Quality strategy update shows sluggish start
Additional data coming soon
Two years ago, the federal government put in place a mechanism for determining quality goals and strategies for the healthcare system. The National Quality Strategy came up with three aims — better care, healthier communities, and affordable care. Those aims, divided into six priorities, have had a year to percolate through healthcare, and in August, the Agency for Healthcare Research and Quality (AHRQ) released its second annual report with the first set of data included. The results aren’t glowing — although some of the data that could show improvement won’t be ready until later this fall or early in 2014. (See table on page 118 with list of baseline measures, current measures, and aspirational goals.)
Here’s how the six priorities did over the last year:
Priority 1: Reduce Harm. Measures included hospital-acquired conditions (HAC) and 30-day readmission rates. HACs declined from 145 per 1,000 admissions to 142. Readmissions data was static. That may change when new numbers are released by the Centers for Medicare & Medicaid Services (CMS), which showed a decline in such rates last year, from 19% to 18%. Other payers, health systems, and cooperatives are also noting reductions in all-payer, all-cause readmissions that might not be reflected in this year’s report. It highlights the Texas-based VHA cooperative of 192 hospitals, which saw a 17.6% reduction in readmissions over a one-year period. The organization cites its "Practice Blueprints," which outline strategies for readmission reduction.
The success with HACs may also be understated this year, as individual hospitals are noting remarkable reductions in ventilator-associated pneumonia, central line-associated bloodstream infections, catheter-associated urinary tract infections, and surgical-site infections.
Priority 2: Patient and Family Engagement. There are no data available on measures related to this priority yet, but the report called out some of the more notable efforts by hospitals to improve engagement and experience. Mount Sinai Hospital in New York City worked to reduce disorienting noise in the ED for its older patients by opening a quieter geriatric ED. Trained volunteers walk around with reading glasses, hearing aids, and magazines. They will sit and talk with the patients to help them get their bearings. Also noted was Kaiser Permanente in Southern California, which piloted shared decision-making at three of its facilities. Patients considering hip or knee replacement surgery to deal with joints damaged by osteoarthritis participated in a video program to help them figure out their treatment goals and the various options. Patients overwhelmingly like the process, and there was a 50% reduction in elective hip replacement surgeries as a result. The program is expanding to other areas.
Priority 3: Effective Communication. This priority has two measures — care coordination for pediatric patients who need it, and a three-item checklist of patient discharge questions. The latter won’t have data until later this fall. The former? The baseline of 69% fell to 66%. The goal is in the other direction, 90%. Still, there were bright spots noted by the report, including a patient-centered medical home in Alaska that received a level three designation from the National Committee for Quality Assurance, the highest level it gives. The medical home’s work has led to a 5% reduction in ED visits by a patient population that is primarily Alaskan native, poor, and often without appropriate access to care. It also reduced hospital admissions by more than half, specialty care visits by nearly two thirds, and visits to the doctor by 20%.
Priority 4: Effective Treatment for Leading Causes of Mortality — Cardiovascular Disease. This is probably the brightest spot in the report. Smoking cessation and cholesterol management need to improve — the declines in those are not considered statistically significant, but the goal is to increase them. Aspirin use and blood pressure control are on the right track, though. The report notes that efforts like the Million Hearts Initiative, as well as other efforts by individual hospitals, non-profit organizations, government entities, and private companies should pay off.
Priority 5: Improving Community Health. While obesity rate data won’t be out until next year, there have been some stories indicating that the increase in it — particularly in children — appears to have leveled off. Depression patients reporting treatment, the other measure for this focus, is currently stagnant. Because coverage for mental health is mandated by the Affordable Care Act, the study anticipates this will show improvement over time.
Priority 6: Making Quality Healthcare More Affordable and Accessible. Out-of-pocket expense data should be available later this year. The baseline rate is 18.5%, and there is thus far no target figure set. Nor is there one for all-payer health care spending per person, which was up from the baseline of $8402 to $8680. Growth has slowed in the health sector — it’s had a 3.9% growth rate for three years running. For Medicare, health spending per capita grew by just 0.4% in FY2012, and it fell for Medicaid by 0.9% in FY2011. But what a family pays for insurance premiums is growing faster — 4.5% in 2012. There are organizations that are making a difference, though. In the Washington, DC area, CareFirst BlueCross BlueShield established a medical home program for more than a million of its members. It links physician payments to the quality of care, and last spring, it reported that it saved $98 million in its second year — up from $38 million the first year. While reducing costs, doctors providing the highest quality of care got increased reimbursement. The question remains, though, how this will impact what the public pays for insurance.
The entire report is available at http://www.ahrq.gov/workingforquality/nqs/nqs2013annlrpt.htm