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Center for Quality of Care Research Selected Projects

Implementation and Outcomes of Noninvasive Ventilation in COPD

PI: Peter Lindenauer, MD, MSc

For the roughly 500,000 individuals hospitalized each year in the US for exacerbations of chronic obstructive pulmonary disease, the discovery of noninvasive forms of mechanical ventilation in the 1990s represented a treatment breakthrough that offered an alternative to being placed on an invasive mechanical ventilator in the intensive care unit, where the risks of prolonged hospitalization, complications, and death are substantial. Yet nearly a decade after its discovery, little is known about the use or outcomes of noninvasive ventilation in routine clinical setting, and if the experience of other biomedical innovations holds true, there are reasons to be concerned that translation of these research findings into day-to-day practice may be occurring slowly and unevenly. Through statistical analyses of records from a representative sample of more than 600 US hospitals, and through interviews and surveys with a diverse set of hospital personnel, we will close the gap in our understanding of the adoption of noninvasive ventilation in the US, and will identify effective strategies that can help speed the implementation process.

Contextual Factors Associated with Implementation Effectiveness within a QI Collaborative

PI: Peter Lindenauer, MD, MSc

A common approach for improving the quality and safety of hospital care in the United States involves bringing teams of doctors and nurses together from different hospitals to work collaboratively towards a common improvement goal. While the concept makes sense, quality improvement collaboratives are costly to run, and evidence of their benefit is limited. More importantly, little is known about why, within the same collaborative, some hospitals are more successful than others. Through surveys of senior hospital leaders and quality improvement staff, this study will examine how perceptions of new clinical practices, together with other hospital factors, contribute to successful implementation efforts. Additionally, this study will evaluate the effects of a large quality improvement collaborative focused on reducing hospital complication and death rates.
Funding: AHRQ

IDEAS for a Healthy Baby: Reducing Disparities in Consumer Use of Quality Data

PI: Sarah Goff, MD

Efforts to increase transparency of healthcare quality data are guided in part by the belief that access to these data will enable consumers to make more informed healthcare choices. Although the amount of quality of care information made available to consumers through websites and other channels has grown tremendously, impact on consumer choices remains low. Barriers to using these data, which may contribute to the low impact, include limited knowledge of the existence of public reporting websites and the challenge of interpreting the complex information the websites present. Patient navigators are healthcare workers who assist patients in ‘navigating’ the complex healthcare system and at the same time ‘activate’ patients to participate in management of their own healthcare. The objective of this randomized controlled trial, “IDEAS for a Healthy Baby” is to evaluate the efficacy of in-person sessions with a patient navigator that are designed to increase the impact of publicly reported quality information on the choice of pediatrician amongst low income women during pregnancy.
Funding: AHRQ

The Impact of Transfer Status on Mortality Measurement

PIs: Evan Benjamin, MD and Peter Lindenauer, MD, MSc

This study is seeking to determine if current methods of measuring hospital mortality account for the issue of the complexity of transferred patients to tertiary hospitals.
Funding: AAMC

Validation of the Premier Harm Index

PI: Evan Benjamin, MD

This study seeks to validate an administrative measure of harm for benchmarking hospital patient safety. Using the hospitals in the Premier QUEST project, we will validate administrative coding of various harm scores against chart review.
Funding: Premier  

Epidemiology and Outcomes of Acute Respiratory Failure in Hospitalized Patients in the United States, 2001 – 2009

PI: Mihaela Stefan, MD

Acute respiratory failure (ARF) is a potential complication of several common medical conditions and the most frequent organ failure in the intensive care unit, but its current epidemiology is not well understood. Using the HCUP Nationwide Inpatient Sample we will perform a national population-based study with time trends of hospitalizations of patients age 18 years and over diagnosed with ARF from 2001 to 2009. 
Funding: Charlton grant from Tufts University School of Medicine

Hospital Leaders’ Views on the Public Reporting of Health Care Quality

PI: Peter Lindenauer, MD, MSc

Public reporting of health care quality is a strategy to improve the quality of health care and to empower patients to make more informed health care choices. Providing information about quality is believed to stimulate improvement activity by appealing directly to the professionalism of clinicians and hospital administrative leaders, and indirectly through the risk that patients might use the data to choose between providers. Despite the dramatic growth of public reporting programs over the past 2 decades, evidence that these efforts have resulted in improved quality or better outcomes is limited. Despite the growth of public reporting programs little is known about the views of hospital based physicians or hospital administrative leaders about the value of current publicly reported measures of hospital quality, or about how they use these measures at their hospitals. We intend to conduct a survey of hospital administrative leaders to assess their views and use of current measures that can be found on the CMS Hospital Compare Website.

Dyspnea in Hospitalized Patients - Recognition, Management, and Outcomes

PI: Mihaela Stefan, MD

Dyspnea is one of the main reason patients seek medical help and relief of breathlessness is central to the management of cardiopulmonary diseases. The goals of the study are to investigate how well health care professionals assess and document dyspnea among hospitalized patients with cardiopulmonary diseases, how much improvement in this symptom is achieved from admission to discharge and to assess the level of agreement between physicians and patients in rating of dyspnea.

Differences in Obstetric Hand-off Quality Based on Time of Day and Day of Week

Co-PI: Sarah Goff, MD

In this study, we are seeking to determine variation in hand-off quality during admissions for labor and delivery. Using ACOG guidelines to measure quality, we are comparing AM and PM hand-offs and weekday versus weekend for attending physicians, residents, nurses and nurse-midwives.

Quality of Care and Outcomes of Healthcare-Associated Pneumonia

PI: Michael Rothberg, MD, MPH

This study will provide important insight into a clinical dilemma faced by physicians who care for as many as 300,000 patients each year with Healthcare-Associated pneumonia (HCAP). This study will assess whether patients with HCAP are receiving care consistent with the recommendations found in guidelines developed by the American Thoracic Society and the Infectious Disease Society of America, and whether those treated according to the guidelines have better outcomes than patients who are treated with other antibiotics. These results will help clinicians balance the potential benefits of the recommended antibiotics against the potential harms of antibiotic side effects, future antibiotic resistance, and increased costs. If recommended therapy is beneficial but underutilized, these results will alert quality improvement officers and policy makers to an important opportunity to improve patient care for a common and deadly illness.
Funding: AHRQ

Completed Projects

Access to Subspecialty Care for Patients in Wheelchairs

PI: Tara Lagu, MD, MPH

According to the Americans with Disabilities Act (ADA), all medical providers are required to provide “full and equal access to their healthcare services and their facilities.” If a person with a disability requires services from a physician, reasonable modifications must be made to accommodate that patient if that patient would otherwise receive services from that practice. However, we have observed that many physician practices routinely deny care to disabled patients who would otherwise receive care in that practice. The literature supports the hypothesis that patients who use wheelchairs appear to have diminished access to care. However, there has been no study that attempted to quantify or characterize this lack of access. We propose to conduct the first study to describe the access to subspecialists in the US for patients who use wheelchairs. We hypothesize that there is very limited access to subspecialty outpatient care for people with mobility disabilities.

The Effectiveness of Antibiotics and Steroids in Patients Hospitalized for Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD)

PI: Peter Lindenauer, MD, MSc

In collaboration with the Division of Infectious Disease at Baystate Medical Center, we examined the effects of antibiotic therapy on the outcomes of patients hospitalized for acute exacerbations of COPD. In a related project, we studied the comparative effectiveness of orally and intravenously administered corticosteroids. We previously reported that the vast majority of hospitalized patients are initially treated with intravenously administered steroids despite the fact that current guidelines suggest that oral therapy is equally effective, less expensive, and may be associated with fewer complications.

Patients’ Evaluations of Health Care Providers in the Era of Social Networking: An Analysis of Physician-rating Websites

PI: Tara Lagu, MD, MPH

In the first study of its kind, Dr. Lagu sought to describe the structure and content of physician-rating websites in the United States, evaluating 33 websites and 300 Boston physicians. Dr. Lagu is continuing her research on the public reporting of patient opinions and expanding her approach to include reviews of hospitals, a wider geographic area, and qualitative analysis.

VTE Prophylaxis in Hospitalized Medical Patients

PI: Michael Rothberg, MD, MPH

We are performing a comprehensive analysis of patient risk, physician prescribing, and outcomes for medical patients at high risk for venous thromboembolism at 400 US hospitals. Specific projects include developing a risk prediction model for developing VTE; describing patient, physician and system factors associated with VTE prophylaxis; and examining the comparative effectiveness and cost-effectiveness of low molecular weight and unfractionated heparins. This project is funded by a grant from the Doris Duke Foundation.

Variation in Treatment and Outcomes in Sepsis

PI: Tara Lagu, MD, MPH

Working with faculty from the Critical Care Division at Baystate Medical Center, we are studying the care and outcomes of more than 200,000 patients hospitalized for the treatment of sepsis. Our work is focused on describing variations in treatment patterns and outcomes across hospitals, examining the effectiveness of common therapies, and exploring the relationship between cost and outcomes of care. In future studies, we hope to identify hospital characteristics and processes associated with high-value sepsis care.

Readmission and Hospital Quality

PI: Mihaela Stefan, MD

Readmission of patients following hospital discharge is a clinically important, expensive, and often preventable adverse outcome. Working with colleagues at the Oklahoma Foundation for Medical Quality, we are using Medicare claims files and patient-level data from Medicare's Hospital Compare database to study the relationship between existing quality measures and risk-adjusted hospital readmission rates for pneumonia, heart failure, and myocardial infarction. This project is supported by a grant from the Baystate Medical Center Incubator Fund and is part of a larger effort to examine the effects of public reporting on readmission rates.

The Effectiveness and Safety of Beta Blockers in Patients Admitted with Acute COPD Exacerbations

PI: Mihaela Stefan, MD

In this study, we are examining the effects of beta-blocker therapy on outcomes of patients admitted with an acute COPD exacerbation with coexistent hypertension, ischemic heart disease, or heart failure.
Funding: CTSI/Tufts Award

Hospital Spending and Mortality in Sepsis

PI: Tara Lagu, MD, MPH

Previous research has documented striking variations in the care and outcomes of patients across geographic regions of the United States and the world, but until now little was known about hospital-level differences in the care and outcomes of sepsis patients. In this issue of the Archives, Lagu and colleagues report that, for sepsis patients, there were significant variations in hospital-level spending and mortality rate across of a nationwide sample of 309 hospitals, but higher spending did not improve outcomes. A subset of sampled hospitals consistently achieved better-than-expected mortality rates at lower-than-expected costs, and further study of the strategies of these hospitals may help to identify potential opportunities to improve the value of sepsis care.

Improving Women’s Health by Identifying Factors Associated with Risk-adjusted Obstetric Complications

PI: Sarah Goff, MD

In this study, we are using Premier's Perspective database to describe risk-adjusted variation in hospital level rates for three common obstetric complications, trauma infection, and hemorrhage. We will also describe the relationship between cost of uncomplicated deliveries and hospital complication rates and begin to assess organizational strategies used by hospitals with lower complication rates.

Informed Consent for PCI: What are Cardiologists Saying?

PI: Michael Rothberg, MD, MPH; Co-I: Sarah Goff, MD

This mixed methods study assesses how often cardiologists meet guidelines for providing informed consent for PCI using transcripts of patient encounters with cardiologists and qualitatively explores the content of these discussions.

A Mixed-Methods Analysis of Patient Reviews of Hospital Care in England: Implications for Public Reporting of Health Care Quality Data in the US

PI: Tara Lagu, MD, MPH

The National Health Service (NHS) in the England encourages patients to provide feedback to hospitals on their quality reporting website, NHS Choices. In this cross-sectional mixed-methods analysis, we aim to describe the scope and content of narrative feedback on NHS Choices. We will conduct further qualitative and quantitative analysis of patients’ reviews of randomly selected hospitals.