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Special Perspectives on Acute Hospital Care Jack E. Christy I want to share the patients' and families' perspectives on caring for the elderly patient in the acute care setting. In describing He concerns people have about the quality of medical care for elderly patients in the hospital, ~ shad address four things: the issues that drive families t interest in how to assure good quality medical care; examples of public and private actions that advance our understanding of quality in medicine; impediments that keep us from getting as far as we have to go as quickly as we want to move; and some suggestions for advancing quality in medical care. FAMILIES' INTEREST IN QUALITY OF CARE ISSUES It is no sue se to anyone that health care is a priority concern to older persons and their families. AU of Be changes In me Medicare program during this decade are causing Medicare patients to examine their basic assumptions about what quality means in the acute care setting. The prospective payment system (PPS) gives hospitals strong in- cen~ves to limit bow the length of stay and the intensity of care for Weir Medicare patients. As a result, PPS has wrought new anxieties among patients about access to care and the continuity of care. Medicare has implemented the new limits by reducing admissions, directing more pa- tients to the outpatient setting, and discharging patients earlier in the hospital stay. Beneficiaries do not regard these events as evidence of poor quality per se, but the operational reality of PPS has dramatically high- lighted how poor Medicare coverage is for needed post-acute-care serv- ~03

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104 JACK E. CHRISTY ices and how little is known about assessing acute care patients and monitoring their care from sewing to setting. Although one cannot predict the future, one can safely bet Cat health care prices will continue to go up. Rising health care costs and the weight of the huge federal deficit portend even tighter controls on Medi- care expenditures. Yet more people are demanding more of the Medicare system, but the system is not keeping up. Thus, consumers faced with tightened health care resources and consequent cutbacks in care are ques- tioning, and rightly so, just what it is they are buying for their health care dollars. The answer to this question asses from the development and implementation of a quality of medical care assessment and assurance system that identifies quality-of-care problems in a timely way, ~mple- ments appropriate corrective actions, monitors He effectiveness of Hose actions, and follows up as warranted. Such a system does not now exist, but it can be developed. ACTIVITIES ADVANCING THE UNDERSTANDING OF QUALITY IN MEDICINE . . The good news is that quality of care is on the national agenda. Forums and conferences are taking place ad over the country. It began with the Senate Committee on Aging raising concerns about quality under PPS, and it has not stopped since. Physicians, hospitals, consumers, government, insurance companies, and employers are trying to under- stand quality in medicine. This is all to the good. The American Association of Retired Persons (AARP) is confident that the development of a quality mowtonng and assurance system win lead to both better care and more efficient care. To a large extent the picture of quality in medicine will be devel- oped in numbers. Valid health care data are an essential prerequisite to understanding the quality of medical care. The interest in quality heath care animated by PPS is nourishing a new era of quality assessment in the health sector. This new era of health-care quality assurance seeks to identify poor quality performance and outcomes by focusing on statisti- cally significant aberrant performances and outcomes. The Health Care Financing Administration (HCFA) further opened the door to statistically based quality analysis when it published hospital- specific mortality data for hospitals with significantly aberrant records.

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SPECIAL PEaRSPECTIVES ON ACUTE HOSPITAL CARE 105 Although legitun ate questions could be raised about various aspects of the HCFA data disclosure, the data showed a strong correlation between the volume of procedures performed and outcomes. Thus, although flawed, the HCFA data helped to establish oudier review as a usefid way to assess quality in medical care. The HCFA's 1987 moronity data disclosure is a great improvement over the 1986 data. The statistical methodology is strengthened and the affected hospitals have better opportunities to com- ment on He data. The 1987 figures represent an advance in getting data on quality out to the public. Similarly, HCFA's 1988 hospital mortality disclosure is an improvement over the 1987 figures. The presentation of two years of data, improved validation procedures, and the Auction of variation in He mortality rates continues the process of making the HCFA mortality data disclosures better. A major step in understanding the outcomes of care is to under- stand the variations in the provision of care. Only after variations in medical practice are understood will the degree to which health care is clinic ally efficacious and appropriate in a given circumstance be under- stood and lead to the development of clear quality standards. HC];A's activity to document practice variation among states and study patient outcomes for selected diagnoses is an important step toward developing a basic quality assurance system. There was much good news about quality in Medicare in the Omnibus Budget Reconciliation Acts of 1987. In addition to the practice variation study begun by HCFA, the 1986 Budget Act requires the De- parunent of Health and Human Services (DHHS) to develop and unple- ment discharge planning systems to be used by hospitals participating in Medicare. This is a requirement. If a hospital participates in Medicare, it must have a discharge planning system that meets the guidelines set by the Secretary of DHHS. As noted previously, a reliable discharge plan- ning mechanism is crucial to assuring that patients discharged from hospi- tals receive appropriate follow-up care. Any accounting of good news in advancing the cause of quality in Medicare would be incomplete without recognizing peer review organi- zations (PROs). PROs are government contractors and as such must implement federal policies. By their nature PROs reflect and represent the perspective of professionals and providers. At the same time, notwith- stand~ng the pressures and dynamics of having that kind of perspective, Medicare beneficiaries look to PROs as the allies and advocates of the patient community if the quality of care that we hold dear is to survive.

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106 JACK E. CHRISTY Despite problems, PROs are one of the bright spots in the advancement of understanding quality in medicine. Much has to be done, however, to make "peer review" a more effective player in the medical quality assur- ance scheme of the nation. Even though national attention is focused on quality of care issues now, this is no guarantee Mat national attention win remain interested tomorrow. The jury is still out on the question of whether public pressure can be sustained long enough to implement a respectable quality assur- ance system. IMPEDIMENTS TO QUALITY OF CARE The bad news is that the United States is a long way from having the technical capability to assure high-quality medical care. The nation's ability to assure quality in medicine is directly related to its understanding of what a quality medical outcome is and to its ability to detect promptly and to correct unacceptable deviations from quality care. At He present time, however, the country lacks adequate information about medical outcomes and the quality monitoring system necessary to alert health care providers and policymakers to unacceptable care. It is starding that the word quality is not even mentioned in the Medicare statute, Title XVITI of the Social Security Act. Indeed, fiscal intermediaries and camers the administrators of the Medicare programhave no statutory function re- lating to quality of care for Medicare patients. Moreover, major gaps remain in our ability to account for differences in patient characteristics. The lack of a reliable and affordable severity of illness index limits me usefulness of outcome measures for evaluating quality In medical care. Even though PROs are part of the good news, they are also part of the bad news. Although PROs are operating, they must continually concentrate their efforts on obtaining the funds that Be government contracted to provide and on keeping their enforcement authority that is so crucial to their peer review responsibilities. As a result, much of the potential gain from PRO review is lost or wasted, instead of further developing the base of knowledge on quality in medical care. PRO opponents must be made to understand and to recognize the vital role that PROs will play in the development of our national health care system.

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SPECIAL PERSPE=IVES ON ACUTE HOSPITAL CARE 107 ADVANCING THE CAUSE OF QUALITY OF CARE The fight to establish a solid, quality assurance system remains, at this point, ours to win Toward that end, we must continue to insist that determinations of quality be based on the entire episode of illness, not just on a particular setting of care Developing the linkages from discharge planning to nursing home to home health care to the physician's office is very important to having a complete picture of an episode of illness HCFA's efforts to link Medicare's Part A and B data must therefore proceed as a high-pnonty project A proper quality assurance system win require much greater coor- dination among the HCFA contractors am sterling Medicare Inte~me- dianes, carriers, and PROs must begin to collect and process basic data elements in a unwon way to assure comparability among providers Standardizing quality of care measures and methodologies win give greater assurance to beneficiaries about the quality of their medical care and win lead to nationally representative information. The information collected by such a quality assurance system should serve as the basis for a national epidemiologic data base of rele- vant, patient-level data on the overall quality of care to Medicare patients, regardless of the seeing of care Such a data base will be an invaluable too} for assessing the access of beneficiaries to the various levels of care, and it win lead to a greater understanding of the ways in which quality affects the heath status and quality of life of beneficiaries The AARP believes that assessing the quality of health care serv- ices is possible. It can be accomplished by considenng population-basedt rates of utilization, denved from small area analyses of the practice patterns of physicians, and pruna~y clinical data, such as test results and findings from the patient's medical chart These two elements can help determine the efficiency, the effectiveness, and the appropriateness of care, which is the quality of care being delivered. The combination of small area analysis and clinical effectiveness data provides an assessment of macro- and microlevels of performance. The challenge is to develop the indicators into a coherent system of quality assurance from setting to sewing and to translate the data into information useful to health care consumers The routine publication of infonnation useful to consumers

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108 JACK E. CHRISTY win assure that health care providers compete on We basis of quality and that me system dynamics help enforce high standards of care. Finally, ~ want to relate a story about the quality of caring, an aspect of quality of care Rat is sometimes overlooked. It comes from Emily Friedman, a Chicago health wnter, and is about a familiar type of patient described to Ms. Fr~e~nan by Dr. Paul Rayon as follows: A white female appears to be her reported age. She neither speaks nor compre- hends me spoken word. She is disoriented about person, place, and time. She does, however, seem to sometimes recognize her own name. Dr. Raskin worked win her for 6 monks, but she does not recognize him. Dr. Raskin pointed out Rat the patient was completely dependent and had to be fed, cloned, bathed, and changed. When Dr. Raskin asked a group of graduate nurses how Hey would fee} about dealing win such a case, He graduate nurses responded win words such as "frustrated," "hopeless," "depressed," and "annoyed." Dr. Raskin was descnb~ng his 6-month-old daughter. You may have envisioned an 86-year-old woman instead of a ~month-old child. ~ think that He story highlights exactly what we mean when we talk about He quality of canny. As we struggle with tile complexities of making He heady care system more responsive to the needs of patients in He twenty- first century, let us be ever minded Hat our humanity and compassion also characterize the quality of our care.