Achieving the Potential of Health Care Performance Measures: Timely Analysis of Immediate Health Policy issues

The United States is on the cusp of a new era, with greater demand for performance information, greater data availability, and a greater willingness to integrate performance information into public policy. This era has immense promise to deliver a learning health care system that encourages collaborative improvements in systems-based care, improves accountability, helps consumers make important choices, and improves quality at an acceptable cost. However, to curtail the possibility of unintended adverse consequences, it is important that we invest in developing sound measures, understand quality measures' strengths and limitations, study the science of quality measurement, and reduce inaccurate inferences about provider performance

Aspirin, beta-blocker, and angiotensin-converting enzyme inhibitor therapy in patients with end-stage renal disease and an acute myocardial infarction

AbstractObjectivesWe sought to examine the use and impact of standard medical therapies in patients with end-stage renal disease (ESRD) faced with an acute myocardial infarction (AMI).BackgroundThe poor prognosis of patients in this high-risk population has become increasingly well recognized.MethodsUsing the ESRD database and the Cooperative Cardiovascular Project (CCP) database, we identified AMI patients who were receiving either peritoneal dialysis or hemodialysis before admission. The early administration of aspirin and beta-blockers was compared between ESRD and non-ESRD patients and the effect of these therapies on 30-day mortality was evaluated with logistic regression models.ResultsThe cohort consisted of 145,740 patients without ESRD and 1,025 patients with ESRD. Aspirin (67.0% vs. 82.4%, p < 0.001), beta-blockers (43.2% vs. 50.8%, p < 0.001), and angiotensin-converting enzyme (ACE) inhibitors (38.5% vs. 60.3%, p < 0.001) were less likely to be administered to ESRD patients than to non-ESRD patients. The benefit of these therapies on 30-day mortality was similar among ESRD patients (aspirin: relative risk [RR] 0.64; 95% confidence interval [CI] 0.50 to 0.80; beta-blocker: RR 0.78; 95% CI 0.60 to 0.99; ACE inhibitor: RR 0.58; 95% CI 0.42 to 0.77) and non-ESRD patients (aspirin: RR 0.57; 95% CI 0.55 to 0.58; beta-blocker: RR 0.70; 95% CI 0.68 to 0.72; ACE inhibitor: RR 0.64; 95% CI 0.63 to 0.66).ConclusionsEnd-stage renal disease patients are far less likely than non-ESRD patients to be treated with aspirin, beta-blockers, and ACE inhibitors during an admission for AMI. The lower rates of usage for these medications, particularly aspirin, may contribute to the increased 30-day mortality. These findings demonstrate a marked opportunity to improve care in this population

Blueprint for the Dissemination of Evidence-Based Practices in Health Care

Proposes strategies for better dissemination of best practices through quality improvement campaigns, including campaigns aligned with adopting organizations' goals, practical implementation tools and guides, and networks to foster learning opportunities

Trends in Intracranial Stenting Among Medicare Beneficiaries in the United States, 2006–2010

Background: It is uncertain how intracranial stenting (ICS) has been adopted nationally during a period characterized by a restrictive payment policy by the Centers for Medicare & Medicaid Services, humanitarian device exemption approval by the Food and Drug Administration, and insufficient evidence of effectiveness. We sought to determine the trends in rates of ICS use and associated outcomes in the United States. Methods and Results: From 65 211 328 Medicare Fee‐for‐Service beneficiaries hospitalized between 2006 and 2010 in acute care hospitals in the United States, we included patients with ICD‐9‐CM procedure codes for intracranial angioplasty and stenting, excluding those with a principal discharge diagnosis code of cerebral aneurysm or subarachnoid hemorrhage. We report operative rates per 1 000 000 person‐years and outcomes including 30‐day and 1‐year mortality rates. There were 838 ICS procedures performed among Fee‐for‐Service beneficiaries. The overall hospitalization rate for ICS increased significantly from ≈1 per 1 000 000 person‐years (n=35 procedures) in 2006 to 9 per 1 000 000 person‐years (n=258 procedures) in 2010 (P=0.0090 for trend). Procedure rates were higher in men than in women, and were highest among patients aged 75 to 84 years and lowest among those ≥85 years. The 30‐day mortality rate increased from 2.9% (95% CI, 0.1 to 15.3) to 12.9% (95% CI, 9.0 to 17.6), P=0.1294 for trend, and the 1‐year mortality rate increased from 14.7% (95% CI, 5.0 to 31.1) to 19.5% (95% CI, 14.9 to 24.9), P=0.0101; however, the annual changes were not significant after adjustment. Conclusions: ICS utilization in the United States has modestly increased during a period of inadequate supportive evidence. Humanitarian device exemption and a restrictive payment policy appear to have caused slow adoption of the technology

Investigation of 89 candidate gene variants for effects on all-cause mortality following acute coronary syndrome

BACKGROUND: Many candidate genes have been reported to be risk factors for acute coronary syndrome (ACS), but their impact on clinical prognosis following ACS is unknown. METHODS: We examined the association of putative genetic risk factors with 3-year post-ACS mortality in 811 ACS survivors at university-affiliated hospitals in Kansas City, Missouri. Through a systematic literature search, we first identified genetic variants reported as susceptibility factors for atherosclerosis or ACS. Restricting our analysis to whites, so as to avoid confounding from racial admixture, we genotyped ACS cases for 89 genetic variants in 72 genes, and performed individual Kaplan-Meier survival analyses. We then performed Cox regression to create multivariate risk prediction models that further minimized potential confounding. RESULTS: Of 89 variants tested, 16 were potentially associated with mortality (P < 0.1 for all), of which 6 were significantly associated (P < 0.05) with mortality following ACS. While these findings are not more than what would be expected by chance (P = 0.28), even after Bonferroni correction and adjustment for traditional cardiac risk factors, the IRS1 972Arg variant association (P = 0.001) retained borderline statistical significance (P < 0.1). CONCLUSION: With the possible exception of IRS1, we conclude that multiple candidate genes were not associated with post-ACS mortality in our patient cohort. Because of power limitations, the 16 gene variants with P values < 0.1 may warrant further study. Our data do not support the hypothesis that the remaining 73 genes have substantial, clinically significant association with mortality after an ACS

Trends in Drug Utilization, Glycemic Control, and Rates of Severe Hypoglycemia, 2006-2013.

ObjectiveTo examine temporal trends in utilization of glucose-lowering medications, glycemic control, and rate of severe hypoglycemia among patients with type 2 diabetes (T2DM).Research design and methodsUsing claims data from 1.66 million privately insured and Medicare Advantage patients with T2DM from 2006 to 2013, we estimated the annual 1) age- and sex-standardized proportion of patients who filled each class of agents; 2) age-, sex-, race-, and region-standardized proportion with hemoglobin A1c (HbA1c) &lt;6%, 6 to &lt;7%, 7 to &lt;8%, 8 to &lt;9%, ≥9%; and 3) age- and sex-standardized rate of severe hypoglycemia among those using medications. Proportions were calculated overall and stratified by age-group (18-44, 45-64, 65-74, and ≥75 years) and number of chronic comorbidities (zero, one, and two or more).ResultsFrom 2006 to 2013, use increased for metformin (from 47.6 to 53.5%), dipeptidyl peptidase 4 inhibitors (0.5 to 14.9%), and insulin (17.1 to 23.0%) but declined for sulfonylureas (38.8 to 30.8%) and thiazolidinediones (28.5 to 5.6%; all P &lt; 0.001). The proportion of patients with HbA1c &lt;7% declined (from 56.4 to 54.2%; P &lt; 0.001) and with HbA1c ≥9% increased (9.9 to 12.2%; P &lt; 0.001). Glycemic control varied by age and was poor among 23.3% of the youngest and 6.3% of the oldest patients in 2013. The overall rate of severe hypoglycemia remained the same (1.3 per 100 person-years; P = 0.72), declined modestly among the oldest patients (from 2.9 to 2.3; P &lt; 0.001), and remained high among those with two or more comorbidities (3.2 to 3.5; P = 0.36).ConclusionsDuring the recent 8-year period, the use of glucose-lowering drugs has changed dramatically among patients with T2DM. Overall glycemic control has not improved and remains poor among nearly a quarter of the youngest patients. The overall rate of severe hypoglycemia remains largely unchanged