendency of women to enter primary care fields and work fewer hours. However, in examining starting salaries by gender of physicians leaving residency programs in New York State during 1999-2008, we found a significant gender gap that cannot be explained by specialty choice, practice setting, work hours, or other characteristics. The unexplained trend toward diverging salaries appears to be a recent development that is growing over time. In 2008, male physicians newly trained in New York State made on average $16,819 more than newly trained female physicians, compared to a $3,600 difference in 1999.

Small And Medium-Size Physician Practices Use Few Patient-Centered Medical Home Processes

Abstract: The patient-centered medical home has become a prominent model for reforming the way health care is delivered to patients. The model offers a robust system of primary care combined with practice innovations and new payment methods. But scant information exists about the extent to which typical US physician practices have implemented this model and its processes of care, or about the factors associated with implementation. In this article we provide the first national data on the use of medical home processes such as chronic disease registries, nurse care managers, and systems to incorporate patient feedback, among 1,325 small and medium-size physician practices. We found that on average, practices used just one-fifth of the patient-centered medical home processes measured as part of this study. We also identify internal capabilities and external incentives associated with the greater use of medical home processes.

National Health Spending Projections Through 2020: Economic Recovery And Reform Drive Faster Spending Growth

Abstract: In 2010, US health spending is estimated to have grown at a historic low of 39 percent, due in part to the effects of the recently ended recession In 2014, national health spending growth is expected to reach 83 percent when major coverage expansions from the Affordable Care Act of 2010 begin The expanded Medicaid and private insurance coverage are expected to increase demand for health care significantly, particularly for prescription drugs and physician and clinical services Robust growth in Medicare enrollment, expanded Medicaid coverage, and premium and cost-sharing subsidies for exchange plans are projected to increase the federal government share of health spending from 27 percent in 2009 to 31 percent by 2020 This article provides perspective on how the nation’s health care dollar will be spent over the coming decade as the health sector moves quickly toward its new paradigm of expanded insurance coverage