 ccording to a recent article,
Texas is in the lowest quartile of states in its delivery
of health care to patients >65 years of age (1).
Physicians may wonder how these statistics came about and
how Baylor Health Care System (BHCS) is trying to improve
health care quality. This article begins by defining
quality. It then discusses the performance measures and
the sixth scope of work, which are key in the state
ranking mentioned above, and closes by outlining some of
BHCS's efforts in quality improvement. A DEFINITION OF QUALITY
As recently as 4 years
ago, physicians believed that quality in health care
meant doing the right thing correctly (2). However, this
discussion focuses on the widely accepted definition of
quality offered by the Institute of Medicine 10 years
ago: “Quality is the degree to which health services
for individuals and populations increase the likelihood
of desired health outcomes and are consistent with
current professional knowledge” (2). As noted by
David Shipon, MD, and David Nash, MD, applying this
definition entails measuring health care and implementing
interventions based on the measurements as a way to
improve care (3). The Health Care Financing
Administration (HCFA) takes the measurements from the
states and hospital systems and compares them nationally.
BACKGROUND FOR THE
RECENT STATE RANKING
For the past 16 years,
HCFA has funded numerous quality management programs
based upon Medicare beneficiaries, known as the first
through sixth scope of work. The current contract with
HCFA and the peer review organizations is the sixth scope
of work, and it focuses on 6 clinical areas--acute
myocardial infarction and congestive heart failure,
atrial fibrillation, thromboembolic stroke,
community-acquired pneumonia, breast cancer, and diabetes
mellitus--with a total of 22 quality indicators. These
quality indicators serve as performance measures and not
as guidelines for practitioners. They are similar to the
measures used by the Joint Commission on Accreditation of
Healthcare Organizations.
Overall, Texas ranked
45th out of 52 states (including Puerto Rico) in the
performance measures based on the clinical indicators;
data on the individual measures are provided in the Table.
The Texas peer review organization--the Texas Medical
Foundation--is working with the hospital systems,
administrators, and practitioners to improve the quality
of care.
RELATED QUALITY
IMPROVEMENT EFFORTS AT BHCS
BHCS is evaluating
baseline data in several of the clinical areas in the
sixth scope of work. For community-acquired pneumonia,
BHCS is pursuing a baseline evaluation study of its 5
major hospitals with physician champions on a system and
local hospital level. The goal is to highlight the areas
where the hospital excels as well as offer a forum for
physician leaders, quality care coordinators, and
administrators to propose new initiatives to improve the
delivery of medicine.
BHCS is participating
with 14 other health care systems across the nation to
evaluate the clinical indicators for acute myocardial
infarction and congestive heart failure as well. Once
again, a physician champion at the system level along
with physician champions from individual hospitals are
evaluating the data and implementing new strategies for
patient care from the moment a patient enters the
emergency department to the day he or she is discharged.
Other studies on the
horizon include a systemwide evaluation of the use of
anticoagulants in patients with atrial fibrillation and
an evaluation of the delivery of health care to the
diabetic patient.
Quality improvement at
BHCS is not the work of only a few. It requires the
support of everyone--from health care practitioners
(physicians, nurses, care coordinators, technicians,
pharmacists, dietitians, and respiratory therapists) and
administrators to unit clerical assistants, medical
records personnel, and the engineering department. With
all of us working together, we can become the symbol of
good health care not only in North Texas but also in the
nation. Let us work together on these clinical
indicators.
| Table.
Percentage of Texas Medicare patients receiving
appropriate care based on the sixth scope of work
compared with the national median |
| |
|
Performance (%
patients
receiving appropriate care) |
| Scope of work |
Texas |
Median |
Texas
rank |
| 1. |
Acute myocardial
infarction and congestive heart failure |
|
|
|
| |
a. Aspirin given
within 24 hours of admission |
78% |
84% |
45 |
| |
b. Aspirin
prescribed on discharge |
84% |
85% |
32 |
| |
c. Beta-blockers
given within 24 hours of admission |
51% |
64% |
49 |
| |
d. Beta-blockers
prescribed on discharge |
58% |
72% |
48 |
| |
e. ACE inhibitor
prescribed on discharge for patients with LVEF
< 40% (AMI) |
63% |
71% |
44 |
| |
f. Counseling
given on nicotine cessation during
hospitalization |
19% |
40% |
52 |
| |
g. Time to
delivery of thrombolytic therapy (min)+
|
39 |
40 |
20 |
| |
h. Time to
percutaneous transluminal coronary angioplasty
(min)+ |
85 |
20 |
NA |
| |
i. Assessment of
LVEF |
64% |
65% |
39 |
| |
j. ACE inhibitor
prescribed at discharge for patients with LVEF
< 40% (HF) |
62% |
69% |
44 |
| 2. |
Atrial
fibrillation |
|
|
|
| |
a. Warfarin
prescribed on discharge** |
45% |
55% |
49 |
| 3. |
Thromboembolic
stroke |
|
|
|
| |
a.
Antithrombotic prescribed at discharge** |
72% |
83% |
52 |
| |
b. Avoidance of
sublingual nifedipine++ |
90% |
95% |
47 |
| 4. |
Community-acquired
pneumonia |
|
|
|
| |
a. Antibiotic
given within 8 hours of arrival at hospital |
80% |
85% |
44 |
| |
b. Antibiotics
consistent with recommendations |
80% |
79% |
19 |
| |
c. Blood
cultures drawn (if done) before antibiotic gi |
84% |
82% |
23 |
| |
d. Screening of
patients and administration of influenza vaccine
if needed |
12%
s, 68% v |
14%
s, 66% v |
36,
18 |
| |
e. Screening of
patients and administration of pneumococcal
vaccine if needed |
8%
s,44% v |
11%
s, 46% v |
40,
31 |
| 5. |
Breast cancer |
|
|
|
| |
a. Mammography
at least every 2 years |
51% |
56% |
44 |
| 6. |
Diabetes
mellitus |
|
|
|
| |
a. Hemoglobin A1C
levels at least every year |
73% |
71% |
21 |
| |
b. Eye
examination at least every 2 years |
68% |
69% |
31 |
| |
c. Lipid profile
at least every 2 years |
66% |
57% |
4 |
| |
|
|
|
|
* Adapted from reference
1. The first three were examinated in an
inpatient setting and the last three in any
setting.
+ Values are in minutes rather than percentages.
** Applies to patients with acute stroke or
transient ischemia attack.
++ Applies to patients with acute stroke.
ACE indicates angiotensin-converting enzyme; AMI,
acute myocardial infarction; HF, heart failure;
LVEF, left ventricular ejection fraction; NA, not
available; s, screened; v, vaccinated. |
- Jencks SF,
Cuerdon T, Burwen DR, Fleming B, Houck PM,
Kussmaul AE, Nilasena DS, Ordin DL, Arday DR.
Quality of medical care delivered to Medicare
beneficiaries: a profile at state and national
levels. JAMA 2000;284:1670-1676.
- Blumenthal
D. Part 1: Quality of care--what is it? N Engl
J Med 1996;335:891-894.
- Shipon D,
Nash D. Quality in health care: what are the
problems and what are the solutions? Texas
Medicine 2000;96(10):61-65.
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