October 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.

Past Issues »

Radiology

Magnetic Resonance Imaging and Low Back Pain Care for Medicare Patients

Health Affairs, November/December 2009; 28(6): w1133–w1140. (Subscription required to view full text)

Magnetic resonance imaging (MRI) is a technology frequently used to evaluate low back pain, despite evidence that challenges the usefulness of routine MRI and the surgical interventions it may trigger. This article analyzes the relationship between MRI supply and care for fee-for-service Medicare patients with low back pain. The article finds that increases in MRI supply are related to higher use of both low back MRI and surgery, and suggests that careful attention be paid to assessing the outcomes for patients.

Health Care Costs

Will the Cost Curve Bend, Even without Reform?

New England Journal of Medicine 361;15 (Subscription required to view full text)

This article challenges prevailing assumptions about the inevitability of rising health care costs. In the author's view, several pieces of evidence suggest that increases in health care costs might actually moderate significantly, if not decline relative to the GDP, over the next few decades — even without the type of systemic changes proposed in current legislative efforts. As a result, the financing crisis in health care could be much less dire than most people believe. The author cites these moderating factors: (1) new technologies may not increase costs as much in the future as they have in the past, and may even have the potential to reduce the number of patients receiving expensive treatments; (2) the potential for technology to lower the administrative costs of care; and (3) improvement in the management of care for chronic conditions. The author acknowledges that the absence of reform has hindered the ability of the health care system to realize efficiencies, but says with or without reform we may find the future cost of the health care system to be lower than many have predicted.

Health Reform

Can Slumping Support for Health Care Reform Be Turned Around?

Health Affairs Blog (Subscription required to view full text)

This blog post discusses a survey of American opinions on health care reform that found that the American public's support for the major health reform legislation being debated in recent weeks has fallen — to 27%, with 59% opposed — and attempted to learn if Americans would in fact read a detailed summary of the health reform bill that is the current focus of the national debate, plus ten amendments, and be willing and able to identify the provisions that would, if enacted, switch their stance from support to opposition (or vice versa), or from unsure to pro or con. The survey found that just one proposed amendment, tort reform, raises support for the bill to "too close to call" (44% for, 46% against). The second biggest boost would come from eliminating the individual mandate, and the third from adding a public option. Several combinations of two amendments would yield plurality or majority support. The authors offer these data as evidence that it is possible, if legislators wish, to craft a bipartisan bill with support from a majority of Americans.

Quality Improvement

Hospital Strategies to Engage Physicians in Quality Improvement

Center for Studying Health System Change, Issue Brief 127, October 2009

Although hospitals have long engaged in quality improvement activities, they continue to face escalating demands to participate in a wide range of quality improvement and reporting programs. Many hospitals historically have relied on the voluntary medical staff model to solicit physician participation-a model generally premised on a loose affiliation between hospitals and community-based physicians. However, as more services shift to outpatient settings and physicians confront quality-of-life issues and financial stresses, physicians feel less obligated to volunteer time for hospital activities, including quality improvement, according to the study. A study by the Center for Studying Health System Change (HSC), funded by the Robert Wood Johnson Foundation, identifies hospital strategies to involve physicians in quality improvement activities, including several that are key to Michigan's BCBSM collaborative quality initiatives (CQIs): employing physicians; using credible data to identify areas needing improvement; providing visible hospital leadership support; identifying and nurturing physician champions to help engage their peers; and communicating the importance of physicians' contributions.

Variation in Hospital Mortality Associated with Inpatient Surgery

New England Journal of Medicine, Volume 361:1368–1375 (Subscription required to view full text)

Hospital mortality associated with inpatient surgery varies widely. Reducing rates of postoperative complications, the current focus of payers and regulators, may be one approach to reducing mortality. However, effective management of complications once they have occurred may be equally important. This article studied 84,730 patients who had undergone inpatient general and vascular surgery from 2005 through 2007, using data from the American College of Surgeons National Surgical Quality Improvement Program. Hospitals were ranked according to their risk-adjusted overall rate of death and divided into five groups. For hospitals in each overall mortality quintile, the authors assessed the incidence of overall and major complications and the rate of death among patients with major complications. The study found that rates of death varied widely across hospital quintiles, from 3.5% in very-low-mortality hospitals to 6.9% in very-high-mortality hospitals. Hospitals with either very high mortality or very low mortality had similar rates of overall complications (24.6% and 26.9%, respectively) and of major complications (18.2% and 16.2%, respectively). Rates of individual complications did not vary significantly across hospital mortality quintiles. In contrast, mortality in patients with major complications was almost twice as high in hospitals with very high overall mortality as in those with very low overall mortality (21.4% vs. 12.5%, P<0.001). Differences in rates of death among patients with major complications were also the primary determinant of variation in overall mortality with individual operations. The authors conclude that, in addition to efforts aimed at avoiding complications in the first place, reducing mortality associated with inpatient surgery will require greater attention to the timely recognition and management of complications once they occur.

Accountable Care Organizations

Primary Care and Accountable Care: Two Essential Elements of Delivery-System Reform

New England Journal of Medicine, October 28, 2009 (Subscription required to view full text)

With discussions about U.S. health care reform focused heavily on insurance reforms, the authors of this article suggest that relatively little attention has been paid to the delivery-system reforms that will be required to improve the quality and coordination of health care and slow the growth of spending. The "patient-centered medical home" (PCMH) and the "accountable care organization" (ACO) are two widely discussed models for delivery-system reform that take complementary approaches to achieving these goals. The PCMH model emphasizes the creation of a strong primary care foundation for the health care system, and the ACO model emphasizes the alignment of incentives and accountability for providers across the continuum of care. These two approaches are synergistic models of delivery-system reform that, together, promise to redirect the U.S. delivery system toward reduced cost growth and improved quality. The authors identify strategies for ensuring that these approaches are mutually reinforcing, and urge ongoing evaluation of both models, preferably in combination and in diverse settings; they also advocate for expanding the capacity of federal agencies, including the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality, to implement, support, and evaluate these promising delivery-system reforms.