2012 Potpourri XXXIV

A presentation from the Medicare Payment Advisory Commission discusses potentially preventable admissions and emergency room visits as quality measures.  The presentation was part of MedPAC’s ongoing effort to help find appropriate population-based quality indicators.  These potential measures reflect potential access to care issues, not hospital quality markers.  The avoidable admissions measure is designed to identify situations where adequate outpatient care likely would have prevented the need for a hospitalization and the ER measure to find situations where the patient could have been treated in a less-intensive ambulatory setting.  In a sample of fee-for-service beneficiaries, the study found that as many of 25% of admissions could have been avoided and almost 60% of ER visits and there was wide variation across hospital referral regions.   (MedPAC Presentation)

Research published in the Archives of Internal Medicine discusses factors related to better quality of life for patients who are dying.  The study looked at about 400 advanced cancer patients and their informal caregivers.  Factors which led to a better end-of-life quality included avoiding being hospitalized, and particularly being in the intensive care unit, being less anxious or worried, use of religious services, including prayer and meditation and having a strong therapeutic alliance with treating physicians.  Much of the variation in quality, however, remained unexplained.   (Archives Article)

An article in the Annals of Internal Medicine discusses whether medication adherence is a worthy goal, particularly in the context of quality measurement.  The Stars program for Medicare Advantage plans is going to add measures on medication adherence to diabetes, blood pressure and cholesterol medications.  More than 75% of beneficiaries must obtain at least 80% of prescribed medications for these conditions.  The author points out that research suggests very modest benefit for greater adherence and that the reasons that patients often don’t take medicine are complex.  One of the common regions is unpleasant side effects and forcing patients to take medications when they incur side effects may actually lower satisfaction with care and add stress.  The authors, however, believe that focus on greater adherence is warranted and that effective interventions can be created.   (Annals Article)

A Viewpoint in the Journal of the American Medical Association describes some innovations in health care delivery which might slow the growth of spending.  Anyone with ideas to help us with this difficult problem is greatly appreciated.  The authors suggest that a focus on reducing hospitalizations among the 5% of Americans who incur almost half of our spending would be a relatively easy, high return intervention.  A similar innovation would target keeping patients at the end-of-life from dying in a hospital, where costs are multiples of the costs for same patients who die at home or in a hospice.  Making better use of hospital capacity and increasing patient flow-through would also help significantly reduce spending.  Finally, encouraging better lifestyles would have a long-term payoff.     (JAMA Viewpoint)

A Health Affairs article examines why many findings from comparative effectiveness research don’t seem to make it into routine medical practice.  The authors attribute the difficulty to five root causes.  One is misalignment of financial incentives, which do not reward providers or patients for choosing conservative treatment options which work as well as more aggressive ones.  Others include ambiguity of results, the ability of any trial outcomes to be challenged on some basis; various cognitive biases, such as that doing something is better than doing nothing; limited use of decision support tools which would bring the information to providers at the point of care; and failure to formulate information in ways that would maximize their utility to end-users.  The authors go on to suggest several fixes for these problems.    (Health Affairs Article)