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Systematic Review: Pay-for-Performance and VA Healthcare
Investigators sought to identify studies that examined the effects of pay-for-performance (P4P) on the quality of care and health of Veterans, including potential unintended consequences, as well as program design features and implementation factors important to P4P both within VA and in the community. Findings showed that overall, evidence is insufficient to determine whether P4P results in durable improvements in the quality of healthcare in VA settings. Only 1 controlled trial and 2 observational studies examined the effectiveness of P4P on intermediate clinical outcomes (e.g., blood pressure) in Veterans. Interviews with key informants were consistent with studies that identified the potential for overtreatment associated with performance metrics in VA. Key informants’ views on P4P in community settings included the need to: develop relationships with providers and strong-performing health systems; improve coordination by targeting documentation and data sharing processes, and troubleshoot the limited impact of P4P among practices where Veterans make up a small fraction of the patient population. Qualitative studies on P4P in VA found that participants felt performance measures may lead to unintended negative consequences, i.e., reduced focus on patient needs, un-incentivized areas of care, and/or healthier patient populations, and that they may negatively affect team dynamics. Key informants recognized the potential for unintended consequences of P4P, such as overtreatment in VA settings, and suggest that implementation of P4P in the community focus on relationship building – and target areas such as documentation and coordination of care.
Date: July 1, 2018
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Identifying Best Strategies to Implement Patient-Centered Care
This paper describes a qualitative study of four early Centers of Innovation (VA medical centers considered early leaders in patient-centered care [PCC]) to inform VA leadership about how best to catalyze and sustain change across the system. Investigators identified seven domains that impacted PCC implementation: 1) leadership, 2) patient and family engagement, 3) staff engagement, 4) focus on PCC innovations, 5) alignment of staff roles and priorities, 6) organizational structures and processes, and 7) environment of care. Within each domain, multi-faceted strategies for implementing change were identified. These included efforts by leadership at all levels of the organization who modeled PCC in their interactions – and who fostered willingness to try novel approaches to care among staff. Capturing patients’ voices, obtaining patient perspectives, and finding out what matters most to Veterans and their families also were essential to selecting, planning, and implementing PCC initiatives. Alignment and integration of patient-centered care within the organization, particularly surrounding roles, priorities, and bureaucratic rules, remained major challenges. Findings from this study were used to create policy-level incentives to change by incorporating the seven domains into VA senior executive performance measures.
Date: March 7, 2018
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Study Identifies which VA Mental Health Program Characteristics are Associated with Patient Satisfaction
This study examined the relationships between a set of patient satisfaction measures and a large collection of mental health program characteristics for Veterans with a recent mental health encounter in the VA healthcare system. Findings showed that broad measures of mental healthcare program reach (i.e., proportion of patients served) and intensity (i.e., number of visits) – and nearly all measures of treatment continuity were consistently and positively associated with patient satisfaction. More narrow performance measures – those that focus on specific diagnostic populations (e.g., those with PTSD and serious mental illness) – were less likely to be positively associated with satisfaction. Satisfaction with access to VA healthcare among Veterans with mental health conditions was higher than satisfaction with care encounters.
Date: May 19, 2017
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VA Diabetes and Cardiovascular Care Quality Comparable between Physicians and Advanced Practice Providers
This study assessed the effectiveness of diabetes and cardiovascular disease (CVD) care provided to Veterans in VA primary care by advanced practice providers (APPs) compared to physicians. Findings showed that the quality of diabetes and CVD care delivered in VA primary care settings was mostly comparable between physicians and APPs. However, a majority of Veterans with diabetes and CVD – irrespective of their provider type – did not meet performance measures geared toward control of multiple risk factors. Only 27% and 28% of Veterans with diabetes and 54% and 55% of Veterans with CVD receiving care from physicians and APPs, respectively, met all eligible measures. Thus, regardless of provider type, there is a need to improve performance on all eligible measures among these Veterans.
Date: November 1, 2016
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Incorporating Health Status into Routine Care
This article describes the early efforts of VA’s Patient Reported Health Status Assessment (PROST) system to capture, report, and initiate clinical action in response to patient-reported health status measures, thereby improving the value of care delivered to Veterans undergoing elective percutaneous coronary intervention. Findings suggest that refocusing performance measures on health outcomes that reflect the patient’s perspective may reduce measurement burden and incentivize care delivery improvements that directly improve patient health. Integrating data from patient-reported health status measures such as PROST could lead to efficient and targeted interventions for specific patient populations.
Date: August 2, 2016
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JGIM Supplement Features Ten Articles by VA Researchers on Next Generation Clinical Performance Measures
Papers discuss empirical research on the effects of performance measurement on improvements in clinical care, as well as on unintended outcomes (e.g., inappropriate treatment or over-treatment). Papers also describe new methods and methodological challenges in the selection and creation of performance measures that incorporate measures of benefit and harm, value, or patient preferences, and also present research on the implementation of performance measures that address human factors, incentives and facilitators, barriers, and expected and unintended consequences.
Date: April 1, 2016
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VA Captures More Complete Quality Performance Data Compared to Medicare Advantage
Investigators in this study examined the agreement between VA and Medicare Advantage (MA) quality assessments for a group of dually-enrolled Veterans, testing the hypothesis that private health plans under-report quality of care relative to a fully integrated delivery system utilizing a comprehensive electronic health record. Findings showed that despite assessing the same Veterans using identical performance measure specifications, reported VA performance was significantly better than reported MA performance for all 12 HEDIS measures. For example, VA’s performance advantage ranged from 10 percentage points (46% for VA vs. 36% for MA) for HbA1c <7.0% in diabetes to 55 percentage points (80% for VA vs. 25% for MA) for blood pressure <140/90mmHg in diabetes. In analyses limited to Veterans having at least 10 MA outpatient encounters, VA reported better performance than MA for 11 of 12 measures – ranging from 10 percentage points to 36 percentage points. Findings suggest that neither Medicare Advantage plans nor VA fully capture quality of care information for dually-enrolled Veterans. However, VA captures significantly more information than MA.
Date: March 31, 2016
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New Approach to Performance Measurement
Innovation in performance measurement often appears too risky to healthcare practitioners and organizations because of its potential effect on current publicly reported measures. This article discusses specific barriers to performance measurement and improvement innovations – and proposes a potential mechanism that could promote innovation in healthcare delivery, while maintaining a focus on accountability.
Date: January 12, 2016
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Among Older Veterans with Diabetes, Few with Low Glucose or Blood Pressure Levels Undergo Treatment De-intensification
This study sought to describe the frequency and predictors of treatment de-intensification among potentially over-treated older Veterans with diabetes. Findings showed that among older Veterans with diabetes who were treated for BP or blood glucose control, Veterans’ BP or A1c levels had only a weak relationship to the likelihood of de-intensification. There was a modest association between a Veteran’s estimated life expectancy and de-intensification rates, but there was no consistent interaction between life expectancy, de-intensification rates, and BP or A1c levels. Authors suggest that practice guidelines and performance measures should focus more on reducing over-treatment through de-intensification.
Date: December 1, 2015
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Study Shows No Evidence that Dual Use of VA and Medicare Advantage Results in Worse Patient Outcomes
This study assessed characteristics of Veterans who were dually enrolled in both VA and Medicare Advantage (MA) – managed care plans administered by private health insurance companies that contract with the Centers for Medicare and Medicaid Services. This study also compared quality of care using intermediate quality outcomes among Veterans exclusively receiving outpatient care in VA with Veterans receiving outpatient care in both systems. No evidence was found that Veterans with dual use of VA and Medicare Advantage experienced either improved or worsened intermediate outcomes compared with Veterans who exclusively used VA healthcare. Outcomes were marginally better for VA-only users on the measures related to hypertension control and CHD control. Conversely, dual VA-MA users experienced slightly better outcomes on measures relating to diabetes control. Dually-enrolled Veterans with fewer VA outpatient visits had comparable outcomes to Veterans with many VA outpatient visits, suggesting the absence of a threshold number of VA visits for achieving better intermediate outcomes in diabetes, hypertension, and heart disease.
Date: April 6, 2015
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VA Maintains Access to Care as Need for Substance Use Treatment Grows
VA has enhanced funding of mental health programs and substance use disorder (SUD)-specific treatment and also has directed approximately $152 million toward hiring additional SUD staff. This study examined the relationship between dedicated SUD funding and SUD performance measures from 2005 and 2010 for VA medical centers. Findings showed that, overall, access and quality of care kept pace with the demand for SUD services in the VA healthcare system. There was a statistically significant and generally positive correlation between additional, dedicated SUD resources and access and treatment intensity. The number of VA patients with an SUD diagnosis grew from about 310,000 in 2005 to 439,000 in 2010 – an increase of 42%. Average dedicated SUD funding per facility grew from $65,870 in 2005 to $324,416 in 2007, falling to $147,151 in 2009 and 2010. However, not all VAMCs received funding in each year.
Date: March 12, 2015
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Improved Performance on Quality Measures is Accompanied by Increased Racial/Ethnic Equity in Care
This study examined the quality and equity of hospital care during the six years following initiation of the Centers for Medicare & Medicaid Services (CMS) Inpatient Quality Reporting (IQR) Program (2005 to 2010), focusing on 17 process-of-care quality indicators publicly reported by the program for white, black, and Hispanic patients hospitalized for AMI, HF, and pneumonia in non-VA hospitals. Findings showed that improved performance on quality measures for white, black, and Hispanic adults hospitalized with AMI, HF, and pneumonia was accompanied by increased racial/ethnic equity in performance rates both within and between U.S. hospitals. Over this time period, adjusted performance rates for the 17 quality measures improved by 3.4 to 57.6 percentage points for these patients. In 2010, unadjusted performance rates exceeded 90% for all subgroups for 14 of 17 measures. Declining racial/ethnic differences occurred through more equitable care for white and minority patients treated in the same hospital, as well as greater performance improvements among hospitals that disproportionately serve minority patients.
Date: December 11, 2014
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JGIM Supplement Highlights VA’s Partnered Research
In this JGIM Supplement, 12 articles describe partnered research at various stages – from conceptualizing partnered research to examples of findings borne from bi-directional collaborations with investigators and leaders from clinical operations. These articles cover a wide range of topics highly relevant to VA policy and practice, including performance measure implementation on provider motivation, opioid management, suicide prevention, homelessness, medical home models, and communication of adverse events.
Date: November 1, 2014
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VA’s Online Quality Improvement Toolkits
In 2009, VA/HSR&D’s Quality Enhancement Research Initiative (QUERI) was tasked by VHA leadership to develop online toolkits that would facilitate the spread of locally developed innovations to improve quality of care for Veterans. The QI Toolkit Series was designed as a two-year pilot project that would offer VHA staff access to innovations to help improve performance on specific performance measures across a variety of high-priority care conditions. The Toolkit Series is now an enhanced Intranet website, accessible by all staff using the VHA network. This article describes the general approach to creating such toolkits, aspects of implementation, and a brief evaluation.
Date: December 1, 2013
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Improvement in VA Patient Outcomes Related to Pay-for-Performance Remains after Removal of Incentives
This study sought to investigate the sustainability of performance levels following removal of performance-based incentives. Findings showed that performance improvements that occurred across 128 VA hospitals for three common conditions among Veterans – acute coronary syndrome, heart failure, and pneumonia – were sustained for up to three years after performance-based incentives were removed. For six of the seven performance measures, mean performance was over 90% prior to removal of the incentives. The only measure that did not demonstrate significant improvement over the study period was the heart failure measure for ACE-inhibitor/ARB therapy prior to admission.
Date: August 9, 2013
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Benefits of a Patient-Centered Performance Management System
All too often, the U.S. healthcare system fails patients on two levels: some patients fail to receive care that would clearly help them, while other patients receive care that will not benefit them (and may even be harmful). The current focus on “one size fits all” guidelines and performance measures may even promote unnecessary and harmful treatment. But now healthcare systems have a rare opportunity to implement patient-centered approaches that will drive appropriate decisions for individual patients, rather than across-the-board adjustments that decrease utilization more or less arbitrarily. A “Patient-Centered Performance Management System” would help clinicians and patients make individualized decisions about optimal care for common clinical situations, would explicitly incorporate patient preferences, and would reinforce such decisions through patient-centered performance measures. The essential element in this system is its commitment to directly considering the net benefit of care at the individual patient level (not using population averages), while also eliciting and capturing individual patient preferences for care.
Date: July 10, 2013
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Veterans Receiving Primary Care in CBOCs Less Likely to Receive Several Types of Colon Cancer Screening Tests
This study evaluated differences in the choice of colorectal cancer (CRC) screening test in Veterans receiving primary care at community-based outpatient clinics (CBOCs) and at VAMCs. Findings showed that Veterans receiving care at a CBOC were less likely to receive colonoscopy, sigmoidoscopy and double-contrast barium enema than Veterans receiving care at VAMCs, even after adjusting for rural location, distance from a parent VAMC, and other patient demographic and clinical characteristics. Lower rates of screening procedures were not offset by higher utilization of fecal occult blood tests, and were consistent in Veterans at average and high risk for CRC. The difference in the use of colonoscopy in CBOCs and VAMCs was larger for Veterans 65 years or older than for patients less than 65 years, suggesting that older Veterans who receive primary care through CBOCs may use more CRC screening services outside VA relative to those under 65. These findings provide indirect evidence of the importance of examining data from non-VA providers when making judgments about adherence to VA performance measures.
Date: July 5, 2013
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Performance Measure for Lipid Management in Veterans with Diabetes Encourages Treatment with Moderate Dose Statins
Clinical action performance measures are increasingly being recommended to help make performance measurement more clinically meaningful. Investigators developed a clinical action performance measure for lipid management in Veterans with diabetes that is designed to encourage appropriate treatment with moderate dose statins, while minimizing overtreatment. They then assessed what proportion of Veterans received appropriate lipid management according to this new clinical action measure vs. the treat-to-target measure of LDL <100mg/dl that was in place at the time of the study. Findings showed that, of Veterans aged 50-75 years in this study, 85% passed the new clinical action measure, compared to 67% using the existing metric of LDL <100. Veterans who did not meet the clinical action measure had fewer primary care visits, on average, during the measurement period than Veterans who did meet the measure. Of the entire cohort aged >=18 years, 14% were potentially overtreated. Facilities with higher rates of meeting the current threshold measure (LDL <100) had higher rates of potential overtreament. Findings suggest that continued use of threshold measures for lipid management may promote overtreatment. A modified version of the clinical action performance measure is being implemented in the VA healthcare system.
Date: December 11, 2012
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Clinically-Guided Approach for Improving Performance Measurement for Hypertension
This study tested a novel performance measurement system for BP control that was designed to mimic clinical reasoning. Using an algorithm that replicates clinical decision-making, this approach focuses on: 1) exempting Veterans for whom tight BP control may not be appropriate or feasible, and 2) assessing BP over time. Nearly one in three Veterans with hypertension would be exempted from BP performance measurement based on clincially-guided criteria. The most common reasons for exemption were inadequate opportunity for clinicians to manage Veterans’ BP, and the patient’s use of four or more anti-hypertensive medications. After accounting for clinically-guided exemptions and methods of BP assessment, only 15 of 72 Veterans (21%) whose last BP was >140/90 mm Hg were classified as problematic by the clinically-guided approach, i.e., eligible for performance assessment and defined as having uncontrolled BP.
Date: May 1, 2012
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Investigators Provide Rationale for New LDL Guidelines
Updated guidelines for cholesterol testing and management from the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults are due to be published in 2012. A primary focus of the previous version of the guidelines was treating patients to low-density lipoprotein (LDL) cholesterol level targets, with the primary goals of therapy and the cut-points for initiating treatment stated in terms of LDL. However, the authors of this commentary believe this reasoning diverges from clinical evidence and present three primary reasons that justify a major change in the next generation of guidelines: 1) There is no scientific basis to support treating to LDL targets, 2) The safety of treating to LDL targets has never been proven, and 3) Tailored treatment is a simpler, safer, more effective, and more evidence-based approach. This perspective is synergistic with recent activities in VA, in which a multidisciplinary group of leaders provided input that led to the suspension of VA’s Performance Measure that was strictly focused on achievement of lipid targets. They are now working to substitute a performance measure that emphasizes the prescription of statin medications.
Date: January 1, 2012
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Despite Guidelines to the Contrary, High Rates of PSA Screening Found among Older Veterans with Limited Life Expectancy
This study sought to identify medical center characteristics associated with prostate-specific antigen (PSA) screening among men with limited life expectancy. Findings showed that high rates of PSA screening were found among older Veterans with life expectancy of less than 10 years, with substantial variation across VAMCs. Among Veterans with limited life expectancy, 45% received PSA screening in 2003. Across 104 VAMCs, the PSA screening rate for this population ranged from 25-79%. VA medical center characteristics associated with higher PSA screening rates included: no academic affiliation, a ratio of mid-level providers to physicians >3:4, and location in the South. Use of incentives and high scores on performance measures did not significantly affect screening practices. The percentages of men screened with limited and favorable life expectancies were highly correlated, indicating that screening is being poorly targeted. As a result of this and other studies, VHA’s National Center for Health Promotion and Disease Prevention has developed a set of goals to reduce over-screening in older adults starting in FY12.
Date: December 17, 2011
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Unintended Consequences of Local Implementation of VA Performance Measures
This study explored the possible relationships between a centralized primary care clinical performance measurement (PM) system, facility-level practices to implement the PM system into daily care, and unintended negative consequences for Veterans. Findings showed that primary care staff described several ways in which PMs may lead to inappropriate care (e.g., over-prescribing of medication), decrease focus on Veterans’ concerns and patient service (e.g., inconveniencing patients for little benefit), and may make it more difficult for Veterans to make informed, value-consistent decisions (e.g., performance system doesn’t acknowledge when a patient makes an informed refusal of a recommended intervention). Staff also described unintended consequences on primary care team dynamics, e.g., requiring nurses to check on providers to be sure they completed and documented PMs, and providing performance bonuses based on PMs to physicians, but not to nurses. In many instances, problems originated from local implementation strategies developed in response to national PM definitions and policies. Some noted benefits of PMs included feedback from the system helping some clinic staff feel more confident that their care was thorough, and performance scores as a source of pride and positive competition. VA is currently making changes to the national PM system based on this and other research, e.g., developing new PMs that reward clinically appropriate action, even if the patient has not achieved specific targets, and developing clinical reminders that facilitate patient-centered decisions.
Date: October 13, 2011
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Survey-based vs. Chart-based Screening Yields Significantly Higher Rates of Depression among Veterans in Primary Care
This study sought to characterize the yield of practice-based screening in 10 diverse VA primary care clinics (rural and urban), as well as the care needs of Veterans assessed as having depression. Findings showed that practice-wide survey-based depression screening yielded more than twice the positive-screen rate demonstrated through chart-based VA performance measures. Practice-wide depression screening yielded 20% positive depression screens and 12% probable major depression. This is substantially higher than most previously reported VA rates. In addition, comorbid medical and mental illness were highly prevalent.
Date: October 6, 2011
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Effect of Active versus Passive Monitoring of VA Quality Performance Measures
This study compared the nature and rate of change in hospital outpatient clinical performance as a function of VA performance measures’ status (active vs. passive), and examined the mean time to stability of performance after changing status. Findings showed that performance measure monitoring status (active vs. passive) did not significantly impact performance over time. Structural organizational characteristics, including facility size, academic mission, and primary care structure, had no impact on this finding. There was variability in whether or not measures stabilized after a status change, suggesting the possibility that some measures may take more than two years to stabilize. However, performance scores for measures with short stability times were no higher or lower than scores for measures with longer stability times. All measures that stabilized did so immediately after the status change (e.g., time to stability was one quarter). Of the 6 measures that did not stabilize, 5 suggested continued improvement after the change.
Date: October 1, 2011
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Despite Improved Quality of VA Healthcare, Racial Disparity Persists for Important Clinical Outcome
This article reports on trends in the quality of care and racial disparities in relation to 10 VA clinical performance measures that assessed cancer screening, cardiovascular care, and diabetes care from 2000 to 2009. Findings show that in the decade following VA’s organizational transformation, quality of care improved and racial disparities were minimal for most process measures, such as glucose and LDL screening. However, these were not accompanied by meaningful reductions in racial disparity for important clinical outcomes, such as blood pressure, glucose, and cholesterol control. A gap in clinical outcomes of as much as nine percentage points was observed between African-American and white Veterans. Almost all of the disparity in outcomes was explained by within-facility disparity, which suggests that VA medical centers will need to measure and address racial gaps in care for their patient populations. Of the five performance measures with an absolute racial disparity of 5 percentage points or more in the initial year of the study, there were statistically significant reductions in racial disparity for three: glucose control, BP control, and CRC screening. However, the reductions in disparity were modest, and none were reduced by more than 2 percentage points.
Date: April 1, 2011
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Article Challenges Process for Disseminating Diabetes Performance Measures
Pressure to develop more stringent measures for “optimal” control of risk factors in patients with diabetes has accelerated, despite the absence of new evidence from 1998 to 2008, and results from recent trials have cast new doubt on the benefits of achieving these “optimal” measures in many patients. This editorial suggests that an examination of Toyota, often portrayed as a leader in quality, may provide some answers as to how diabetes performance measures got ahead of the evidence.
Date: February 16, 2011
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Threshold for Glycemic Control among Veterans with Diabetes
In 2009, the National Committee for Quality Assurance (NCQA) – Healthcare Employer Information Data Set (HEDIS) measure for good (<7% A1c) glycemic control for individuals with diabetes was revised to apply only to persons younger than 65 years without cardiovascular disease, end-stage diabetes complications, or dementia. However, multiple guidelines recommend that glycemic control targets be individualized, especially in the presence of comorbid medical and mental health conditions. This retrospective study used the NCQA <7% measure to compare overall VA facility rankings with a subset of Veterans receiving complex glycemic treatment regimens (CGR). Findings show that the assessment of the quality of good glycemic control among VA facilities differs using the NCQA-HEDIS measure for the overall study population compared to a subset of patients receiving CGR. For example, the overall top 10% performing facilities achieved a rate of 57% at the <7% A1c threshold compared to 34% for Veterans on CGR using the same measure. Therefore, the authors suggest that reliance upon a <7% A1c threshold measure as the “quality standard” for public reporting or pay-for-performance could have the unintended consequence of adversely impacting patient safety. Moreover, they propose that rather than assessing “good glycemic control” by an all-or-none threshold, developers of measures should provide credit for an A1c result within an acceptable range (e.g. incremental credit for improvement between 7.9% and <7%) in order to balance the trade-offs of benefits, harms, and patient preferences.
Date: October 1, 2010
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VA’s Brief Alcohol Intervention Strategy Successful
This study evaluated the prevalence of documented brief interventions among VA outpatients with alcohol misuse before, during, and after implementation of a national performance measure linked to incentives and dissemination of an electronic clinical reminder for brief interventions. Findings show that VA’s strategy of implementing brief alcohol interventions with a performance measure supported by a clinical reminder meaningfully increased documentation of brief interventions over a one-year period. Among Veteran outpatients with alcohol misuse, the prevalence for brief interventions increased significantly over successive phases of implementation – from 5.5% at baseline – to 7.6% after announcement of the brief intervention performance measure – to 19.1% following implementation of the measure – to 29% following dissemination of the clinical reminder. Brief interventions increased among patients without prior alcohol use disorders or addictions treatment, as well as those with recognized drinking problems, with proportionately greater increases among the former group after clinical reminder dissemination.
Date: September 28, 2010
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Risk Related to Serious Hypoglycemia among Diabetics is Under-stated by Current Guidelines and Performance Measurements
Rapidly evolving evidence from clinical trials and observational studies indicates that serious hypoglycemia is frequent among individuals with type 2 diabetes. Notwithstanding the absence of proven causality between hypoglycemia and mortality, the risks and consequences of hypoglycemia are significant. Despite the significant health burden associated with hypoglycemia, its risks appear to be understated by guideline and performance measurement groups. To increase public and professional awareness about this risk – and to decrease its occurrence, several recommendations are suggested.
Date: May 26, 2010
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Processes of Care to Improve Stroke Outcomes
After adjusting for patient characteristics and other processes of care, three processes of care were independently associated with a reduction in the combined outcome: 1) swallowing evaluation, 2) deep vein thrombosis (DVT) prophylaxis, and 3) treating all episodes of hypoxia with supplemental oxygen. Two of the three processes (swallowing evaluation, DVT prophylaxis) are similar to existing stroke quality measures, but the treatment of hypoxia is not a current performance measure. Thus, authors recommend that organizations that establish national performance measures add treatment of hypoxia to their assessment of stroke care quality, and continue to measure DVT prophylaxis and swallowing assessment among stroke patients.
Date: May 10, 2010
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Obese and Overweight Patients Receive Equal or Better Care than Patients of Normal Weight
Among Medicare and VA patients, there was no evidence across eight quality performance measures that obese and overweight patients received worse care than normal weight patients. In fact, obese and overweight patients received marginally better care on certain measures.
Date: April 7, 2010
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Comparing Treat-to-Target Strategies to Tailored Approach for Statin Therapy
This study examined how a simple Tailored Treatment strategy for statin therapy compared with a Treat-to-Target strategy based on National Cholesterol Education Program (NCEP) III treatment recommendations. Findings show that a simple Tailored Treatment strategy was more efficient and prevented substantially more coronary artery disease morbidity and mortality than any of the currently recommended Treat-to-Target approaches. The Tailored Treatment approach was predicted to save 520,000 more quality-adjusted life years among Americans aged 30-75 than the best NCEP III Treat-to-Target approach for every five years of treatment, even though fewer people were treated with high doses of statins. The authors indicate that these results suggest that a Tailored Treatment approach to medicine can substantially improve care, while also reducing unnecessary treatment and costs. Thus, they recommend that given its potential to better tailor treatments to individual patients, the principles underlying a Tailored Treatment approach should be considered during deliberations about guidelines and performance measures.
Date: January 19, 2010
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Veterans with Hypertension and Comorbidities Receive Better Care than Veterans with Hypertension Alone
This study sought to determine the impact of different types of co-existing chronic diseases on quality of care for hypertension, as well as patient perceptions of quality. Findings show that Veterans with hypertension and comorbid conditions had greater odds of receiving good quality of care. Moreover, as the number of chronic conditions increased, so did the odds of receiving appropriate overall care for hypertension. No relationship was found between the provision of guideline-recommended care for hypertension and Veterans’ perception of quality of care, nor did Veterans’ assessment of quality of care vary by the presence of co-existing conditions.
Date: June 16, 2009
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Continuity of Care Performance Measure Not Associated with Improved Outcomes for Veterans with Substance Use Disorders
The Continuity of Care (CoC) performance measure specifies that patients should receive at least two substance use disorder (SUD) outpatient visits in each of the three consecutive 30-day periods after they qualify as new SUD patients. Findings from this study show that meeting the CoC performance measure was not associated with patient-level improvements in the Addiction Severity Index (ASI) alcohol or drug composites, days of alcohol intoxication, or days of substance-related problems. Higher facility-level rates of CoC were negatively associated with improvements in ASI alcohol and drug composites – and were not associated with follow-up abstinence rates.
Date: April 1, 2009
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New Process for Quality Improvement Suggests Local Focus on Improving, in Addition to Measuring Quality
Authors suggest reforming quality improvement (QI) so that instead of a focus on measures with national benchmarks, there is a focus on rewarding local actions that improve quality of care using local norms to guide progress. Quality improvement efforts should be tied to local actions and local results rather than national norms, acknowledging that QI efforts are not generalizable – one size does not fit all. Measures would be tailored to each institution to reflect local core causes. Measurement could remain a key part of local QI initiatives, however, the measurement of core causes and incentives to improve would be conducted at the local sites.
Date: April 1, 2009
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Multi-faceted Quality Improvement Intervention Improves Follow-up Colonoscopy for Veterans with Positive Colorectal Cancer Screening Test
Inadequate follow-up of abnormal fecal occult blood test (FOBT) screening for colorectal cancer (CRC) may be related to patient, provider, or system-level factors. Thus, in calendar years 2004 and 2005 the Houston VAMC implemented multi-faceted quality improvement (QI) activities to improve follow-up of positive FOBT results. This study examined the effects of these activities on timeliness and appropriateness of positive-FOBT follow-up for 800 Veterans, and also identified factors that affect colonoscopy performance. Findings show that in cases where a colonoscopy was indicated, the proportion of Veterans who received timely referral and performance was significantly higher after the implementation of the QI activities. In addition, there was a significant decrease in median times to colonoscopy referral and performance. However, colonoscopy was not indicated in more than one-third of Veterans with positive FOBTs, raising concerns about current screening practices and the appropriate performance measures related to CRC screening.
Date: April 1, 2009
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Evaluating Profiling Program and New Quality Indicators for Diabetes Care
This study evaluated the addition of new quality indicators to an ongoing clinician feedback initiative that profiles diabetes care and suggests that rather than relying on benchmarks with high and consistent attainment, profiling programs may want to target indicators that demonstrate low and variant performance to better differentiate care across sites.
Date: March 1, 2009
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Transparency Standards for Diabetes Performance Measures
The development and adoption of performance measures must be transparent. Transparency has been defined as “a process by which information about existing conditions, decisions and actions is made accessible, visible and understandable.” This JAMA Commentary discusses several examples of transparency that might help guide the development of hemoglobin A1c performance measures in the future. Authors suggest that, considering the potential effect on millions of patients and the high cost of antiglycemic medications alone, the upfront investment in ensuring evidence-based, transparently developed performance measures would be worthwhile to protect the public health and restore public and professional confidence.
Date: January 14, 2009
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Clinically Complex Veterans have Higher Rates of Performance Measurement and Higher Satisfaction with Care
Veterans with higher clinical complexity had higher measured performance on common process measures used to assess the quality of outpatient care. In addition, satisfaction with care was higher among clinically complex patients with high measured performance, suggesting that compliance with performance measures does not crowd out unmeasured care.
Date: November 1, 2008
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