medical news: Improved clinical quality leads to decline in quality of patients' experiences

Improved clinical quality leads to decline in quality of patients' experiences

....."Clinical quality is about doing things correctly - strict guidelines, standardization and checklists, for example - so when you consider experiential quality is about customizing health-care delivery to an individual patient's needs, there is a tension there," said Aravind Chandrasekaran, assistant professor of management sciences at Ohio State and lead author of the study.
How might this tension play out?......

YouTube: Interview with Dr Stukel, Author of Hospital Spending Intensity and Patient Outcomes

Also, planning a comparison study with London School of Economics and Havard

open access: Association of Hospital Spending Intensity With Mortality and Readmission Rates in Ontario (Canada) Hospitals, March 14, 2012 — JAMA

 Blogger's Note: universal healthcare system, this study included colorectal cancer patients, comparisons between Canadian/U.S. systems, note authors' affiliations

Association of Hospital Spending Intensity With Mortality and Readmission Rates in Ontario Hospitals, March 14, 2012

"Our objective was to assess whether acute care patients admitted to Canadian hospitals that treat patients more intensively (and at higher cost) have lower mortality and readmissions and higher quality of care.......We studied 4 common conditions that have moderate to high incidence and mortality, that can be validly ascertained using health administrative data, and for which treatment follows relatively standard protocols. "

Design Overview

We undertook a longitudinal cohort study of patients hospitalized with selected acute clinical conditions in Ontario, Canada, and assessed the content, quality, and outcomes with respect to “exposure” to the index hospital's medical spending intensity. Medical intensity is defined as the quantity of medical care provided overall to similarly ill patients and is a marker of a hospital's propensity to treat similarly ill patients more (or less) intensively. It reflects the component of spending variation attributable to practice style rather than to differences in illness or price.

Because sicker patients use more services, higher-spending hospitals may appear to have worse outcomes, in part because patients are more severely ill. We used several techniques to remove this potential “reverse causality,” as in previous work.1,2​,3,4

 COMMENT

We found that higher hospital spending intensity was associated with better survival, lower readmission rates, and better quality of care for seriously ill, hospitalized patients in Ontario in a universal health care system with more selective access to medical technology. Higher-spending hospitals were higher-volume teaching or community hospitals with high-volume or specialist attending physicians and having specialized programs, such as regional cancer centers, and specialized services, such as on-site cardiac catheterization, cardiac surgery, and diagnostic imaging facilities. The study also points to plausible mechanisms through which higher spending may be associated with better outcomes. 

Benefits appeared early, suggesting an acute-phase hospital effect. For acute conditions, timely access to preoperative and in-hospital specialist care, skilled nursing staff, rapid response teams, cardiac high-technology services, and regional cancer centers, all found in the higher-spending systems, are related to better outcomes.^{21​,27,34​,35,36​,37,38​,39} These systems also provided consistently, but not strikingly, higher levels of evidence-based care and collaborative ambulatory care, both shown to improve care.^{22​,23,40​} Higher spending on evidence-based services delivered in the acute phase of care for severely ill hospitalized patients—by far the largest component of spending for our cohorts—is indeed likely to be beneficial. 

It would be facile to interpret this study as demonstrating that higher spending is causally related to better outcomes and that providing more money to lower-spending hospitals would necessarily improve their outcomes. Higher-spending hospitals differed in many ways, such as greater use of evidence-based care, skilled nursing and critical care staff, more intensive inpatient specialist services, and high technology, all of which are more expensive. 

To place the study in context, the United States has a 3- to 4-times higher per capita supply of specialized technology, such as computed tomography and magnetic resonance imaging scanners, but a similar supply of acute care beds and nurses.⁴¹ Ontario 2001 population rates of cardiac testing and revascularization lagged behind corresponding 1992 US rates and paralleled the supply of cardiologists and catheterization facilities.^{42​,43,44​} It is therefore possible that Canadian hospitals, with fewer specialized resources, selective access to medical technology, and global budgets, are using these resources more efficiently, especially during the inpatient episode for care-sensitive conditions.^45,46​ Canada's health care expenditures per capita are about 57% of those in the United States.⁴⁷ At this spending level, there might still be a positive association between spending and outcomes. For example, the same-day PCI rate for patients with AMI in low-intensity hospitals in 2008 was 3.5%, leaving room for improvement. This pattern is consistent with studies in the United States showing a positive association between spending and outcomes among low-intensity hospitals or regions but no association at average or higher intensity levels.^5​,6

Strengths of the study include the population-based, longitudinal cohort design; the consistency of findings across cardiac, cancer, medical, and surgical patients; the examination of plausible clinical mechanisms whereby higher intensity may be associated with better outcomes; and the examination of readmissions. The “look-back” (EOL-EI) and “look-forward” (AC-EI) measures of spending intensity were highly correlated and produced similar findings, as in US studies.²

 ^​

Several limitations should be considered. Because the design precludes strong inferences about causation, we cannot know which components of care may have led to better outcomes. In observational studies, comparisons of exposure groups may be biased because of unobserved selection bias.¹³ It is unlikely that the findings are the result of unmeasured case mix, because patients in higher-spending hospitals had similar or higher illness severity at admission, which would, if anything, bias toward finding worse outcomes. We cannot rule out the possibility that higher-intensity hospitals coded more aggressively, but there is less incentive to do so in a system with global hospital budgets. Although admission severity would be determined more accurately using clinical detail from medical charts, previous work has shown high concordance between risk-adjusted hospital outcomes using chart and administrative data.^48​,49 Canadian data distinguish between comorbidities present at admission and complications, leading to improved admission severity coding. The EOL-EI has been critiqued for the purpose of estimating hospital efficiency^50​,51 but is used here simply to distinguish high- and low-intensity hospitals, as in other US studies.^{1​,2,3​,4} The findings may not generalize to chronic conditions, for which avoiding exacerbations of disease that lead to hospitalization through coordinated ambulatory care is key. The findings also may not generalize to jurisdictions in which hospital resources are more abundant and are used in cost-effective as well as cost-ineffective ways, leading to inefficiency.^45​,46

This study shows that in Ontario, a province with global hospital budgets and fewer specialized health care resources than the United States, outcomes following an acute hospitalization are positively associated with higher hospital spending intensity. Higher spending intensity, in turn, is associated with greater use of specialists, better patient care, and more use of advanced procedures. These results suggest that it is critical to understand not simply how much money is spent but whether it is spent on effective procedures and services. 

pdf file: 

http://jama.ama-assn.org/content/307/10/1037.full.pdf

Association of Patient-Centered Outcomes With Patient-Reported and ICD-9–Based Morbidity Measures

Association of Patient-Centered Outcomes With Patient-Reported and ICD-9–Based Morbidity Measures

CONCLUSIONS
"A comprehensive assessment of morbidity requires both subjective and objective measurement of disease burden as well as an assessment of emotional symptoms. Such multidimensional morbidity measurement is particularly relevant for research or quality assessments involving the delivery of patient-centered care to complex patient populations."

Editorial: Never Enough Time for Patient Care — What Can We Do? | Journal of Participatory Medicine

Never Enough Time for Patient Care — What Can We Do? | Journal of Participatory Medicine

open access: Pharmaceutical care for patients with breast and ovarian cancer - adverse drug events

Blogger's Note:  'tag' line includes breast cancer only; study included few ovarian cancer patients

Conclusions

 

In conclusion, our results suggest that pharmaceutical care for patients with breast and ovarian cancer is feasible and may have an impact on PROs as particularly indicated by significant improvements of the antiemetic response and patient satisfaction. 

Although there is no doubt that a higher awareness of drug-related problems is beneficial, final conclusions on the effectiveness of a new health care intervention can only be drawn when studied in a randomized trial. Therefore, our data may serve as a valuable basis for planning a large randomized multicenter trial.

ESMO: Community Oncology: Ensuring the Best Standards of Care

“The important thing is that community oncologists should not work alone. They should be part of a network and participate in a common reflection and also work with others in clinical research. In France, community oncologists work closely with university hospitals or big cancer centers and are in contact with larger teams. National and international guidelines are followed and ensure that patients receive quality treatment.”

Abstract/free full access: What doctors think about the impact of managed care tools on quality of care, costs, autonomy, and relations with patients

full free access: Associations Between Physician Characteristics and Quality of Care - The Commonwealth Fund

Synopsis

A Massachusetts study found many of the criteria available to patients when selecting a physician—including years of experience, paid malpractice claims, and medical school rankings—are not associated with higher quality care.

Key Findings

•  
• Three of the characteristics studied were associated with marginal differences in performance quality: female physicians scored 1.6 percentage points higher than male physicians; board-certified physicians scored 3.3 points higher than physicians without board certification; and U.S.-trained physicians scored 1 point higher than physicians trained abroad.
• There were no statistically significant associations between performance and malpractice claims, disciplinary actions, years of practice, medical school ranking, or type of medical degree (i.e., allopathic vs. osteopathic).
• The difference in overall performance between the average physician with the best combination of characteristics (female, board-certified, domestically trained) and the average physician with the worst combination (male, noncertified, internationally trained) is only 5.9 percent.
• Among the middle 90 percent of physicians studied who had the best combination of characteristics, there was a wide range of performance scores—from 49 percent to 75 percent—very similar to the range for all physicians. This suggests that patients are unlikely to receive higher-quality care by switching to a physician who has these characteristics.

End of life 'quality' index | Open Medicine Blog The Quality of Death: Ranking end-of-life care across the world 2010 The Economist Intelligence Unit

"....Advancements in healthcare have been responsible for the most significant quality-of-life gains in the recent past: that humans are (on average) living longer, and more healthily than ever, is well established. But “quality of death” is another matter. Death, although inevitable, is distressing to contemplate and in many cultures is taboo......Few nations, including rich ones with cutting-edge healthcare systems, incorporate palliative care strategies into their overall healthcare policy—despite the fact that in many of these countries, increasing longevity and ageing populations mean demand for end-of-life care is likely to rise sharply. Globally, training for palliative care is rarely included in healthcare education curricula. Institutions that specialise in giving palliative and end-of-life care are often not part of national healthcare systems, and many rely on volunteer or charitable status...."cont'd

(abstract) From randomized trial to practice: single institution experience using the GOG 172 i.p. chemotherapy regimen for ovarian cancer — Ann Oncol

Background: The objective of the study was to evaluate completion rates and toxic effects of an i.p. chemotherapy regimen in a cross-section of nonselected patients with ovarian cancer (OC).

'New' Evidence for Clinical Practice Guidelines: 'New' Evidence for Clinical Practice Guidelines: Should we Search for 'Preference Evidence'?

Abstract

Clinical practice guidelines (CPGs) are systematically developed statements to assist both patient and practitioner decisions. They link the practice of medicine more closely to the body of underlying evidence, shift the burden of evidence review from the individual practitioner to experts, and aim to improve the quality of care. CPGs do not routinely search for or include evidence related to patients' values and preferences.

We argue that they should.

We think that such evidence can tell us whether a decision is preference sensitive; how patients feel about important health outcomes, treatment goals, and decisions; and whether preferences vary in different types of patients. The likely effects of reviewing the literature are a general sensitization to the importance of preferences in decision making, the recognition that some decisions are simply all about preferences, a more considered approach to forming preferences among patients and other stakeholders, and more effective integration of preferences into decisions.