ED quality performance moves into the public reporting arena
ED quality performance moves into the public reporting arena
'Top performers' are named What does that really mean?
HealthGrades, a Golden, CO-based health care ratings organization that provides the public with ratings on more than 750,000 physicians and 5,000 hospitals, has just released a study it claims "evaluates hospital emergency medicine for the first time."
The report, which HealthGrades says is the first annual "HealthGrades Emergency Medicine in American Hospitals" study, examined more than 5 million Medicare records of patients admitted through the ED at 4,907 hospitals from 2006 to 2008. It identified hospitals that performed in the top 5% in the nation in emergency medicine.
HealthGrades then compared those top performers with the other facilities and found a 39% lower risk-adjusted mortality rate and a faster rate of quality improvement. HealthGrades postulated that if all hospitals performed at that higher level, 118,014 more patients potentially could have survived their emergency hospitalization.
The study examined these 11 conditions:
- bowel obstruction;
- chronic obstructive pulmonary disease;
- diabetic acidosis and coma;
- gastrointestinal bleed;
- heart attack;
- pancreatitis;
- pneumonia;
- pulmonary embolism;
- respiratory failure;
- sepsis;
- stroke.
HealthGrades also ranked the states according to overall performance. Ohio, Arizona, and Michigan had the best rankings, while Mississippi, Alabama, and Hawaii ranked lowest.
What does it mean?
Emergency medicine proponents, even some whose facilities received high rankings, were critical of HealthGrades' methodology.
"HealthGrades basically looked at mortality on the inpatient side," says Rick Bukata, MD, clinical professor of emergency medicine at the Los Angeles County University of Southern California Medical Center. Bukata recently retired after serving as ED director at San Gabriel (CA) Medical Center for 25 years.
Although he says his facility ranked among the top 10% in the country, Bukata he notes that "any ED doc who's honest with themselves knows that if we had a patient for two hours before admitting them, in most cases nothing could have been done to change the ultimate outcome." To take credit or blame for whether an admitted patient lives or dies after a six-day hospital stay "is absolutely nutty," he says.
Jon Mark Hirshon, MD, MPH, associate professor in the Department of Emergency Medicine, Department of Epidemiology and Preventive Medicine, the National Study Center for Trauma and EMS, Baltimore, MD, agrees. "They call this an 'emergency medicine excellence award,' but it's not necessarily related to emergency medicine," Hirshon says. "The issue I have is the fact that they looked at in-hospital mortality and said that was a marker for how good an ED is."
The fact remains, however, that this study is just the latest in a growing number of public reports that include a focus on the ED. For example:
- The National Quality Forum (www.qualityforum.org) reports on quality improvement and covers care in the ED.
- Medicare's Hospital Compare service (www.healthcare.gov/compare) offers a condition-by-condition rating of how hospitals care for their patients, and it recently began adding data on ED care.
- The Physician's Quality and Reporting Initiative (PQRI, www.cms.gov/pqri) offers doctors an opportunity to earn payment incentives by reporting on and meeting specific quality measures, including some that apply to the ED.
Bukata argues that in many cases, the methodology used can be questioned, but ultimately that might not matter. Administrators are paying more and more attention to these reports, he says. "My most candid view is that the methodologies are generally poor," Bukata says, but Bukata adds that "CEOs love this stuff when your marks are good and use it to promote the hospital and give themselves 'attaboys.'"
When the numbers are bad, of course, they become concerned that the facility will be perceived by the community with less favor than they would like, he says.
Responding to the rankings
If your ED receives a poor ranking, you have two options, Bukata says.
"I would tell the administration that we need more resources to achieve higher rankings, because one of the ongoing stresses of being a medical director of an ED is the inordinate emphasis that the hospital administration puts on keeping the staffing lean in the ED," he says.
The other option, which Bukata does not favor, is to challenge the numbers. "Most people are not going to take your challenge very seriously, even if it is totally legitimate," he says. "It looks like sour grapes to criticize the methodology, even though it is absolutely legitimate in the majority of these cases."
Hirshon takes a different tack. "If someone came to me and asked why we did not get an award of excellence, I'd say this is an in-hospital metric," he says. "You may call it emergency medicine, but the bottom line is what are you doing to do to improve the metrics in your hospital?"
To support any criticism of methodology, he says, "Have an epidemiologist or statistician look at your data, or someone who understands how to do research someone who understands the population being studied, where the data came from, how it was analyzed, and whether the results support the conclusion."
Of course, if you receive a favorable ranking, the path is much clearer. "Frankly, when I like our numbers, I think the surveys are terrific," Bukata says. "However, we should have no delusion that what is being measured really matters." If administration doesn't know about the report, he will let them know, he adds, "but they subscribe to most of them, like the patient satisfaction surveys."
Hirshon says the overall message for ED managers is this: "We need to recognize that we live in a time when a large amount of information is being disseminated, and that gives attention to real problems." While he has an issue with how HealthGrades performed its study, he says, "It's a good thing that people are paying attention to emergency medicine."
Sources/Resource
For more information, contact:
- Rick Bukata, MD, Clinical Professor of Emergency Medicine, Los Angeles County University of Southern California Medical Center, Los Angeles. E-mail: [email protected].
- Jon Mark Hirshon, MD, MPH, Associate Professor, Department of Emergency Medicine, Department of Epidemiology and Preventive Medicine, National Study Center for Trauma and EMS, Baltimore, MD. Phone: (410) 328-7474.
The HealthGrades study of emergency medicine can be downloaded free of charge at www.healthgrades.com/business/img/HealthGradesEmergencyMedicineStudy2010.pdf.
Managers paying attention to data In light of the growing trend toward public reporting of performance, an increasing number of ED managers are seeking better ways to track their data, says Mark D. Crockett, MD, FACEP, president of the Emergency Care Division at Picis, an information solutions provider based in Wakefield, MA, and an attending ED physician at Morris (IL) Hospital. "From my perspective, we have a large number of EDs that report anything from wait times to their latest performance," he says. "We see requests from customers to put those kinds of metrics into our software." With the growing emphasis on reporting quality performance, "you'd better have data," Crockett says. If you don't understand the data behind your ED's processes, the time to understand them is not after you've been questioned by administration, he says. "You can't say 'I'll go look into that and see what is going on,'" Crockett says. "You need a ready answer." This preparation is particularly important for "global" data such as time in the department or door-to-doc time, he says. "It also applies to PQRI [Physician's Quality and Reporting Initiative] measures like time to antibiotics," he says. "And this is tied to better outcomes. It's not just administrators being annoyed for no reason." Having an automated system to collect such data is becoming a "must" for EDs, says Jon Mark Hirshon, MD, MPH, associate in the Department of Emergency Medicine, Department of Epidemiology and Preventive Medicine, the National Study Center for Trauma and EMS, Baltimore, MD. "Personally, I think you need some form of automated system," Hirshon says. "With government requirements for electronic health records going forward, that may allow us to have a more automated system for collecting information." While the fact that these metrics are reported on publicly by private and government organizations frequently can put other areas of performance in the background, it's important that an ED manager maintain focus on all areas of patient care, cautions Rick Bukata, MD, clinical professor of emergency medicine at the Los Angeles County University of Southern California Medical Center, who recently retired after serving as ED director at San Gabriel (CA) Medical Center for 25 years. "The emphasis others put on specific measures does not mean we should not concentrate on those things that not measured," he says. "After all, those measures are very limited. They shouldn't distract us from other things." The real issue, from a medical point of view, is that "all we can really measure is our processes," he says. "We can't measure outcomes." Source For more information on collecting data on ED performance, contact:
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