Published in the September 2006 issue of Today’s Hospitalist
When Peter K. Lindenauer, MD, decided to examine how U.S. hospitals care for patients with chronic obstructive pulmonary disease (COPD), he fully expected to find that not all physicians were following the well-established evidence. While a large body of research has found tremendous treatment variation in U.S. health care, Dr. Lindenauer and his colleagues didn’t expect COPD care to be any different.
What they were not prepared for, however, was just how much COPD care varies across different hospitals. Their study, which appeared in the June 20, 2006, Annals of Internal Medicine, found that in some hospitals, only 10 percent of COPD patients receive care that follows national recommendations. While that figure jumped to 66 percent at some facilities, Dr. Lindenauer found the degree of variation troubling because COPD guidelines have been around for nearly 20 years and have been remarkably consistent in their recommendations.
Dr. Lindenauer, lead author of the Annals article and a hospitalist and quality improvement specialist at Baystate Medical Center in Springfield, Mass., says those data provide a sobering commentary not only on the state of inpatient COPD care, but on the state of the quality improvement movement.
If COPD, which is a leading cause of death and hospitalization in this country, can be left behind in the current wave of pay-for-performance programs, Dr. Lindenauer wonders, what does that say about hospitals’ ability to “or interest in “improving care for less common diseases?
Who is receiving ideal care?
Dr. Lindenauer’s team began by reviewing the records of 70,000 patients in 360 hospitals across the country who had been hospitalized in 2001 for acute exacerbations of COPD.
They then put patients into one of three groups: those who received measures recommended by guidelines from several national societies; those who received care that the guidelines recommended against, or non-recommended care; and those who received ideal care. That last category refers to patients who not only received guideline-recommended care, but also did not receive non-recommended care.
What exactly qualifies as recommended care? According to the guidelines, the category includes chest radiography, supplemental oxygen, bronchodilator therapy, systemic corticosteroid therapy and antibiotic treatment. Non-recommended care includes sputum examination, acute spirometry, chest physiotherapy, and therapy with methylxanthine bronchodilator or mucolytic agents.
The study found that only 33 percent of patients received ideal care. By comparison, 66 percent received recommended care, and 45 percent received at least one non-recommended measure.
Surprising levels of variation
For Dr. Lindenauer, the study’s biggest surprise was the nature of the variation that researchers found. When it came to a core group of therapies recommended by practice guidelines, the good news was that virtually all patients in all the hospitals received a chest X-ray, supplemental oxygen and a bronchodilator.
But there were significant levels of variation for some of the other recommended measures. While the guidelines consider steroids a must for nearly every patient, Dr. Lindenauer’s team found that a surprisingly low 85 percent of patients received steroids. That figure plunged to 70 percent in some hospitals.
And when it came to measures that got a thumbs-down from guidelines “typically because they offered no benefit, harmed patients or had no evidence behind them “there was even wider variation in practice patterns. More than 20 percent of patients received methylxanthine bronchodilator therapy, for example. While some hospitals ordered it for none of their patients, others gave it to nearly half the patients they treated for COPD exacerbations.
The study likewise found that 14 percent of patients received a sputum evaluation, which is not recommended by the guidelines. Hospital variation for that therapy ranged from 5 percent to 60 percent of patients.
Where can you get better care?
While the data show a startling level of practice variation in COPD care, they don’t tell the whole story.
Researchers have previously found that factors like patient volume and hospital size sometimes give hospitals an edge when it comes to quality. But Dr. Lindenauer says that simply wasn’t the case with COPD. That makes it difficult to predict which hospital was likely to give patients ideal COPD care.
“It’s not that hospitals that take care of a lot of patients with COPD are knocking the ball out of the park, which is an interesting finding,” Dr. Lindenauer explains. “For a common problem like COPD, whether you seek care at a low-volume institution or a high-volume institution, whether you travel to a large academic medical center or a small community hospital, you can expect a similar level of quality.”
The study did reveal some trends, however. Women and patients older than 75, for example, were the most likely to have received ideal care. Researchers say that was largely due to the fact that these COPD patients were less likely to receive non-recommended measures.
Older patients were less likely to receive any treatment, either recommended or non-recommended. And black patients were the least likely of all to receive ideal care, probably because they were admitted to hospitals with poor performance rates.
Are quality measures “scalable”?
While the study exposes big gaps in the COPD care that hospitals deliver, Dr. Lindenauer says the data raise an even bigger question: Will hospitals be able to expand the scope of their quality improvement programs to focus on multiple conditions?
While hospitals are busy improving the quality of their pneumonia and cardiac care, Dr. Lindenauer wonders whether they can continue to add more and more conditions to their list of quality improvement targets. It’s a key question, he says, because groups like the National Quality Forum and Medicare are creating programs that give bonuses to hospitals based on their ability to meet quality measures.
“We are going to have increasing numbers of measures of hospital quality over time,” he says, “so we need to come up with different approaches to doing quality improvement in patient safety work. But the question is how we can scale quality improvement to address a greater number of measures, and with a stable number of personnel.”
In many ways, Dr. Lindenauer sees COPD as a perfect example of the challenges that hospitals will face in expanding their quality-improvement efforts beyond a few core measures. And so far, he says, the results have been less than impressive.
Why public reporting matters
He recalls that back in 1999, he pulled together a multidisciplinary team to create an electronic order set for COPD exacerbation patients. While everyone at that time was focused on building measures for pneumonia, he figured that work would be completed in a few years and attention would shift to another prominent condition, like COPD. “Little did I know that we would still be focusing on pneumonia in 2006,” Dr. Lindenauer explains.
Even more disturbing is the fact that, despite the availability of national guidelines, “COPD has not received anywhere near the kind of attention that pneumonia care has received by quality improvement programs, in large part because nobody has asked hospitals to publicly report the data. There is no pay for performance for COPD. There are no managed care companies asking about it.”
And while he may have some doubts about how far the current wave of public reporting programs can push hospitals to improve quality for a growing list of conditions, Dr. Lindenauer still thinks they are American medicine’s best shot. As his study shows, merely publishing guidelines “even over a 20-year period “is simply not enough to bring about change.
“You need measurement and feedback about performance,” he explains. “And you need public reporting to grab the attention of the senior leadership of hospitals to garner some of the resources needed to carry this work on.”
Deborah Gesensway is a freelance writer who reports on U.S. health care from Toronto, Canada.