Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 103
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
OCR for page 104
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.
OCR for page 105
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.
OCR for page 106
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 program—have 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.
OCR for page 107
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
OCR for page 108
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.
Representative terms from entire chapter:
acute hospital
