Quality changes by hospitals aren't across the board

Two studies that appeared in the July 21 New England Journal of Medicine came to starkly different conclusions about how well hospitals are implementing evidence-based standards of care for heart attacks, congestive heart failure and pneumonia.

Hospitals significantly improved on 15 of 18 quality-of-care measures over the course of two years, according to a study of 3,377 hospitals conducted by researchers at the Joint Commission on Accreditation of Healthcare Organizations.

But the second study showed that there are huge gaps in quality of care across regions in implementing relatively simple treatments such as giving heart attack patients aspirin at admission and discharge or vaccinating pneumonia patients to prevent a reoccurrence. The Boston-area medical researchers who conducted that study using data collected under the Medicare Modernization Act of 2003 also found that hospitals excelling in one area didn't necessarily do well in others.

"I think these studies demonstrate that quality measurement and quality reporting is here to stay," said Robert Wachter, MD, chief of medicine at the University of California, San Francisco Medical Center. "The science of the field has advanced to the point where we can make reasonable assessments of quality based on standardized measures."

Dr. Wachter, editor of the online patient safety journal AHRQ WebM&M, said that outcome-based measurement is valuable but imperfect because it's difficult to get an "apples-to-apples" comparison of hospitals, thanks to varying patient populations. He said the JCAHO study demonstrates that "the act of public reporting focuses the attention of providers on improving quality of practice."

The JCAHO study, "Quality of Care in U.S. Hospitals as Reflected by Standardized Measures, 2002-2004," was based on data voluntarily reported by the hospitals the group accredits. It discovered that poor performers improved by as much as 33% during the eight quarters they were studied.

"The faster rate of improvement among low-level performers represents an important finding," wrote the study's authors, who were unavailable for comment at press time. "Whereas low-level performers have the most room for improvement, one might have expected different results, since such hospitals may be less likely to focus on quality or make an effort to improve performance than their counterparts with a higher level of performance."

For example, hospitals in the lowest-performing quartile in the first quarter of the study gave heart-attack patients a beta-blocker at discharge 59% of the time. This figure improved to 85% by the study's eighth and concluding quarter. For pneumonia patients, the worst-performing hospitals took 380 minutes to give pneumonia patients antibiotics. By the eighth quarter, they had cut the wait time by 126 minutes.

Quality gaps across regions

The second study, "Care in U.S. Hospitals -- The Hospital Quality Alliance Program," seemed to present a less favorable picture, with median performance scores above 90% on only half of the 10 measures studied.

"For these important but simple measures, I hope that we can have every hospital get close to 100%," said Ashish K. Jha, MD, MPH, the study's lead author and a professor of medicine at the Harvard School of Public Health.

The 3,558 hospitals that reported data on 10 core measures of quality care for the three conditions to the Centers for Medicare & Medicaid Services had a strong financial incentive to cooperate: They faced a 0.4% reduction in their Medicare reimbursements if they didn't.

"These are clearly three very common, important medical conditions with significant mortality and morbidity associated with them," Dr. Jha said, estimating that they represent 15% of hospital inpatient care. "We know a lot about how to treat them. Relatively speaking, it's easier to get consistency on how to treat them."

Yet there are big gaps in the quality of care across regions. The top-ranked region in pneumonia care, for example, was Oklahoma City, and its composite score bettered the bottom-ranked region, San Bernardino, Calif., by 23 percentage points.

However, hospital excellence in one area did not guarantee all-around excellence.

Of hospitals scoring in the top 10% on treatment of heart attacks, 91% were in the top half in treating congestive heart failure but only 59% were in the top half in treating pneumonia.

"This is not about individual doctors," said Dr. Jha, who is also a practicing physician. "You can have the same doctors working on different types of patients. It says to me that this has a lot to do with the kind of systems that are put in place to get consistent care. There is not going to be a silver bullet."