Background Performance measures that reward achieving blood pressure (BP) thresholds may contribute to overtreatment. We developed a tightly-linked clinical action measure designed to encourage appropriate medical management; and a marker of potential overtreatment, designed to monitor overly aggressive treatment in the face of low diastolic BP. Methods We conducted a retrospective cohort study in 879 Department of Veterans Affairs (VA) medical centers and smaller community based outpatient clinics (CBOCs). The clinical action measure for hypertension was met if the patient had a passing index BP at the visit or had an appropriate action. We examined the rate of passing the action measure and of potential overtreatment in the Veterans Health Administration (VHA) during 2009-2010. Results There were 977,282 established VA patients, ages 18 years and older, with diabetes. 713,790 patients were eligible for the action measure. 94% passed the measure: 82% because they had a BP<140/90 at the visit; and an additional 12% with BP>140/90 and appropriate clinical actions. Facility pass rates varied from 77% to 99% (p<0.001). Among all diabetics, 197,291 (20%) had a BP<130/65; of these, 80,903 (8% of all diabetics) had potential overtreatment. Facility rates of potential overtreatment varied from 3% to 20% (p<0.001). Facilities with higher rates of meeting the current threshold measure (<140/90 mm Hg) had higher rates of potential overtreatment (p<0.001). Conclusions While 94% of diabetic Veterans met the action measure, rates of potential overtreatment are currently approaching the rate of undertreatment and high rates of achieving current threshold measures are directly associated with overtreatment. Implementing a clinical action measure for hypertension management, as VHA is planning to do, may result in more appropriate care and less overtreatment.
Executive Summary In 2020 a group of U.S. healthcare leaders formed the National Organization to Prevent Hospital-Acquired Pneumonia (NOHAP) to issue a call to action to address non–ventilator-associated hospital-acquired pneumonia (NVHAP). NVHAP is one of the most common and morbid healthcare-associated infections, but it is not tracked, reported, or actively prevented by most hospitals. This national call to action includes (1) launching a national healthcare conversation about NVHAP prevention; (2) adding NVHAP prevention measures to education for patients, healthcare professionals, and students; (3) challenging healthcare systems and insurers to implement and support NVHAP prevention; and (4) encouraging researchers to develop new strategies for NVHAP surveillance and prevention. The purpose of this document is to outline research needs to support the NVHAP call to action. Primary needs include the development of better models to estimate the economic cost of NVHAP, to elucidate the pathophysiology of NVHAP and identify the most promising pathways for prevention, to develop objective and efficient surveillance methods to track NVHAP, to rigorously test the impact of prevention strategies proposed to prevent NVHAP, and to identify the policy levers that will best engage hospitals in NVHAP surveillance and prevention. A joint task force developed this document including stakeholders from the Veterans’ Health Administration (VHA), the U.S. Centers for Disease Control and Prevention (CDC), The Joint Commission, the American Dental Association, the Patient Safety Movement Foundation, Oral Health Nursing Education and Practice (OHNEP), Teaching Oral-Systemic Health (TOSH), industry partners and academia.
Care coordination between the specialty care provider (SCP) and the primary care provider (PCP) is a critical component of safe, efficient, and patient-centered care. Veterans Health Administration conducted a series of focus groups of providers, from specialty care and primary care clinics at VA Medical Centers nationally, to assess 1) what SCPs and PCPs perceive to be current practices that enable or hinder effective care coordination with one another and 2) how these perceptions differ between the two groups of providers. A qualitative thematic analysis of the gathered data validates previous studies that identify communication as being an important enabler of coordination, and uncovers relationship building between specialty care and primary care (particularly through both formal and informal relationship-building opportunities such as collaborative seminars and shared lunch space, respectively) to be the most notable facilitator of effective communication between the two sides. Results from this study suggest concrete next steps that medical facilities can take to improve care coordination, using as their basis the mutual understanding and respect developed between SCPs and PCPs through relationship-building efforts.
Background Performance measures that emphasize only a treat-to-target approach may motivate overtreatment with high dose statins, potentially leading to adverse events and unnecessary costs. We developed a clinical action performance measure for lipid management in patients with diabetes that is designed to encourage appropriate treatment with moderate dose statins while minimizing overtreatment. Methods and Results We examined data from July 2010 to June 2011 for 964,818 active VA primary care patients >=18 years with diabetes. We defined 3 conditions as successfully meeting the clinical action measure for patients 50-75 years old: 1) LDL < 100 mg/dL; 2) On a moderate dose statin, regardless of LDL level or measurement; or 3) If LDL > 100 mg/dL, received appropriate clinical action (starting, switching or intensifying statin therapy). We examined possible overtreatment for patients 18 and older by examining the proportion of patients without ischemic heart disease who were on a high dose statin. We then examined variability in measure attainment across 881 facilities using two level hierarchical multivariable logistic models. Of 668,209 patients with diabetes aged 50-75 years, 84.6% passed the clinical action measure: 67.2% with LDL <100 mg/dL; 13.0% with LDL >=100 mg/dL and on either a moderate dose statin (7.5%) or with appropriate clinical action (5.5%); and 4.4% with no index LDL on at least a moderate dose statin. Of the entire cohort aged >=18 years, 13.7% were potentially overtreated. Facilities with higher rates of meeting the current threshold measure (LDL <100 mg/dL) had higher rates of potential overtreatment (p <0.001). Conclusions Use of a performance measure that credits appropriate clinical action indicates that almost 85% of diabetic Veterans aged 50-75 are receiving appropriate dyslipidemia management. However, many patients are potentially overtreated with high dose statins.
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