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PFP demonstration project: how much of a success?

March 2007

Recent analyses of the hospital pay-for-performance demonstration project funded by the Centers for Medicare and Medicaid Services (CMS) come to different conclusions about the project’s effect on the quality of care.

According to the CMS, second-year results of the Hospital Quality Improvement Demonstration project showed that the incentive program spurred “substantial improvement” among the more than 250 participating hospitals. The average second-year improvement across five clinical focus areas, the CMS said, was 6.7%, for total quality-improvement gains of 11.8% for the project’s first two years.

The hospitals performing in the top 10% received a 2% incentive payment, while those in the second 10% received a 1% incentive increase. (Hospitals that score in the bottom 20% for year three will have to return either 1% or 2% of their DRG payments for that year.) Second-year incentives totaled close to $8.7 million, paid out to 115 hospitals.

However, an analysis written by lead author and hospitalist Peter K. Lindenauer, MD, found lower rates of improvement among the project’s participants. In a study published in the Feb. 1, 2007, New England Journal of Medicine, researchers compared the improvement demonstrated by hospitals that participated in both the demonstration project and a CMS program for public reporting of quality data vs. hospitals participating in just the public-reporting program alone.

Researchers found that hospitals in the incentive program “which tended to be larger, more urban and more likely to have housestaff “showed a higher rate of quality improvement. However, that rate of improvement was more modest than that touted in the CMS analysis. The study found that hospitals showed a 2.6% quality increase for composite acute myocardial infarction measures and 4.1% for composite heart failure measures.

Researchers also outlined issues that they said should be resolved before going forward with pay for performance beyond public reporting. They noted that without infusing new funds into an incentive program, poorer performing hospitals will be penalized to incentivize better performers, which could jeopardize safety-net institutions.

Policy-makers also need to decide, researchers said, whether to pay better performers or those that show the greatest improvement. The authors also said it
remains to be determined whether program benefits are worth the added costs.

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Antiplatelets and drug-eluting stents
A new advisory cautions physicians to make sure that patients with drug-eluting stents take at least one year’s worth of antiplatelet therapy to avoid stent thrombosis.

The advisory, issued by the American College of Cardiology and the American Heart Association as well as other organizations, warns that stent thrombosis may affect as many as 29% of patients who discontinue therapy too soon. The advisory recommends dual antiplatelet therapy with both aspirin and a thienopyridine.

Specific recommendations include:

  • Before stenting, physicians should counsel patients about the need for one year’s worth of antiplatelet therapy. Bare metal stents should be used in patients not expected to comply.
  • Patients should receive bare metal stents or angioplasty if they’re likely to require surgery within 12 months.
  • At discharge, physicians need to emphasize to patients the need for continuing therapy.
  • Physicians at discharge need to tell patients to contact their cardiologist before stopping antiplatelets, even when patients are counseled to do so by other health care professionals.
  • Physicians should postpone elective procedures that have bleeding risks until patients with drug-eluting stents have completed a one-year course of thienopyridine therapy.
  • For patients who must have procedures that mandate stopping a thienopyridine, physicians should continue patients on aspirin and restart thienopyridine as soon as possible.

More options for evaluating violent patients
The Centers for Medicare and Medicaid Services (CMS) has expanded the category of clinicians who can conduct the one-hour face-to-face evaluation of patients who demonstrate violent or self-destructive behavior as a result of psychiatric disorders or substance abuse.

The CMS requires any patient who has been restrained or secluded to be evaluated within one hour. Previously, the CMS said those evaluations must be conducted by physicians or another licensed independent practitioner. Beginning in January, however, trained registered nurses (RNs) or physician assistants (PAs) can perform the evaluation, as long as they consult with a physician or other practitioner.

The CMS also called for more rigorous training requirements for RNs and PAs performing such evaluations. The final rule also requires hospitals to give patients or their families on admission a formal notice of their rights.

Palliative care certification about to debut
he American Board of Medical Specialties (ABMS) has announced the addition of a subspecialty certificate in hospice and palliative care.

The certificate marks the first time that different ABMS member boards are collaborating to offer certification in one specific area. Participating boards include the American Board of Internal Medicine, the American Board of Family Practice and the American Board of Pediatrics.

The first exam for the new certificate will be held in 2008. Analysis of the most recent American Hospital Association data shows that the number of hospitals with palliative care services is on the rise. Currently, 30% of American hospitals offer palliative care programs, almost twice as many as in 2000.

More information is online. http://www.abms.org

Wanted: nominations for patient safety awards
The Joint Commission and the National Quality Forum are accepting nominations for the 2007 John M. Eisenberg Patient Safety and Quality Awards. The awards recognize individuals and organizations making significant advances to improve patient safety and quality of care.

The awards are presented every year in up to four categories:
individual achievement, research, and patient safety and quality innovations at both the national and the local level.

More than one award may be given in each category every year. Hospitalists who have previously won awards include Robert Wachter, MD, and Kaveh Shojania, MD, who were both with the University of California, San Francisco, in 2004, the year they won for innovation at the national level.

The deadline for nominations is April 16, 2007. More information and a nomination form are online. [http://www.jointcommission.org]