Media Briefing: A JAMA Article Evaluating QIO Work in Hospitals

What:On the record briefing to provide perspective on the article, "Do Quality Improvement Organizations Improve the Quality of Hospital Care for Medicare Beneficiaries," to be published in JAMA on Tuesday, June 14.

Experts on the call will challenge the article's contention, based on data from a few states collected years before the current QIO program was devised, that QIO assistance to hospitals is ineffective.

When:Monday, June 13, 2004; 4PM Eastern Time

Who:Jonathan Sugarman, MD, President, American Health Quality AssociationDavid Schulke, Executive Vice President, American Health Quality Association

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JAMA STUDY: ADDITIONAL ASSESSMENT OF QIO WORK NEEDED

Statement by AHQA Executive Vice President David Schulke

The authors of the JAMA article conclude -- and we agree -- that the study "does not definitively answer the question of whether the QIOs improve the quality of care for Medicare beneficiaries."

During the period covered by the Snyder study, the design of the QIO work assignment made it extremely difficult to assess the contribution of QIOs to the quality improvement that was seen across the nation and documented in an earlier JAMA article. The new study sheds little new light on this issue.

The major challenge confronting Dr. Snyder and others is this: starting in 1999, Medicare officials gave the QIOs new directions to improve hospital care across entire states. As a result, every QIO attempted to give some degree of information and support to all hospitals.

For this study, in 2004 Dr. Snyder asked QIO staff in these five states to recollect and look back at records in an attempt to separate the institutions in their state into hospitals that received a little support, and ones that received a lot. The study therefore compares two different levels of QIO support for hospitals. That approach might have yielded useful information about which QIO strategies work best, but it was not possible to separate out the different strategies used at each hospital several years after the work was done.

In addition, in the Snyder study the data used to assess the QIOs' impact was gathered at the halfway point in the three year QIO contract. This means many hospitals in the study sample had been working with the QIO for only a short time, and some had not yet have started working with the QIO at all.

We agree with the authors' conclusion that "additional efforts to assess and improve the QIO's effectiveness may be needed." Some of this work was possible in the QIO contract cycle before the period studied by Snyder (1996-99). At that time, before QIOs had to work with every hospital, it was possible for QIOs to work intensively with a small group of hospitals and compare the results with institutions they had not worked with. One such study was done with 36 small rural hospitals, finding that pneumonia patients in hospitals working with the QIO were 10 times more likely to receive antibiotics within 4 hours of hospital arrival than patients who came into the control hospitals during the same time frame.

In the years since the period studied by Dr. Snyder, CMS has improved its ability to track progress in groups of providers working with QIOs. Soon CMS will have completed its analysis of the 2002-2005 cycle of QIO work, where every QIO was asked from the first day to keep track of the providers they worked with most closely, and remeasurement of progress was done every quarter. We hope JAMA will publish these results too, when they are completed.

Preliminary data from the current cycle of QIO work, recently presented by CMS to the Institute of Medicine, shows QIOs are having a significant impact on hospital improvement. The study shows that hospitals working intensively with QIOs achieved greater improvement in 9 out of 10 quality measures than did hospitals that received little or no QIO assistance

In 2002, CMS funded the QIOs to launch a nationwide effort to improve prevention of surgical infections, with specific attention to the administration of antibiotics within the recommended 60 minutes prior to incision. So far, QIOs in 32 states report that the hospitals they are working with have made strong gains. For example:"¢ 26 California hospitals working their QIO increased the proportion of surgical patients receiving antibiotics within one hour of incision from 73.8% to 84.3%. "¢ In Colorado, 16 hospitals increased antibiotics delivered within one hour of incision from 62% to 88%."¢ In Maryland, 16 hospitals went from 72% to 92% of patients. "¢ In New Mexico, 19 hospitals went from 48% to 68%. "¢ In Texas, 42 hospitals went from 61% to 84%.

Another set of newly available data that strongly suggests QIO efforts are effective is the growing number of physicians and hospitals that report benefiting from QIO assistance. In December 2004, the research firm Westat conducted an independent survey of over 4,000 hospitals, finding that 92% of them were either very satisfied or satisfied with the QIO's quality improvement assistance. Busy hospital staff are unlikely to express satisfaction with QIO assistance if it were not valuable.

It is critical that the QIO program be as effective as possible because its assignment is enormous. At the time covered by the Snyder study the QIO program had $150 million a year to improve the product of the trillion dollar health care industry -- the largest industry in America. In the spirit of quality improvement, QIOs are continuously improving their techniques to be more effective. A number of strategies are now in use that were not used five years ago, including --"¢ Helping hospitals to measure and publicly report their quality performance; "¢ Recruiting and engaging provider board members and executive leadership in culture change; and"¢ Hosting and facilitating breakthrough collaboratives, invented by the Institute for Healthcare Improvement, where providers learn best practices not only from QIOs but directly from each other.

These changes since 2001 are motivating hospitals to examine their performance, improving the timeliness of quality measurement, and speeding up the pace of quality improvement. Over the next three years, QIOs work will expand to also include:"¢ Helping doctors and hospitals use information technology to provide better care."¢ Ensuring and improving the quality of prescription drug therapy."¢ Helping nursing homes focus on resident satisfaction."¢ Reducing hospital admissions for home care patients."¢ Supporting organizational culture change in all clinical settings."¢ Reviewing expedited appeals for beneficiaries facing discharge or termination of service.

For specific examples of QIO work in every state improving care in hospitals and other clinical settings, please visit our website at www.ahqa.org.

The American Health Quality Association is dedicated to improving the safety and effectiveness of health care. AHQA represents the national network of Quality Improvement Organizations (QIOs) that work with hospitals, medical practices, health plans, long-term care facilities, home health agencies, and employers to encourage the spread of best clinical practices and improve systems of care delivery. Visit: http://www.ahqa.org.