Patient Safety beyond the Hospital | Health Policy and Reform

Tejal K. Gandhi, M.D., M.P.H., and Thomas H. Lee, M.D.

The vast majority of health care is delivered in ambulatory settings, yet we are only just beginning to understand the safety risks that exist outside of hospital walls. There are 900 million visits to physicians’ offices in the United States each year, as compared with 35 million hospital discharges,¹ and spending on outpatient care is the fastest growing segment of health care spending.² Yet most patient-safety research and safety-improvement work have been done in inpatient settings; indeed, a search of the Patient Safety Network Web site of the Agency for Healthcare Research and Quality shows that since 2005 only about 10% of patient-safety studies have been performed in outpatient settings.

Experience to date indicates that safety issues in the ambulatory setting differ from those in the inpatient setting in obvious and not-so-obvious ways. There are differences in the types of errors (treatment errors predominate in inpatient settings, whereas diagnostic errors do in outpatient settings), the provider–patient relationship (e.g., adherence is more critical in outpatient settings), organizational structure (ambulatory practices tend to lack the infrastructure and expertise to address quality and safety improvement), and regulatory and legislative requirements (e.g., there are staffing ratios and accreditation requirements for hospitals that do not exist for private practices).³ In addition, the signal-to-noise ratio is much lower in outpatient settings: in ambulatory care, a physician may see 100 patients with chest pain before seeing one with an actual myocardial infarction.

The outpatient setting also presents greater challenges for information transfer. Particularly in the case of patients with complex medical needs, the responsibility for care is often shared by multiple providers at many institutions. These clinicians may never meet, and they often use different medical-record systems. Such care has long, fragile feedback loops. In the hospital, if a patient has an adverse drug event, clinicians become aware of it very quickly; in the outpatient setting, a complication or missed diagnosis may not be identified for months, if ever.
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Administration Announces Regulations Requiring New Health Insurance Plans to Provide Free Preventive Care

The Departments of Health and Human Services (HHS), Labor, and the Treasury issued new regulations today, requiring new private health plans to cover evidence-based preventive services and eliminate cost sharing requirements for such services.  The new rules will help Americans gain easier access to services such as blood pressure, diabetes, and cholesterol tests; many cancer screenings; routine vaccinations; pre-natal care; and regular wellness visits for infants and children.

"Today, too many Americans do not get the high-quality preventive care they need to stay healthy, avoid or delay the onset of disease, lead productive lives, and reduce health care costs," said HHS Secretary Sebelius.  "From the Recovery Act to the First Lady's Let's Move Campaign to the Affordable Care Act, the Administration is laying the foundation to help transform the health care system from a system that focuses on treating the sick to a system that focuses on keeping every American healthy."

Chronic diseases, such as heart disease, cancer, and diabetes, are responsible for 7 of 10 deaths among Americans each year and account for 75 percent of the nation's health spending - and often are preventable.  Nationally, Americans use preventive services at about half the recommended rate.  An estimated 11 million children and 59 million adults have private insurance that does not adequately cover immunization, for instance.  Cost sharing, including deductibles, coinsurance, or copayments, has been found to reduce the likelihood that preventive services will be used. 

"Getting access to early care and screenings will go a long way in preventing chronic illnesses like diabetes, heart disease, and high-blood pressure," said First Lady Michelle Obama.  "And good preventative care will also help tackle an issue that is particularly important to me as First Lady and as a mother - and that is the epidemic of childhood obesity in America today.  These are important tools, and now it's up to us to use them."

"One of the best ways to improve the quality of your life - and control health care costs - is to prevent illness in the first place," said Dr. Jill Biden. "Focusing on prevention and early treatment makes more sense than trying to play catch-up with a potentially deadly disease. Quite simply, these preventative services will save lives."

Under the regulations issued today, new health plans beginning on or after September 23, 2010, must cover preventive services that have strong scientific evidence of their health benefits, and these plans may no longer charge a patient a copayment, coinsurance or deductible for these services when they are delivered by a network provider.  Specifically, these recommendations include:

* Evidence-based preventive services: The U.S. Preventive Services Task Force, an independent panel of scientific experts, rates preventive services based on the strength of the scientific evidence documenting their benefits.  Preventive services with a "grade" of A or B, like breast and colon cancer screenings, screening for vitamin deficiencies during pregnancy, screenings for diabetes, high cholesterol and high blood pressure, and tobacco cessation counseling will be covered under these rules. 

* Routine vaccines: Health plans will cover a set of standard vaccines recommended by the Advisory Committee on Immunization Practices ranging from routine childhood immunizations to periodic tetanus shots for adults.

* Prevention for children: Health plans will cover preventive care for children recommended under the Bright Futures guidelines, developed by the Health Resources and Services Administration with the American Academy of Pediatrics.  These guidelines provide pediatricians and other health care professionals with recommendations on the services they should provide to children from birth to age 21 to keep them healthy and improve their chances of becoming healthy adults.  The types of services that will be covered include regular pediatrician visits, vision and hearing screening, developmental assessments, immunizations, and screening and counseling to address obesity and help children maintain a healthy weight. 

* Prevention for women: Health plans will cover preventive care provided to women under both the Task Force recommendations and new guidelines being developed by an independent group of experts, including doctors, nurses, and scientists, which are expected to be issued by August 1, 2011.

Today's announcement builds on other provisions in the Affordable Care Act that support prevention, including the creation of a first-ever National Prevention, Health Promotion and public Health Council tasked with developing a national strategy and a Prevention and Public Health Fund to invest in prevention initiatives and, this year, policies to increase the number of primary care professionals to help ensure access to these services.  The Affordable Care Act also helps make it easier and more affordable for Americans enrolled in Medicare or Medicaid to access critical preventive screenings and services.

More information on the Affordable Care Act's new rules on preventive care can be found at: http://www.healthcare.gov/law/about/provisions/services/index.html.

The regulations can be found at: http://www.healthcare.gov/center/regulations/prevention/regs.html.

US Task Force Leads the way on Prevention Recommendations

by Kim Krisberg

For more than 25 years, the U.S. Preventive Services Task Force has been a pioneer in the fields of prevention and primary care, examining the evidence and using strict criteria to make recommendations that are often the gold standard for clinical preventive services.

First convened in 1984 by the U.S. Public Health Service and now sponsored by the Agency for Healthcare Research and Quality, the task force has a reputation for being fiercely diligent about sticking to the evidence — a characteristic that has garnered acclaim, respect and, most recently, national controversy. Most people outside of health, medical and policy circles probably knew little, if anything, about the U.S. Preventive Services Task Force until November, when the group released recommendations against routine mammography for women ages 40 to 49, recommending that such screening begin at age 50.
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Looking Back, Moving Forward | Health Care Reform Center - NEJM

by Jonathan Skinner, Ph.D., Douglas Staiger, Ph.D., and Elliott S. Fisher, M.D., M.P.H.

The recent Senate election in Massachusetts may reshape or delay health care reform, but we still face the twin challenges of unsustainable cost increases and uneven quality that plague U.S. health care. Recent controversies have left many people confused about how we might wisely move forward.

One such controversy is the debate over the “value index,” a reimbursement approach that would adjust providers’ payments on the basis of regional performance on quality and cost measures. Legitimately concerned that careless implementation of a value index might hurt some preeminent teaching institutions, some leaders of academic medical centers have responded to this proposal by questioning the validity of existing measures of cost performance, many of which have been generated from Medicare data by our Dartmouth research group.
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A Map to Bad Policy — Hospital Efficiency Measures in the Dartmouth Atlas | Health Care Reform Center - NEJM

by Peter B. Bach, M.D., M.A.P.P.

In showing that regional spending variations do not correlate with differences in disease burden or outcome, the Dartmouth Atlas of Health Care has felled the notion that higher health care spending necessarily leads to improved health outcomes. Policymakers have seized on two possible ways to wring savings out of this information. The health care reform bill passed by the House of Representatives contains provisions for identifying regions where Medicare spending appears disproportionately high and adjusting payment rates accordingly. And some policymakers, including President Barack Obama, have proposed that the features of high-performing, “efficient” health care systems should be identified and their lower-cost practices emulated.

Dartmouth Atlas researchers have also begun attempting to convert their observations into cost-saving policies. By analyzing Medicare claims for people who have been treated in hospitals and have died, they aim to identify and rank high- and low-efficiency hospitals.1 Because the Atlas is so influential, their rankings could have broad effects on policy. They could affect hospitals’ payments and prestige, and Consumer Reports is already publicizing them to consumers (www.consumerhealthreports.org). Given their potentially far-reaching implications, it is concerning that the rankings are unsound, both conceptually and methodologically.

The conceptual problem lies in the fact that in Atlas analyses all health care costs that are incurred by patients over the 2 years before their death are attributed to the hospital where they were admitted most frequently during that period. This method assumes that the hospital controls all, or at least most, patient care, even if it occurs outside the hospital or in another hospital. It thus seems to presuppose a system in which hospitals are accountable for all care — perhaps a noble long-term objective, but not a current reality.
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Advancing Excellence in America's Nursing Homes

Advancing Excellence in America’s Nursing Homes is a national campaign to encourage, assist and empower nursing homes to improve the quality of care and life for residents.

Comprised of long term care providers, medical professionals, consumers, employees, and state and federal agencies, AE is the largest and first coalition of its kind to measure quality by setting clinical and organizational goals for nursing homes.

The coalition stimulates quality improvements by providing nursing homes with free, current and practical evidence-based resources, empowering residents and their families with education, and helping participants reach their targets. Homes can compare their progress with state and national averages.
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H.R. 3895: To authorize the Secretary of Health and Human Services to conduct or support research and... (GovTrack.us)

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To authorize the Secretary of Health and Human Services to conduct or support research and demonstration projects on the use of financial and in-kind subsidies and rewards to encourage individuals and communities to promote wellness, adopt healthy behaviors, and use evidence-based preventive health services, and for other purposes.

Sponsor: Rep. Kathleen Dahlkemper [D-PA3]
Cosponsors:

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Status:
Occurred: Introduced Oct 21, 2009
Occurred: Referred to Committee on Energy & Commerce

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