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Search results for "Policy Makers"
- Policy Makers
Journal Article > Study
Hospital characteristics associated with penalties in the Centers for Medicare & Medicaid Services Hospital-Acquired Condition Reduction Program.
Rajaram R, Chung JW, Kinnier CV, et al. JAMA. 2015;314:375-383.
Hospital-acquired conditions (HACs) are thought to be preventable, and the Centers for Medicare and Medicaid Services reduces payments to hospitals with the highest rates of these conditions. This analysis sought to assess the association between measures of hospital quality, such as accreditation, and penalties for HACs. Researchers found that accredited hospitals were more likely to incur HAC penalties. Teaching institutions, hospitals whose case mix included more complex patients, and safety-net hospitals were all more likely to face penalties than nonteaching, nonsafety institutions with healthier patients. These results add weight to concerns about unintended consequences of pay-for-performance programs leading to widening health disparities and selective treatment, or "cherry-picking" of healthier patients. A related editorial co-authored by two United States Senators calls for including socioeconomic status in the HAC penalty formula.
Journal Article > Review
A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes.
Ahmed N, Devitt KS, Keshet I, et al. Ann Surg. 2014;259:1041-1053.
The 2011 duty hour regulations for resident physicians were intended to improve patient safety by reducing resident fatigue. Examining the effects of duty-hours reform on surgical trainees, this systematic review concluded that there were no improvements in patient outcomes. Both perceived education and performance on certification exams have declined following reform, and more frequent handoffs have led to safety concerns. Even though some improvements in residents' quality of life were observed after the first duty-hours reform, the subsequent limitation of 16-hour shifts has not enhanced well-being. The authors express concern about current surgery residency training and urge caution prior to reforming graduate medical education further. A previous AHRQ WebM&M perspective explored the impact of duty hours on patient safety.
Smith M, Saunders R, Stuckhardt L, McGinnis JM, eds. Committee on the Learning Health Care System in America, Institute of Medicine. Washington, DC: National Academies Press; 2012. ISBN: 9780309260732.
This Institute of Medicine (IOM) report presents evidence of poor quality care and significant waste (to the tune of an estimated $750 billion per year) in the American health care system. It emphasizes the importance of continuous learning—not only from high performing health care systems but also from industries such as manufacturing, banking, and aviation—and highlights the role of mobile technologies and electronic health records in continuously improving health care.
Ulmer C, Wolman DM, Johns MME, eds. Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety, Institute of Medicine. Washington, DC: The National Academies Press; 2008. ISBN: 9780309127721.
The 2003 regulations limiting housestaff work hours have had a profound impact on residency training. Although clinical outcomes appear to be unaffected, faculty and residents have expressed concern that education has been harmed, and the regulations' effect on patient safety remains unclear. The Institute of Medicine's report bases its recommendations on the growing body of research linking clinician fatigue and error, and recommends eliminating extended-duration shifts (defined as more than 16 hours), increasing days off, and improving sleep hygiene by reducing night duty and providing more scheduled sleep breaks. The report estimates that approximately $1.7 billion would be required to hire additional staff to allow residency programs to adhere to these recommendations. A related editorial discusses the balance between patient safety, resident safety, and resident education that was central to the development of these recommendations.
Web Resource > Government Resource
Agency for Healthcare Research and Quality.
In order to encourage "voluntary, provider-driven initiatives to improve the safety and quality of patient care," the Agency for Healthcare Research and Quality (AHRQ) is spearheading the certification of Patient Safety Organizations (PSOs)—public or private organizations with expertise in the analysis of patient safety and hazards in health care. This Web site provides information on the rules governing PSOs and the requirements for an organization to be listed as a PSO. Development of PSOs was authorized by the 2005 Patient Safety and Quality Improvement Act.
Journal Article > Commentary
Auerbach AD, Landefeld CS, Shojania KG. N Engl J Med. 2007;357:608-613.
Since the publication of the Institute of Medicine's influential To Err Is Human report in 1999, clinicians and policymakers have embarked on an unprecedented quest to improve patient safety and the quality of health care. While some successes have been achieved, the best methods of improving care remain uncertain, and tension exists between those advocating for rapid dissemination of innovative strategies and those calling for evaluation of such strategies via clinical trials before dissemination. In this commentary, the authors outline arguments supporting and opposing each approach. They conclude that quality improvement interventions should be held to the same standards for determining effectiveness as other medical therapies, and use examples of recent patient safety interventions to illustrate the possible unintended consequences of ineffective initiatives.
Journal Article > Commentary
Leape LL, Berwick DM. JAMA. 2005;293:2384-2390.
Two of the leaders in the patient safety movement, Lucian Leape and Donald Berwick, share their perspectives on the progress made since the Institute of Medicine's (IOM) release of To Err is Human. They summarize the shifts in thinking that have occurred, from blaming individual physicians towards targeting systems as a method to improve both quality and safety. Discussion includes the evolution of error prevention strategies, the role of interested stakeholders in the safety movement, and the impact of implementing best practices. Barriers to ongoing progress are also shared, including the increasing complexity of health care, a tradition of autonomy in care, and the current financial incentive systems. The authors provide a vision for the next five years with expectations for rapid change in adoption of electronic medical records, teamwork training, and full disclosure to patients. While they applaud several efforts and initiatives, such as the growth of AHRQ-funded research, the authors call for a rededication of providers and policymakers to the cause of patient safety, promoted by increased funding, better alignment of incentives, and the setting of ambitious but achievable safety targets.
Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academies Press; 2001. ISBN: 9780309072809.
Following up on the 1999 Institute of Medicine report, To Err is Human, this report outlines a strategy for improving quality through redesign of the entire health care system. This report famously points to six key aims of a high-quality health care system: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. It is a call to action for providers and institutions as well as a strategic guide for clinicians, administrators, and policy makers regarding the changes needed to improve the quality of American health care.
Kohn L, Corrigan J, Donaldson M, eds. Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine. National Academies Press; 1999. ISBN: 9780309068376.
One measure of the impact of this report, the first in the series of reports by the Institute of Medicine (IOM) on the quality of health care in the United States, is that one can still refer to ''The IOM Report'' and everyone will recognize the reference to To Err is Human (despite the fact that, as of this writing, the IOM has released approximately 250 reports since To Err). In fact, many argue that the modern field of patient safety began with this report's publication. Although the report has been criticized for its strong focus on medication errors and computerized order entry (to the exclusion of other safety concerns) and the relatively limited discussion of the impact of the malpractice system, there is no mistaking its impact. Perhaps its most famous contribution was the extrapolation of the Harvard Medical Practice Study data and the Utah and Colorado Medical Practice Study data, which led to the famous estimate of 44,000 to 98,000 deaths per year from medical errors (the equivalent of a jumbo jet a day). Whether one believes these numbers or not, it is clear that the IOM report was essential in placing the issue of medical mistakes on the public and professional agenda.
Journal Article > Government Resource
Characteristics of initial prescription episodes and likelihood of long-term opioid use—United States, 2006–2015.
Shah A, Hayes CJ, Martin BC. MMWR Morb Mortal Wkly Rep. 2017;66:265-269.
Opioid use has become a growing patient safety concern. Recent studies have documented wide variation in opioid prescribing for acute pain and a significant rate of chronic opioid use after patients receive a first prescription for an acute indication. This retrospective medical record review study identified risk factors for remaining on an opioid medication for more than 1 year following their initial prescription. Older, female, and publicly or self-insured patients were more likely to remain on an opioid compared with younger, male, and privately insured patients. Patients started on higher doses (cumulative dose ≥ 700 mg morphine equivalent), provided prescriptions with longer duration (more than 10 days), or given 3 or more prescriptions for opioids were most likely to continue to use opioid medications 1 year later. The authors recommend prescribing fewer than 7 days of opioids for acute pain and adhering to the Centers for Disease Control and Prevention guideline for opioid use to improve prescribing practices.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2016. Report No. OEI-06-14-00110.
The Office of the Inspector General (OIG) has issued a series of reports analyzing the incidence and preventability of adverse events among Medicare beneficiaries receiving care in acute care hospitals and skilled nursing facilities. This report used similar methodology based on trigger tools to determine adverse event incidence among patients in rehabilitation hospitals—post-acute care facilities that provide intensive rehabilitation to patients recovering from hospitalization for an acute illness or injury. The study found that 29% of patients experienced an adverse event during their stay, a proportion nearly identical to rates at acute care hospitals and skilled nursing facilities. Nearly half of the events were considered preventable, with the most common types of events including pressure ulcers, delirium, and medication errors. Nearly one-fourth of patients who had an adverse event required transfer to an acute care hospital for diagnosis or management, leading to a large increase in costs of care. Based on these data, the OIG has recommended that the Agency for Healthcare Research and Quality and Centers for Medicare and Medicaid Services disseminate information about patient harms in the rehabilitation setting and work to improve safety at rehabilitation hospitals. A previous WebM&M commentary discussed an adverse event at a rehabilitation facility.
Journal Article > Study
Implementation of prescription drug monitoring programs associated with reductions in opioid-related death rates.
Patrick SW, Fry CE, Jones TF, Buntin MB. Health Aff (Millwood). 2016;35:1324-1332.
Opioid medications carry high risk for adverse drug events, and increases in opioid abuse have led to an epidemic of overdose deaths. State-level prescription drug monitoring programs are intended to identify high-risk prescribing and patient behaviors associated with opioids. This study used secondary data sources to determine whether implementing a drug monitoring program decreased opioid overdose deaths compared to the pre-implementation period. States with more complete and timely opioid monitoring achieved greater overdose reductions compared to states with less comprehensive programs. These results clearly support universal implementation and strengthening of state prescription drug monitoring programs. A WebM&M commentary discussed a death due to an opioid overdose.
Journal Article > Study
Meara E, Horwitz JR, Powell W, et al. N Engl J Med. 2016;375:44-53.
Growing rates of opioid misuse endanger public health. The impact of legal restrictions to limit high-risk prescribing and resultant adverse events is unclear. One recent study found that opioid-related adverse events were effectively reduced in states with stringent prescription drug monitoring programs compared to states without such regulations. However, this study examined data regarding Medicare beneficiaries with disabilities before and after adoption of controlled-substance laws and found no significant decrease in rates of nonfatal overdose, high opioid doses, or receipt of opioids from four or more prescribers. These results suggest that current regulatory policy may not be sufficient to address high-risk prescribing practices among Medicare beneficiaries with disabilities. More work is needed to develop effective strategies to treat chronic pain safely in this high-risk population. A WebM&M commentary described risks related to prescribing opioids for patients with chronic pain.
Journal Article > Review
Validity of the Agency for Healthcare Research and Quality Patient Safety Indicators and the Centers for Medicare and Medicaid Hospital-acquired Conditions: a systematic review and meta-analysis.
Winters BD, Bharmal A, Wilson RF, et al. Med Care. 2016;54:1105-1111.
The ability to use administrative data to measure patient safety is critical, because chart review is time-consuming and resource-intensive. The AHRQ Patient Safety Indicators (PSIs) and the CMS Hospital-acquired Conditions (HACs) aim to measure and track patient safety using administrative data. PSIs are often used for pay-for-performance, and CMS has a policy of nonpayment for hospitalizations associated with HACs. This systematic review found that PSIs and HACs have not been adequately validated compared to chart review and therefore may be subject to coding error. Establishing hospital quality or payment based on unvalidated metrics has consequences for patient safety efforts. These results suggest that unless further development and validation of administrative metrics occurs, widespread implementation of pay-for-performance efforts may not significantly improve patient safety.
Journal Article > Study
Zuckerman RB, Sheingold SH, Orav EJ, Ruhter J, Epstein AM. N Engl J Med. 2016;374:1543-1551.
The Centers for Medicare and Medicaid Service's policy on nonpayment for certain hospital readmissions has reduced their incidence. However, this policy change may have unintended consequences. One possible outcome is an increased number of patients who return to the hospital being placed on observation status. Comparing readmission rates and observation stays for targeted and nontargeted conditions, this secondary data analysis examined how observation stay rates changed in parallel with readmission rates. The authors found that readmissions decreased, consistent with prior studies, and observation stays increased. Interestingly, a within-hospital analysis determined that the decline in readmissions was not explained by an increase in observation stays. This finding should allay concerns about this specific unintended consequence of the readmission policy, although other issues such as length of stay changes should be addressed.
Journal Article > Study
Sustaining reductions in central line–associated bloodstream infections in Michigan intensive care units: a 10-year analysis.
Pronovost PJ, Watson SR, Goeschel CA, Hyzy RC, Berenholtz SM. Am J Med Qual. 2016;31:197-202.
A major challenge in improving patient safety is sustaining gains from new interventions over time. The landmark Michigan Keystone ICU project was a large-scale quality improvement effort that led to near elimination of central line–associated bloodstream infections (CLABSIs). This study examined practices to prevent CLABSIs in Michigan over the 10 years following that study. Investigators found a continued decline in CLABSIs from 2005 through 2013, with many participating hospitals reaching the benchmark rate of less than 1 CLABSI per 1000 hospital days after the initial project period ended. The authors credit robust training in change management principles and ongoing support for maintaining CLABSI prevention work. They further suggest that policymakers harness these methods to sustain patient safety efforts instead of relying on pay-for-performance incentives. A PSNet interview with the study's lead author explores, among other things, how to sustain changes in practice.
Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms: Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013.
Rockville, MD: Agency for Healthcare Research and Quality; December 2014. AHRQ Publication No. 15-0011-EF.
This report from the Agency for Healthcare Research and Quality provides estimates on hospital-acquired conditions (HACs)—including never events and health care–associated infections—for hospitals in the United States from 2010 to 2013. These adverse events continue to decline steadily, with an estimated 9% decrease in most recent year over year comparison. In 2013, there were 121 HACs for every 1000 hospital admissions. These improvements resulted in significant cost-savings and reduced morbidity and mortality rates. The authors attribute this change to CMS payment reform and to the Partnership for Patients initiative. Although uncertainty about the cause of these improvements remains, the lower HAC rate clearly demonstrates that efforts to reduce patient safety problems in hospitalized patients are yielding results. The substantial remaining burden of HACs argues for more investment in patient safety in hospital settings.
Boston, MA: Harvard School of Public Health; December 2014.
This statewide public telephone survey in Massachusetts found that more than 20% of respondents experienced a medical error in the prior 5 years, and more than half of these incidents resulted in harm. Prior patient surveys have brought to light previously unrecognized safety problems, although discrepancies have been shown to exist between patient reports and other methods for detecting adverse events. Most respondents attributed adverse events to individual physicians and nurses rather than health systems, underscoring the challenge of conveying blame-free culture and systems approaches to the public. Diagnostic errors were the most common type of error reported. About half of patients who experienced medical errors reported the incident to a clinician, hospital, or official agency. Most patients did not look for safety or quality information in choosing a physician or hospital, and only a third of respondents view patient safety as a serious problem for the state. Importantly, prior to being given an explanation, less than half of respondents understood the term "medical error." These findings emphasize the divide between the high prevalence of safety hazards and the lack of public awareness of patient safety efforts and policy.
Journal Article > Commentary
Sittig DF, Classen DC, Singh H. J Am Med Inform Assoc. 2015;22:472-478.
The Institute of Medicine and the Food and Drug Administration have called for the establishment of a national organization to oversee health information technology (IT) safety in the United States. This commentary, written by leaders in the IT field, recommends goals for the proposed Office of the National Coordinator-based Health IT Safety Center, including monitoring and tracking safety events, investigating incidents and disseminating guidance, building a process and infrastructure to examine the safety of health IT systems, and generating support for vigilance around health IT safety in the public and private sectors. The authors also highlight the convening ability of such a center as a critical component for transforming the safety of health IT.
Hearing Before the Subcommittee on Primary Health and Aging, 113th Cong (July 17, 2014). (Testimony of John James, PhD; Ashish Jha, MD, MPH; Tejal Gandhi, MD, MPH; Peter Pronovost, MD, PhD; Joanne Disch, PhD, RN; Lisa McGiffert.)
A group of patient safety experts, including Drs. Peter Pronovost, Ashish Jha, and Tejal Gandhi, testified to Congress that more must be done to track and prevent widespread patient harms. The title of the hearing was based on the seminal study estimating that as many as 200,000 to 400,000 patients experience harms that contribute to their death each year. The medical experts recounted the lack of significant progress since the landmark Institute of Medicine report in 1999, and they called on Congress to task the Centers for Disease Control and Prevention with tracking medical errors and patient harm. Dr. John James, a scientist who became engaged in patient safety efforts following the death of his son due to medical errors, recommended that lawmakers establish a National Patient Safety Board, similar to the current National Transportation Safety Board. A prior AHRQ WebM&M perspective discussed the many challenges of measuring patient safety.