Application of HEDIS measures within a Veterans Affairs medical center.

OBJECTIVE: To pilot test 3 HEDIS performance measures--beta-blocker treatment after a heart attack, ambulatory follow-up after hospitalization for mental illness, and cervical cancer screening--within a Veterans Affairs (VA) medical center. STUDY DESIGN: Retrospective review of administrative data. For 1 performance measure (beta-blocker treatment after a heart attack), a medical record review was performed for purposes of data validation. METHODS: The eligibility criteria differed by the performance measure. Eligible populations for the first, second, and third performance measures, respectively, were: (1) patients aged 35 years or older who were hospitalized and discharged alive with a primary diagnosis of acute myocardial infarction in calendar year 1996; (2) patients hospitalized for treatment of selected mental health disorders in fiscal year 1997; and (3) female patients aged 21 to 64 years enrolled in VA primary care clinics during fiscal years 1995-1997. We collected data in accordance with HEDIS 3.0 specifications for administrative data. RESULTS: With few or no modifications to the HEDIS specifications, we successfully adapted the HEDIS performance measures to the VA setting. We found that, in some areas, VA performance compared favorably to or exceeded that of the private sector. We also identified opportunities for quality improvement. CONCLUSIONS: HEDIS performance measures can be applied within the VA system, both as a means of quantifying performance and as a tool for improving the quality of care. Adopting HEDIS measures would provide additional value to VA medical centers by allowing them to compare their performance with that of private-sector providers

Therapeutic substitution of cimetidine for nizatidine was not associated with an increase in healthcare utilization.

OBJECTIVE: To examine changes in healthcare utilization resulting from a formulary switch to cimetidine from nizatidine at the Veterans Affairs Pittsburgh Healthcare System. STUDY DESIGN: A retrospective analysis of administrative and clinical data 6 months before and 6 months after the therapeutic substitution. METHODS: The 704 patients who were switched from nizatidine to cimetidine were included in the study. Administrative data included total and primary care clinic visits, emergency room visits, gastrointestinal (GI)-related radiological studies, and GI endoscopic procedures. Discharge summaries were examined, and rates of total and GI-related hospitalizations were calculated. RESULTS: There was no evidence of increased utilization of healthcare resources during the 6 months after the formulary switch. Estimated monthly pharmaceutical savings for the Veterans Affairs Pittsburgh Healthcare System were $7260. CONCLUSIONS: A formulary switch from nizatidine to cimetidine can be accomplished at significant pharmaceutical cost savings, and this retrospective study suggests that this can be done without increasing other aspects of healthcare resource utilization

Effect of panel composition on physician ratings of appropriateness of abdominal aortic aneurysm surgery: elucidating differences between multispecialty panel results and specialty society recommendations.

OBJECTIVE: To investigate how the composition of multispecialty physician panels is associated with both the summary ratings assigned by such panels and the agreement of such panels with the recommendations of specialty societies. DATA SOURCES/STUDY SETTING: We examined the final ratings assigned by a nine-member multispecialty RAND Corporation physician panel regarding indications for abdominal aortic aneurysm surgery and the recommendations of a specialty society representing vascular surgeons who perform the same surgery. STUDY DESIGN: The panel was retrospectively divided into two sub-panels, one composed of the three vascular surgeons on the panel and the other composed of the six remaining physicians. We analyzed the two sub-panels\u27 rating patterns with respect to each other and with respect to concurrent guidelines generated by the Joint Council of the Society of Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery. PRINCIPAL FINDINGS: Of the 782 indications considered by the panel for appropriateness, the vascular surgeons had an average of mean ratings for appropriateness of 5.1, significantly higher than the 4.5 average of the other physicians. Across the 221 indications considered by the panel for necessity, the vascular surgeons had an average of mean necessity ratings of 6.8, significantly higher than the 5.8 average of the other physicians. The vascular surgeons\u27 rankings of agreement with the guidelines of the Joint Council were significantly higher than those of the physician panelists from other specialties. CONCLUSIONS: statements of clinical appropriateness and necessity produced by summarizing ratings assigned to indications by expert panel members may disguise marked underlying disagreements among well-defined groups of practitioners within these panels. In the case of abdominal aortic aneurysm management, these disagreements within the RAND panel explain the marked discrepancy between the RAND multidisciplinary panel ratings and the recommendations issued by vascular surgeon professional societies

Implementation and Evaluation of a Low Health Literacy and Culturally Sensitive Diabetes Education Program

Low health literacy is more prevalent in persons with limited education, members of ethnic minorities, and those who speak English as a second language, and is associated with multiple adverse diabetes-related health outcomes. This study examined the effectiveness of a low health literacy and culturally sensitive diabetes education program for economically and socially disadvantaged adult patients with type 2 diabetes. A pre-post prospective study design was used to examine outcomes over 12 months. Outcome measures included diabetes knowledge, self-efficacy, and self-care, measured using reliable and valid survey tools, and A1C. Over this period of time 277 patients were enrolled in the program, with 106 participants completing survey data. At the completion of the program patients had significant improvements in diabetes knowledge (p \u3c .001), self-efficacy (p \u3c .001), and three domains of self-care including diet (p \u3c .001), foot care (p \u3c .001), and exercise (p \u3c .001). There were no significant improvements in the frequency of blood glucose testing (p = .345). Additionally, A1C values significantly improved 3 months after completing the program (p = .007). In conclusion, a diabetes education program designed to be culturally sensitive and meet the needs of individuals with low health literacy improves short-term outcomes. (© 2013 National Association for Healthcare Quality.

Management strategies for Helicobacter pylori-seropositive patients with dyspepsia: clinical and economic consequences.

BACKGROUND: Noninvasive testing for Helicobacter pylori is widely available and has been considered as an initial management strategy for uninvestigated dyspepsia. However, data to guide clinicians in the management of patients with dyspepsia who are seropositive for H. pylori are lacking. OBJECTIVE: To examine the economic, clinical, and policy implications of alternative initial management strategies for patients with uninvestigated dyspepsia who are seropositive for H. pylori. DESIGN: Decision analysis comparing the costs and outcomes of initial anti-H. pylori therapy and initial endoscopy. PATIENTS: Helicobacter pylori-seropositive patients with dyspepsia. MEASUREMENTS: Cost estimates were obtained from the Medicare reimbursement schedule and a health maintenance organization pharmacy. Probability estimates were derived from the medical literature. RESULTS: Initial endoscopy costs an average of $1276 per patient, whereas initial anti-H, pylori therapy costs$820 per patient; the average saving is $456 per patient treated. The financial effect of a 252% increase in the use of antibiotics for initial H. pylori therapy is more than offset by reducing the endoscopy workload by 53%. Endoscopy-related costs must be reduced by 96% before the two strategies become equally cost-effective. In patients with nonulcer dyspepsia, the financial benefits of initial anti-H. pylori therapy are not substantially affected by varying the rates of H. pylori eradication, the complications of antibiotics, or the response of symptoms to cure of H. pylori infection. CONCLUSIONS: In H. pylori-seropositive patients with dyspepsia, initial anti-H. pylori therapy is the most cost, effective management strategy. Randomized studies of these strategies that evaluate outcomes and patient preferences are needed to optimize management decisions. In the meantime, unless physicians are concerned about resistance to antimicrobial agents or the lack of proven benefit of anti-H. pylori therapy in nonucler dyspepsia, the strategy outlined in this analysis can be used as a basis for management and policy decisions about H. pylori-seropositive patients with dyspepsia