Optimizing the prevention of venous thromboembolism: recent quality initiatives and strategies to drive improvement

BACKGROUND

Venous thromboembolism (VTE) is associated with a substantial health care and economic burden, yet many VTE events are preventable. Despite the availability of evidence-based guidelines derailing effective thromboprophylaxis strategies, the underuse and inappropriate prescribing of VTE prophylaxis are common. Current national quality initiatives were reviewed to identify strategies that may help hospitals and health care professionals optimize current VTE prophylaxis practices.

METHODS

A computerized literature search was performed using PubMed and MEDLINE, and this was complemented by hand searches of relevant journals and Web sites to identify additional literature related to VTE prevention and quality improvement.

FINDINGS

Many organizations, including the Centers for Medicare & Medicaid Services, the National Quality Forum, the Joint Commission, and the Agency for Healthcare Research and Quality have developed performance measures, quality indicators, public reporting initiatives, incentive programs, and "negative reimbursement" that are designed to help improve VTE prevention.

CONCLUSIONS

It remains the responsibility of individual hospitals to identify specific areas in which they can improve their VTE prophylaxis rates to obtain positive results from the reporting initiatives and incentive programs. If performance measures are to be met, all hospital departments will need to implement effective VTE prevention policies, including early risk assessment, appropriate prophylaxis prescribing, monitoring, and follow-up. Multifaceted, integrated initiatives involving risk assessment tools, decision support, electronic alert systems, and hospitalwide education, with a mechanism for audit and feedback, may help ensure that all health care professionals comply with VTE-prevention policies and initiatives.

Results from the first 4 years of pay for performance

Some of the lessons hospitals that have participated in the Hospital Quality Incentive Demonstration project have learned include: the need to tie in quality-of-care initiatives to the organization's strategic plan and to incentive plans for all employees, from executives on down; the value in allowing hospital physicians to "own" quality improvement initiatives; the importance of making results of the initiative available to all staff; the benefit of creating best-practice teams to address improvements in specific clinical areas.

An international perspective on the basis for payment for performance

This discussion paper reflects on the pay-for-performance system in UK general practice - the Quality and Outcomes Framework (QOF) - from an international viewpoint. The QOF intends to bring the best scientific evidence to bear on primary care practice. However, the QOF and patient-centred medicine are often at odds. Inadequacies and commercial bias in the creation of evidence make the scientific basis of the QOF questionable. The framework for the QOF does not align well with the scope of primary care, making its basis as a tool for quality measurement questionable. The extent of impact of the QOF on health outcomes and on equity of health outcomes needs examination. Attention to resolution of patients' problems is an important aim of quality improvement activities. Alternative modes of improving patient care may be better than the QOF.

Physician incentives: cure versus prevention

This paper distinguishes between two scenarios for the physician-patient encounter. In the cure scenario, the patient does not know whether a loss can be recovered. In the prevention scenario, the patient faces a threat but does not know whether this threat is real enough to justify preventive action. The patient wants to induce the physician both to give an accurate diagnosis and to put appropriate effort into cure or prevention. It is shown that in the cure scenario, a contingent fee solves both these incentive problems. In the prevention scenario, however, putting up with low effort makes it easier to get an accurate diagnosis, and the use of contingent fees should be limited. These results are interpreted as providing a rationale for observed exceptions to legal and ethical restrictions on the use of contingent fees. Indeed, such exceptions are often granted for cases that fit the cure scenario.

Pay-for-performance in dentistry: what we know

Little is known about the effect of a pay-for-performance system (P4P) on primary medical care providers and even less is known about its potential impact in dentistry. Based on the growing acceptance of performance-based reimbursements in medicine and the dissemination of innovative technologies, structures, and processes of care from medical to dental services, it is likely that the dental profession will face performance-based payments in the not-too-distant future. In this paper, we present the current experience of P4P in primary medical care that has relevance to dentistry and discuss the dental performance-based programs to date. Taking into consideration these lessons, the structure of dental service delivery in the United States, and the paucity of evidence-based quality indicators in dentistry, we provide several guidelines for the design of P4P pilot programs for dental services. We conclude that large-scale implementation of P4P for dentistry may not be a realistic option before significant progress is achieved in quality of dental care indicators.

Reform incentives to create a demand for health system reengineering

America needs a far more efficient health care financing and delivery system than the one we have. Our present system is a serious threat to public finances and is pricing itself out of reach. At the root of the problem are incentives and organization. The present fragmented fee-for-service small practice model is filled with cost-increasing incentives. There are some relatively efficient organized delivery systems, mostly based on large multi-specialty group practices. Unfortunately, most consumers are not offered the opportunity to save money and get better care by choosing such a system. This situation presents great opportunities for improvement in performance by re-engineering the system. However, for this to happen, incentives must be fundamentally changed so that everyone is cost conscious and care is organized in accountable care systems seeking improvement.

Pay for performance schemes in primary care: what have we learnt?

BACKGROUND

Pay for performance (P4P) schemes have become increasingly popular innovations in primary care and have generated questions about their effect on improving quality of care.

AIMS

To provide a brief outline of the international evidence on the relationship between P4P schemes and quality improvement.

METHOD

We conducted a literature search using relevant databases and reference lists of retrieved articles which discussed P4P schemes, quality in primary care and the Quality and Outcomes Framework (QOF). These included two recent systematic reviews of P4P schemes.

RESULTS

Evidence on the effect of P4P on quality is limited. What we can say is that P4P schemes can have an effect on the behaviour of physicians and can lead to better clinical management of disease, but that there is cause for concern about the impact on the quality of care.

CONCLUSION

P4P schemes need to take more account of broader definitions of quality, as whilst they can have a positive impact on incentivised clinical processes, it is not clear that this translates into improving the experience and outcome of care.

[The bitter pay back--perverse financial incentives in healthcare]

This article analyses the stimuli that arise from the current design of the healthcare system. Hospital care is fragmented into an endless series of interventions and subsidiary interventions that are parts of chains, lines of care, care trajectories and care protocols. Each intervention has its own logic and quality standards. And each of these interventions not only bears an estimate of the intensity of care but increasingly a price tag as well. These interventions are vitally important because they form the basis for the declarations of costs. Consequently this set-up provides a perverse incentive that elicits greed and meanness. Three factors underlying this are discussed in this article: a meritocratic culture, Taylorism in the care process and misplaced market thinking.

How do we compare? Applying UK pay for performance indicators to an Australian general practice

BACKGROUND

United Kingdom general practitioners receive payment based on their performance in multiple clinical indicators. We set out to apply the same indicators in an Australian general practice to benchmark our performance and to see how much work was required to obtain the data.

METHODS

Clinical indicators for the 2008-2009 UK Quality and Outcomes Framework (QOF) cycle were examined and achievement levels measured in a large rural Australian general practice, mainly by computer searching of the clinical database.

RESULTS

Outcome measures were obtainable for 79 out of 80 indicators. Manual perusal of computer records was required for 16 indicators. Data collection takes approximately 130 hours. The Australian general practice achieved 66% of available pay for performance points compared to the UK average of 97%.

DISCUSSION

United Kingdom QOF clinical data is obtainable relatively easily in a well computerised Australian rural general practice. The exercise identified significant areas in which clinical performance could be improved.

Cost cutting in health systems without compromising quality care

Intermountain Healthcare is a high-performing health system and a recognized leader in quality improvement. We use a clinical integration strategy focused on eight clinical programs to support the practice of evidence-based care. Accelerated improvements that enhance patient safety, clinical excellence, and operational efficiency are tested and then spread across the system via care process models and program-specific board goals. While we have nearly 60 evidence-based care process models in place (in addition to multiple operational effectiveness initiatives), we provide three exemplars to illustrate cost savings and the relative impact on hospital/medical group versus payer benefit. These clinical best practices include very early lung recruitment (VE LR) for neonates with respiratory distress syndrome, guidelines for elective inductions in labor and delivery, and prevention of congestive heart failure (CHF) readmissions. Due to perverse incentives in the third party payment system--where healthcare providers are often paid to do more tests and treatments as opposed to providing clinical value--doing what's right for our patients commonly yields savings to our payers while negatively impacting the delivery system budget. In this article, we present a suggested strategy for negotiated capture of these savings.

Influences on patient satisfaction survey results: is there a need for a rethink?

BACKGROUND

Patient experience is a key principle of the NHS and is increasingly linked to payment of providers.

AIM

To establish if any correlation exists between patient satisfaction scores (as measured in the MORI survey) and practice list size or deprivation score.

METHOD

This was a retrospective correlation review using data for general practices in Derbyshire County Primary Care Trust extracted from existing publicly available sources. Correlation between satisfaction score and both deprivation index and practice list size was examined.

RESULTS

Data from all 96 practices were reviewed. Overall satisfaction showed a statistically significant negative correlation with deprivation (r=-0.28, P=0.006). Neither question pertaining to QOF payment showed a correlation with deprivation, however, there was a statistically significant negative correlation with list size (Q5a r=-0.52, P <0.01. Q7 r=-0.43, P <0.01). Questions regarding satisfaction with the doctor showed weak but statistically significant negative correlations with deprivation, (r varying from -0.21 to -0.39, P <0.05). Satisfaction with nurses showed positive correlations with deprivation, with satisfaction increasing in line with deprivation (r varying from 0.24 to 0.36, P <0.05). Regarding list size, for nurse care the reverse was seen, with increased list size being linked to decreased satisfaction (r varying from -0.21 to -0.45, P <0.05).

CONCLUSION

Although variables showed weak correlations, there were correlations between list size and deprivation in the results of the patient experience questionnaire. Linking this to payment has implications for primary care contracting.

[From pay-for-effort to pay-for-performance--an analysis of the Swiss health care system with focus on the inpatient sector]

INTRODUCTION

The Swiss health care system is facing the implementation of lump compensation in the form of diagnosis related groups from 2010 on. In addition there is an increasing discussion about the quality of health care in the media. We have analyzed current remuneration in Swiss health care and their steering effects on providers in order to deduct future developments in Swiss health care remuneration.

METHODS

Based on the remuneration contracts and tariff regularities at the Basel University Hospital we conducted an internet and literature search. The identified Swiss remuneration systems were classified after remuneration scales and remuneration item using a typology of performance-related remuneration systems. The steering effects of the remuneration systems on the providers were deducted.

RESULTS

Remuneration scales can be classified in <<costs incurred>>, <<standardized costs>> or <<negotiated costs>>. Remuneration items can be classified in <<activities>>, <<cases>> or <<outcome oriented cases>>. Remuneration systems can lead to increased or decreased services or to patient selection. In the Swiss health care system we find a trend away from traditional <<pay-for-effort>> to <<pay-for-performance>> remuneration systems. In that context diagnosis related groups are identified as an intermediate step in the development of remuneration systems.

CONCLUSIONS

Future developments of medical remuneration in terms of a consideration of quality of medical performance and negotiated costs seem likely in Switzerland in the long term. Both, economics and quality should be considered adequately in a health care remuneration system.

[Quality and saving: do they run together?]

In the healthcare debate, it is often stated that better quality leads to savings. Quality systems lead to additional costs for setting up, running and external evaluations. In addition, suppression of implicit rationing leads to additional costs. On the other hand, they lead to savings by procedures simplification, improvement of patients' health state and quicker integration of new collaborators. It is then logical to imagine that financial incentives could improve quality. First evidences of pay for performances initiatives show a positive impact but also some limitations. Quality and savings are linked together and require all our attention.

Cost to primary care practices of responding to payer requests for quality and performance data

PURPOSE

We wanted to determine how much it costs primary care practices to participate in programs that require them to gather and report data on care quality indicators.

METHODS

Using mixed quantitative-qualitative methods, we gathered data from 8 practices in North Carolina that were selected purposively to be diverse by size, ownership, type, location, and medical records. Formal practice visits occurred between January 2008 and May 2008. Four quality-reporting programs were studied: Medicare's Physician Quality Reporting Initiative (PQRI), Community Care of North Carolina (CCNC), Bridges to Excellence (BTE), and Improving Performance in Practice (IPIP). We estimated direct costs to the practice and on-site costs to the quality organization for implementation and maintenance phases of program participation.

RESULTS

Major expenses included personnel time for planning, training, registry maintenance, visit coding, data gathering and entry, and modification of electronic systems. Costs per full-time equivalent clinician ranged from less than $1,000 to $11,100 during program implementation phases and ranged from less than $100 to $4,300 annually during maintenance phases. Main sources of variation included program characteristics, amount of on-site assistance provided, experience and expertise of practice personnel, and the extent of data system problems encountered.

CONCLUSIONS

The costs of a quality-reporting program vary greatly by program and are important to anticipate and understand when undertaking quality improvement work. Incentives that would likely improve practice participation include financial payment, quality improvement skills training, and technical assistance with electronic system troubleshooting.