June 2009

Healthcare Topics and Trends Update

CHRT's monthly online newsletter, providing convenient access to recently-published articles relating to healthcare quality, sustainability and access.

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Coronary Artery Disease

Impact of Optimal Medical Therapy With or Without Percutaneous Coronary Intervention on Long-Term Cardiovascular End Points in Patients with Stable Coronary Artery Disease (from COURAGE Trial)

Am J Cardiol. 2009 Jul 1; 104(1):1–4. (Subscription required to view full text)

The main results of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial revealed no significant differences in the primary end point of all-cause mortality or nonfatal myocardial infarction [MI] or major secondary end points (composites of death/MI/stroke; hospitalization for acute coronary syndromes [ACSs]) during a median 4.6-year follow-up in 2,287 patients with stable coronary artery disease randomized to optimal medical therapy (OMT) with or without percutaneous coronary intervention (PCI). This study attempts to assess the impact of PCI when added to OMT on major pre-specified tertiary cardiovascular outcomes (time to first event) during study follow-up. Overall, the researchers found that, compared with an initial management strategy of OMT alone, addition of PCI did not decrease the incidence of major cardiovascular outcomes including cardiac death or the composite of cardiac death/MI/ACS/stroke in patients with stable coronary artery disease.

Patient Centered Medical Home

The Political Economy of U.S. Primary Care

Health Aff (Millwood). 2009 Jul–Aug;28(4):1136–45. (Subscription required to view full text)

Compelling evidence suggests that the United States lags behind other developed nations in the health of its population and the performance of its health care system, partly as a result of a decades-long decline in primary care. This paper outlines the political, economic, policy, and institutional factors behind this decline. The authors contend, a large-scale, multifaceted effort-a new Charter for Primary Care-is required to overcome these forces. They further state that there are grounds for optimism for the success of this effort, which is essential to achieving health outcomes and health system performance comparable to those of other industrialized nations.

Health Care Costs

The Cost Conundrum

Gawande, The New Yorker, June 1, 2009.

This article explores the question of why two border towns in Texas of similar size, location, and circumstances-McAllen and El Paso-should cost Medicare such enormously different amounts of money. In 2006, McAllen cost $14,946 per enrollee, which is the second-highest in the United States and essentially double El Paso's cost of $7,504 per enrollee. Analysis of Medicare data by the Dartmouth Atlas project shows the difference is due to marked differences in the amount of care ordered for patients-patients in McAllen receive vastly more diagnostic tests, hospital admissions, operations, specialist visits, and home nursing care than in El Paso. But quality of care in McAllen is not appreciably better, and by some measures, it is worse. Indeed, studies have shown that the care for patients in the highest-cost regions of the country tends to go this way-with more high-cost care across the board, but less low-cost preventive services and primary care, and equal or worse survival, functional ability, and satisfaction with care. The cause that Gawande found locally was a system of care that was highly fragmented for patients and often driven to maximize revenues over patient needs. And he pointed to positive outliers across the country, including Grand Junction, Colorado, and the Mayo Clinic that deliver markedly lower-cost, higher-quality care. The article advocates for a better understanding of small area variations on how physicians practice and applying lessons learned at the hospital and regional level to national health reform.

Health Care Reform

Physician Performance Measurement: A Key to Higher Quality and Lower Cost Growth or a Lost Opportunity?

Draper, Center for Studying Health System Change, June 2009

Although the United States spends more than $2 trillion annually on health care, patient outcomes lag other developed countries that spend far less per capita. Physicians wield significant influence-directly and indirectly-over the quality and cost of health care, and efforts to measure and improve physician performance have gained momentum. Much of the impetus has come from purchasers seeking to engage consumers to be more active participants in their health and health care decisions. In response, health plans have developed physician performance measurement programs to provide information to consumers. However, methodological limitations, including the use of claims data, small sample sizes, and non-standardized measures and assessments, have fueled skepticism about plan programs. While measuring performance is an important step, health plans often fail to take the next step-supporting and rewarding physician performance improvement to encourage and reinforce desired behaviors. Arguably, physician performance measurement has such profound implications for all Americans' health and health care that it should be a public good, transcending competitive dynamics. Standardizing measures, combining payers' data, providing effective support for improvement, and creating robust rewards for good results offer some ways to improve the current state of physician performance measurement. However, the author suggests that these early efforts to measure physician performance may prove a lost opportunity to improve the nation's health care system if methodological and other shortcomings are not addressed.

Safety Net

Rescuing the Safety Net

N Engl J Med. 2009 Jun 18; 360(25):2598–601. (Subscription required to view full text)

Millions of low-income Americans are dependent on safety-net facilities for care. As the economic recession deepens, safety-net hospitals have been forced to close or to curtail key services. The effects of these closures are widespread, reaching beyond the uninsured. This article discusses the creation and evolution of disproportionate-share hospital (DSH) programs and outlines the importance of such funds to the survival of safety net hospitals. It concludes with recommendations to change federal law in order to make DSH funding more efficacious for the safety net hospitals for which it was created.