Goal 2—Quality

Making Quality Count

The United States has many of the world's finest health care professionals, academic health care centers, and other institutions. Every day, millions of Americans receive high-quality health care services that help to maintain or restore their health and ability to function. However, far too many do not. Some patients receive substandard care.

Quality problems may be reflected in a wide variation in the use of health care services, underuse of some services, overuse of other services, and even misuse of services, including an unacceptable level of errors. Sometimes patients receive more services than they need or they receive unnecessary services that undermine the quality of care and needlessly increase costs. At other times they do not receive needed services that have been proven to be effective.

The research that provided much of the basis for the 2001 report by the Institute of Medicine (IOM), Crossing the Quality Chasm, goes back several decades to early studies on quality of care, most of which were supported by AHRQ and its predecessor agencies. In its report, the IOM pointed out that quality problems occur across all types of cancer care and in all aspects of the process of care. For example, the IOM report described "underuse of mammography for early cancer detection, lack of adherence to standards for diagnosis, inadequate patient counseling regarding treatment options, and underuse of radiation therapy and adjuvant chemotherapy following surgery."

Poor quality care leads to patients who are sicker, have more disabilities, incur higher costs, and have lower confidence in the Nation's health care system. There is great potential to improve the quality of health care provided to Americans, and AHRQ is committed to this goal. We are working to maintain what is good about the existing health care system while focusing on the areas that need improvement.

Improving the quality of care and reducing medical errors are priority areas for the agency. AHRQ is working to develop and test measures of quality, identify the best ways to collect, compare, and communicate data on quality, and widely disseminate information about effective strategies to improve the quality of care.

Following are examples of AHRQ-supported research now in progress that focuses on improving health care quality:

• Benefits of regionalizing surgery for Medicare patients. In this ongoing study, researchers at Dartmouth Medical School are using Medicare data and data from AHRQ's Nationwide Inpatient Sample (NIS) to investigate the potential benefits of regionalizing patients who have certain high-risk procedures. In a recent journal article, they reported a 12 percentage point difference in survival for patients being treated for cancer of the pancreas at high- and low-volume hospitals. Only 4 percent of patients treated at the highest volume hospitals died, compared with 16 percent at the lowest volume hospitals. Indeed, they found that elderly patients undergoing treatment for any one of 14 high-risk cardiovascular or cancer operations were more likely to survive if they were treated in high-volume hospitals.
• Improving obesity and diabetes education in vulnerable populations. These researchers are examining the effectiveness of a multimedia, computer kiosk-based program to educate patients about prevention of obesity and diabetes and diabetes self-management. Programs have been designed to be culturally competent for Hispanic and black patients and are intended to improve their knowledge, self-care practices, and ultimately, glucose control for those with diabetes. The computer kiosks have been placed in clinics and churches in Chicago in order to reach patients both within and outside the health care system.
• Bringing evidence-based medicine to the hospital bedside. Researchers at the University of Iowa are carrying out a 3-year randomized study at 12 hospitals in Iowa, Missouri, and Illinois to evaluate the effectiveness and cost-effectiveness of implementing an evidence-based acute pain management guideline for hospitalized elderly hip fracture patients. The intervention targets both nurses and prescribing physicians and includes training, computerized learning modules, the use of opinion leaders, the use of feedback and reminder cards, and system interventions for modifying chart forms and institutional policy. The goals are to determine whether a multidimensional organizational intervention alters nurse and physician behaviors and whether institutional barriers to change are reduced.

Examples of recent findings from AHRQ-supported research on improving health care quality include:

• Effects of nurse staffing levels on postoperative outcomes. A study published in June 2002, shows a relationship between fewer registered nurses in hospitals and an unusually high number of cases of postoperative pneumonia. AHRQ researchers linked discharge data from hospitals in 13 States with American Hospital Association data on hospital characteristics and nurse staffing. They used the data to examine the impact of nurse staffing on four postsurgical complications: Venous thrombosis/pulmonary embolism, pulmonary compromise, urinary tract infection, and pneumonia among patients undergoing major surgery. After controlling for severity of illness and hospital characteristics, fewer RN hours per patient day were found to be significantly associated with more postsurgical pneumonia. This study used different data and different methods but reached the same conclusions as another recent AHRQ-funded study by researchers at the Harvard School of Public Health and Vanderbilt University, which was published in the May 30, 2002, issue of the New England Journal of Medicine.
• Implementing evidence-based screening for chlamydia. Chlamydia infection is the most common sexually transmitted disease in the United States. These infections cause severe reproductive problems and account for billions of dollars in costs to the U.S. health care system. Nevertheless, only about 20 percent of eligible women aged 15-25 are screened for chlamydia infection. Effective treatment of chlamydia will reduce future infertility. A team from the University of California, San Francisco, and Kaiser Permanente found that it was possible to dramatically increase chlamydia screening rates through a sustainable and reproducible intervention. By engaging leadership, identifying barriers and solutions, and monitoring progress, participating clinics were able to increase screening 13-fold and decrease the average infection rate compared with control sites.
• Enhancing the quality of primary care for depression. Most depressed patients who visit primary care doctors want to be treated for their depression, but many do not receive adequate treatment despite the availability of effective medications and psychotherapies. Two AHRQ-supported studies from Partners in Care—a dissemination trial of two quality improvement (QI) interventions for depression—found that QI programs that support treatment choices of depressed patients can improve the likelihood they will be treated and receive preferred treatments, and that the cost-effectiveness of these QI programs is comparable to that of accepted medical interventions. The studies were led by researchers at the University of California, Los Angeles, and involved 46 primary care clinics in 6 managed care organizations. Participants were randomized to a medication QI program, a psychotherapy QI program, or usual depression care.

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Patient Safety and Reducing Errors in Medicine

The November 1999 report of the Institute of Medicine (IOM), To Err is Human: Building a Safer Health System, galvanized attention on the unacceptable number of medical errors occurring in the United States every day.

The report brought patient safety to the forefront of our attention and led to unprecedented efforts to find solutions. The report showed that a wide gap exists in the quality of care people receive and the quality of care that we as a Nation are capable of providing. According to the IOM, as many as 44,000 to 98,000 people die in hospitals each year as a result of medical errors. Even using the lower estimate, this would make medical errors the eighth leading cause of death in this country.

Medical errors cause more deaths annually than automobile accidents (43,458), breast cancer (42,297), or AIDS (16,516). It is estimated that about 7,000 people each year die from medication errors alone—about 16 percent more deaths than the number attributable to work-related injuries.

Research on medical errors and other patient safety issues is not new to AHRQ. We have recognized for some time that reducing medical errors is critically important for improving the quality of health care. In 1993, the agency published one of the first reports focused on medical errors. This landmark report noted that 78 percent of adverse drug reactions were due to system failures, such as the misreading of handwritten prescriptions. Subsequent studies sponsored by AHRQ have focused on the detection of medical errors, investigation of diagnostic inaccuracies, the relationship between nurse staffing and adverse events, computerized adverse drug event monitoring, and tools for computer-assisted decisionmaking that can reduce the potential for errors and improve safety.

In FY 2001, AHRQ invested $50 million in 94 new research grants, contracts, and other projects to reduce medical errors and improve patient safety. This effort represents the Federal government's largest single investment in research on medical errors. These projects will address key unanswered questions about when and how errors occur and provide science-based information on what patients, clinicians, hospital leaders, policymakers, and others can do to make the health care system safer. The results of this research will identify improvement strategies that work in hospitals, doctors' offices, nursing homes, and other health care settings across the Nation. AHRQ is making a substantial investment in a multi-year effort to reduce medical errors, enhance patient safety, and improve quality in all areas of health care.

The results of this investment in patient safety research are now being incorporated into practice. The following are examples of how this research is being used:

• AHRQ's Center for Education and Research in Therapeutics (CERT) in the University of Arizona Health Sciences Center developed a unique educational and research tool at http://www.qtdrugs.org. This Web site contains a list of 72 drugs that can cause life-threatening heart arrhythmias (abnormal heartbeat). Caregivers around the world can use this online resource to research specific drugs that might pose a risk to their patients, and they can submit clinical cases of drug-induced arrhythmias to the registry. Researchers are using the information submitted to develop profiles of people most at risk for drug-induced arrhythmia and to develop a genetic test that can identify them in advance of treatment.
• Patients and their families can use a new consumer tip sheet, published by AHRQ in English and Spanish, to help them play a more active role in ensuring that they get the best health care possible. The tips also help consumers prevent medical errors.
• AHRQ research has evaluated information about 73 proven patient safety practices to assist health care administrators, medical directors, health professionals, and others who are responsible for patient safety programs. AHRQ research has also identified 11 other patient safety practices proven to work but not used routinely in the Nation's hospitals and nursing homes. Voluntary Hospitals of America and Premier, Inc., use the information to guide their member hospitals in selecting projects to improve safety. Many chief executive officers, medical directors, and hospital safety officers have reported that they use the information to help them initiate projects to improve patient safety.
• To help patients assess the safety of their care, AHRQ, the Centers for Medicare & Medicaid Services, and other organizations supported the National Quality Forum (NQF), a not-for-profit membership organization created to develop and implement a national strategy for health care quality measurement and reporting. The NQF developed a list of serious, avoidable, adverse events that are so significant and so preventable that their occurrence should trigger an investigation of the organization in which they occurred. An example of such an event would be surgery on the wrong site. This list is now available to the public. For information on how to obtain a copy of Serious Reportable Events in Healthcare, go to the NQF's Web site (http://www.qualityforum.org) and click on "Activities/Consensus Reports" to find a description of the report, an executive summary, and ordering information for the full report.
• AHRQ supported the NQF's effort to develop a list of safe practices proven to be effective in reducing harm to patients. The list, which soon will be available to the public, is a tool to identify and encourage practices to reduce errors and improve care. Hospitals will be encouraged to report their use of these practices so that patients can determine what hospitals have done to improve the safety of care.

Examples of patient safety projects funded in FY 2002 and now in progress include:

• Shared online health records for patient safety and care. This 3-year project underway at Boston's Brigham and Women's Hospital is assessing the impact on patient care and safety of tools for electronic patient-provider communication and shared online health records. The researchers are investigating four related questions: (1) Is medication safety improved with patient prompts and a shared patient/physician medication list? (2) Do patient prompts, reminders, and entries in an online system improve chronic disease outcomes and adherence to guidelines in health care maintenance and chronic disease? (3) Does a prompted patient family history assessment improve detection of familial risk factors? And, (4) How does electronic communication and shared use of the online system by patients and physicians impact on medical practice, and how might barriers be addressed?
• Improving patient safety by examining pathology errors. These researchers are focusing on anatomic pathology diagnostic errors and their effects on patient outcomes. Previous studies have been limited to single institutions and reported variable diagnostic error percentages from less than 1 percent to 43 percent of all patients who underwent a biopsy or excisional procedure, with no correlation between error and outcome. These researchers are establishing a Web-based, pathologist-driven, national, voluntary anatomic pathology error database. The data will be used for continuous quality improvement targeted at error reduction and clinical outcomes improvement. Reporting institutions will receive quarterly and annual quality performance reports relating to errors and outcomes at their facilities. Specific factors associated with increased risk for diagnostic error will be identified. An analysis will be performed to determine the potential sources of errors, and error reduction programs will be implemented at each institution based on the results of the analysis. This project will provide valuable information regarding diagnostic pathology errors and will lay the groundwork for future studies on other types of diagnostic pathology error and the effects of error reduction programs in pathology practice.
• Menopause interactive decision aid system. To improve menopausal counseling and help menopausal women more actively participate in the decisionmaking process, these researchers developed a novel prototype Web-based decision aid. They are further refining this prototype technology into a comprehensive Menopause Interactive Decision Aid System (MIDAS) that will provide personalized feedback about menopausal symptoms, risks for common conditions, and the effects of different treatment options on the short- and long-term consequences of menopause. Their main study hypotheses are that MIDAS can: (1) lead to better decisions and improve the quality of menopausal counseling; (2) improve compliance with a chosen menopausal plan; and (3) reduce medical errors associated with the use of menopausal therapies. Results from the Women's Health Initiative, published in July 2002, reinforce the importance of tools that help women make the best decisions for their needs and risk profile.

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Working Conditions and Quality of Care

Understanding how working conditions affect health care workers, the risks for errors, and the quality of services provided to patients is of major importance to the health care industry. Recent efforts to reduce costs and streamline the delivery of care have led to significant changes in the health care workplace. The experiences of other industries demonstrate that differences in the equipment and physical characteristics of the workspace, changes in work responsibility and process, and differences in staffing levels can affect the quality of the products or services provided. For example, research on working conditions in the aviation industry has provided evidence of the relationship between aviation safety and work hours, including the effect of factors such as fatigue, lack of sleep, and shift work.

Despite the importance of these factors, there has been scant research focused on the importance of the quality of the workplace environment—not only for worker satisfaction, worker health, and the avoidance of disability, but also for the quality and productivity of the work performed. Workplace factors, including the way work is organized and staffed, may pose a threat, not only to the health and well-being of workers, but also to the quality of care they provide to patients and the safety of the patients.

Over the last 2 years, AHRQ has funded more than 30 projects to examine the effects of working conditions on health care workers' ability to provide safe, high-quality care in ambulatory, inpatient (both hospital and long-term care institutions), and home care settings. Examples of the critical issues now being addressed by these researchers include:

• Effects of extended work hours, sleep deprivation, fatigue, and stress on residents and nurses working in hospital-based settings.
• Relationship between working conditions—such as nurse-to-patient ratios, workload and skill mix—and the occurrence or near occurrence of medical errors or adverse events.
• Impact of workplace characteristics, organizational culture, and teamwork on the safety, quality, and outcomes of care in inpatient settings, specifically intensive care units and surgical settings.
• Relationship between nursing home working conditions—such as staffing levels, job design, and job satisfaction—and worker outcomes, patient outcomes, and quality of care.
• Impact of financial incentives and the work environment on the quality of care in both ambulatory and inpatient settings.
• Effects of employee training, satisfaction, and understanding of patient safety on patient outcomes and quality of care.

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