Wednesday, May 7, 2014

New HHS data show quality improvements saved 15,000 lives and $4 billion in health spending

May 7, 2014
Contact: HHS Press Office
(202) 690-6343

Hospital Readmissions Fall by 8 percent among Medicare beneficiaries
Today, the Department of Health and Human Services announced that new preliminary data show an overall nine percent decrease in hospital acquired conditions nationally during 2011 and 2012.  National reductions in adverse drug events, falls, infections, and other forms of hospital-induced harm are estimated to have prevented nearly 15,000 deaths in hospitals, avoided 560,000 patient injuries, and approximately $4 billion in health spending over the same period.
The Affordable Care Act is also helping reduce hospital readmissions.  After holding constant at 19 percent from 2007 to 2011 and decreasing to 18.5 percent in 2012, the Medicare all-cause 30-day readmission rate has further decreased to approximately 17.5 percent in 2013.  This translates into an 8 percent reduction in the rate and an estimated 150,000 fewer hospital readmissions among Medicare beneficiaries between January 2012 and December 2013. 
“We applaud the nationwide network of hospital systems and providers that are working together to save lives and reduce costs,” said HHS Secretary Kathleen Sebelius.  “We are seeing a simultaneous reduction in hospital readmissions and injuries, giving patients confidence that they are receiving the best possible care and lowering their risk of having to be readmitted to the hospital after they get the care they need.”
These improvements reflect policies and an unprecedented public-private collaboration made possible by the Affordable Care Act.  The data demonstrates that hospitals and providers across the country are achieving reductions in hospital-induced harm experienced by patients.  These major strides in patient safety are a result of strong, diverse public-private partnerships and active engagement by patients and families, including efforts from the federal Partnership for Patients initiative and Hospital Engagement Networks, Quality Improvement Organizations, the Centers for Medicare & Medicaid Services, the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, the Administration on Community Living, the Indian Health Services , and many others.  
The public-private partnerships are working collaboratively – along with health care providers – to identify and spread best practices and solutions to reducing hospital acquired conditions and readmissions.
HHS will continue to accelerate delivery system reform efforts by working with nationwide partners to capitalize on these promising results so that the nation continues on the path of increasing patient safety and reducing health care costs while providing the best, safest possible care to patients.  

Socioeconomic factors may make Medicare’s hospital readmissions data more useful

Barnes-Jewish Hospital
By Diane Duke Williams
Some hospitals facing financial penalties from Medicare for readmitting too many patients soon after discharge have said they are being unfairly penalized. Hospitals that treat a large number of patients with limited income and education are more likely to face such penalties.
A new study shows that if socioeconomic factors related to patients’ income and education are taken into account, differences in readmission rates among hospitals may not be as great as Medicare data indicate. Those factors were gleaned from census data.
The study, published today in the May issue of the journal Health Affairs, was conducted by researchers at Washington University School of Medicine in St. Louis and BJC HealthCare. BJC operates Barnes-Jewish andSt. Louis Children’s hospitals, which are staffed by Washington University physicians.
“We still need to better understand which social factors contribute to patients being readmitted,” said senior author William C. Dunagan, MD, professor of medicine and vice president of quality for BJC. “But we think models that do not include social factors deprive hospitals of valuable data that will help them determine how to use limited resources to help the most vulnerable patients.”
The formula Medicare uses to calculate readmission rates and levy fines against hospitals does not include socioeconomic factors, which can affect patients’ health after they leave the hospital. Poorer patients may not be able to afford prescription medicines or have transportation to doctors’ offices for follow-up care. Patients with limited education may have a hard time understanding hospitals’ instructions for care at home.
Hospitals are paying a lot of attention to their readmission rates, which are being used by the federal government as a measure of hospital performance. In October 2012, Medicare began reducing payments to hospitals that have a higher than average share of patients who return within a month of being treated and discharged.
A concern is that not adjusting readmissions data for poverty or other socioeconomic factors could mislead the public into thinking that hospitals with a large share of disadvantaged patients provide lower-quality care than hospitals with more affluent patients.
For the current study, first author Elna Nagasako, MD, PhD, and her colleagues looked at hospital readmissions for nearly 60,000 patients treated for heart attacks, heart failure or pneumonia at acute care hospitals in Missouri from 2009 to 2012.
They compared two different models for calculating hospital readmission rates within 30 days of discharge. One is the same model used by the Centers for Medicare and Medicaid Services. The other is a similar model that adds socioeconomic information drawn from census tract data. That model linked a patient’s most recent address to poverty rate, level of educational attainment and housing vacancy rate in the census data. The housing vacancy rate can be a measure of neighborhood stability.
The model that incorporated socioeconomic data substantially narrowed the differences in readmission rates among the hospitals. For example, for patients treated for heart attacks, the model used by Medicare shows that readmission rates for Missouri hospitals ranged from 14 percent to nearly 21 percent.
The model that incorporates socioeconomic data showed a much narrower range of readmissions, 15.3 percent to 17.1 percent.
“A narrower range suggests that socioeconomic factors could explain a substantial portion of the observed differences in hospital readmission rates,” said Nagasako, an instructor of medicine.
The researchers found a similar narrower range of readmissions for patients treated for heart failure or pneumonia.
For heart failure, the Medicare model showed readmissions ranged from 14.5 percent to 28.5 percent, while the other model showed a range of 17.6 percent to 25 percent.
And for pneumonia, the Medicare model pinned hospital readmissions at 11.2 percent to 18.6 percent, compared with 13.4 percent to 17.1 percent for the model that incorporated socioeconomic data.
The study’s results also support the conclusions of an expert panel commissioned by the Obama administration that recommended a closer look at the effects of socioeconomic factors on performance measures. The panel also pointed out that financial penalties levied against hospitals may have the unintended consequence of transferring money away from hospitals that treat large numbers of disadvantaged patients.
Because the study used socioeconomic information from census tract data, which is easily obtained, rather than patients’ actual data on income, education and housing, the study can’t make specific recommendations about which patients are most likely to be readmitted. And, because the study looked only at Missouri hospitals, it is not known whether these findings extend to other areas of the country.
Rather, given the debate over whether Medicare should include socioeconomic factors in its formula to calculate hospital readmissions, the study raises questions about whether Medicare’s readmission rates reflect social factors related to the hospital’s patient mix as well as hospital performance and quality.
“We want to make sure that all patients, regardless of their social circumstances, receive the support they need after they are discharged,” Nagasako said. “For some patients, this may prevent returning to the hospital, but for others, the best support may mean being readmitted to the hospital for care. So, in addition to tracking the readmission rates themselves, we also need to better understand why patients return.”

Health Law Requires Medicare To Cover Dementia Evaluation

MAY 06, 2014
For the millions of seniors who worry that losing their keys may mean they’re losing their minds, the health law now requires Medicare to cover a screening for cognitive impairment during an annual wellness visit.
But in a recent review of the scientific research, an influential group said there wasn’t enough evidence to recommend dementia screening for asymptomatic people over age 65.
What’s a worried senior to think?
Dementia screening tests are typically short questionnaires that assess such things as memory, attention and language and/or visuospatial skills. One of the most common, the mini-mental state examination, consists of 30 questions (such as “What month is this?” and “What country are we in?”) and may be completed in about 10 minutes.
In its review, the U.S. Preventive Services Task Force, an independent panel of medical experts, evaluated the evidence of the benefits, harms and clinical utility of various screening instruments for cognitive impairment. It concluded that the evidence for routine population-based screening was insufficient. While declining to recommend the practice for everyone older than 65, the reviewers noted that some screening tools can be useful in identifying dementia.
“Clinicians need to use their judgment,” says Albert Siu, professor and chair of geriatrics and palliative care at Mount Sinai School of Medicine in New York who was co-vice chair of the task force on dementia screening. “The evidence isn’t clear that there is a net benefit to screening for individuals that are asymptomatic.”
The risk of dementia increases with age: its prevalence is 5 percent in people aged 71 to 79, rising to 37 percent of those older than 90. Mild cognitive impairment has many definitions, but the term generally refers to people whose impairment isn’t severe enough to hamper their ability to manage their daily lives. By some estimates up to 42 percent of people older than 65 have it. Mild cognitive impairment is a warning sign, but it may not progress to Alzheimer’s disease, says Dean Hartley, director of science initiatives at the Alzheimer’s Association.  
Alzheimer’s is the most common form of dementia, accounting for up to 80 percent of cases. Other types include vascular dementia, many cases of Parkinson’s disease and Huntington’s disease.
Someone without symptoms who does poorly on a screening test may have other medical conditions, such as depression or sleep apnea, that can cause memory or other problems, says Hartley. That’s why it’s important that people take the tests in a medical setting with a trained professional who can evaluate them and take a good medical history from patients and their family members, he says.
One-time screenings at shopping malls or health fairs should be avoided, experts agree. Taking a quick test without any accompanying medical evaluation may raise more questions than it answers.
But seniors may want to consider having an evaluation for cognitive impairment as part of their annual wellness visit with their health provider. It is covered with no out-of-pocket charge.
The Alzheimer’s Association recommends seniors undergo cognitive impairment screening and evaluation to establish a baseline for comparison, and then have regular follow-up assessments in subsequent years.
There is no cure for Alzheimer’s disease. Some drugs, such as Aricept, may improve memory or other symptoms temporarily, but no medical treatment halts or reverses the disease.
That is a key argument against large-scale routine screening of people older than 65, says Ariel Green, a geriatrician at Johns Hopkins Bayview Medical Center. “We don’t have studies that show that such a screening program improves the care of people with dementia,” she says.
Still, if an individual has concerns about dementia because of a family history of Alzheimer’s or memory lapses, for example, a medical professional should evaluate the person and a screening test may be appropriate.
And although research hasn’t yet shown that large-scale screening is effective at improving dementia care overall, screening may help individuals and their families identify a cognitive impairment or dementia early on. The drugs that are available are most effective in the early stages of the disease. In addition, Green says, “it’s helpful for people to hear a diagnosis of dementia, if it’s an accurate diagnosis, because it can help people anticipate their future needs and plan for that.”
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Health watchdog finds 20 services need to improve

Health watchdog, the Care Quality Commission, has criticised 20 areas of care at hospitals in Hull, following inspections in February.
In his first report on the quality of services provided by Hull and East Yorkshire Hospitals NHS Trust, England's Chief Inspector of Hospitals rated both the Hull Royal Infirmary and Castle Hill Hospital at Cottingham as Requiring Improvement.
While end of life care, critical care and maternity and family planning services were rated Good - the inspection concluded that all other services were below required standards.
Inspectors found that both hospitals were facing staff shortages and insufficient capacity to deal with the increasing numbers of admissions.
Staffing levels and skill mix did not always meet national guidance, the report found, although the trust board had agreed to invest in recruiting more nurses, and was in the process of recruiting for doctors' posts.

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At the Hull Royal Infirmary, the accident and emergency department was found not to have enough facilities or staff to deal with the numbers of patients attending. There was a lack of appropriate senior clinicians and the children's accident and emergency department could not provide a dedicated 24-hour service.
In response, the Trust says it was aware of some of the issues raised in the report, and is already actively making improvements.
We welcome the CQC's inspection report as a way of holding a mirror up to the Trust and understanding what works well and where the real pressure points are in the system. The most serious of the findings are clearly the breaches in regulation. We have already developed an action plan to address these, with actions directly assigned to members of the Executive Team to ensure immediate action is taken, and this plan will be monitored regularly by the Trust Board.
Intensified by an increasing demand for hospital care and a population which is living longer, we are very clear that we cannot implement long-term, effective solutions to these challenges alone. Instead, working with local commissioners and providers of health and social care, we must press forward with plans to align all parts of the care system, ensuring patients are able to access hospital care when they need it and then continue their recovery in the safest and most suitable place, which isn't always in hospital.