Care Quality in Seven Boston Hospitals Case Study Compile your answers from each case study (continued fro Aged 25-44 PR Rate Rate Men Rate Women Aged 45-6

Care Quality in Seven Boston Hospitals Case Study Compile your answers from each case study (continued fro
Aged 25-44
PR
Rate
Rate
Men
Rate
Women
Aged 45-64
Rate Rate
Men Women
Aged 65+
Aged 67
PR Rate Rate
Men Women
Freq.
Hypertension
Women
Low physical activity
Obesity
Smoking
Heavy alcohol use
Rate
o
o
Age 25-44
2,700
Hypercholesterolemia
Atrial fibrillation
Ischemic heart
disease
Transient ischemic
attack
.
Rate
Diabetes mellitus
Aged 65+
Freq.
Source: With permission from Hunter DJW, Spasoff RA, Dorland JL, Purdue MPH, Bai
Determining the Need and Provision of Health Services for Stroke in Eastern Ontario
demiologic Approach to Needs Assessment. Health Information Partnership, Easter
Region, 2000. Published by the Public Health Agency of Canada.
Rate
Aged 45-64
Men
Notes: Population for men: 25-44 (250,345), 45-64 (163,914), 65+ (80,077); population for women: 25-44 (248,748), 45-64(166,248), 65+
Source: With permission from Hunter DJW, Spasoff RA, Dorland JL, Purdue MPH, Bains N. “Determining the Need and Provision of Health Services
for Stroke in Eastern Ontario: An Epidemiologic Approach to Needs Assessment.” Health Information Partnership, Eastern Ontario Region, 2000.
(112,581); and total (1,021,913). ? = estimates unavailable.
Published by the Public Health Agency of Canada.
Freq.
Rate
Age 25-44
o
0
Freq.
2,300
2,800
7. Is hypercholesterolemia more common among men or wom
are 65 and older?
8. The literature would suggest that hypertension is associate
an increased risk of 2.0-4.0 for ischemic stroke, and smoki
is associated with an increased risk of 1.4-5.7 for the same
kind of stroke. Calculate and interpret the range of popula
attributable risk (PAR) for each risk factor.
9. Use Exhibit D.3 to calculate the incidence rates (per 100,000
acute stroke and the prevalence rates (per 100,000) of chrom
using the population estimates from Exhibit D.1 for both rat
Rate
Total
.
Freq.
203,000
397,000
343,100
282,500
35,500
177,200
17,800
55,200
13,600
41,200
Chrot
Acute Stroke
Rate/100,000 Prevalence
Population
Incidence
378
Aged 25-44 males
81
249
Low physical activity
250,345
Hypertension
Risk Factor
Hypercholesterolemia
Aged 25-44 females
Heavy alcohol use
Atrial fibrillation
Transient ischemic
attack
Smoking
Ischemic heart
disease
Diabetes mellitus
649
65
Obesity
248,748
432
378
163,914
Aged 45-64 males
Aged 45-64 females
Aged 65+ males
Aged 65+ females
267
1,464
166,248
1.140
80,077
1,166
4,312
Total
112,581
1,568
2525
(continued from previous page)
Aged 25-44
Aged 45-64
Aged 65+
PR
Rate
Men
Rate
Women
Rate
Men
PR
Rate
Women
PR
Rate Rate
Men Women
EXHIBIT D.2
Prevalence
Ratios for
Stroke Risk
Factor by Age
and Gender
Hypertension
Low physical activity
Obesity
Smoking
Heavy alcohol use
Hypercholesterolemia
Atrial fibrillation
Ischemic heart
disease
Transient ischemic
attack
Diabetes mellitus
Source: With permission from Hunter DJW, Spasoff RA, Dorland JL, Purdue MPH, Bains N.
Determining the Need and Provision of Health Services for Stroke in Eastern Ontario: An Epi-
demiologic Approach to Needs Assessment. Health Information Partnership, Eastern Ontario
Region, 2000. Published by the Public Health Agency of Canada.
7. Is hypercholesterolemia more common among men or women who
are 65 and older?
8. The literature would suggest that hypertension is associated with
an increased risk of 2.0-4.0 for ischemic stroke, and smoking
is associated with an increased risk of 1.4-5.7 for the same
kind of stroke. Calculate and interpret the range of population
attributable risk (PAR) for each risk factor.
9. Use Exhibit D.3 to calculate the incidence rates (per 100,000) of
acute stroke and the prevalence rates (per 100,000) of chronic stroke
using the population estimates from Exhibit D.1 for both rates.
Acute Stroke
Chronic Stroke
Prevalence Rate/100,000
378
Incidence
Rate/100,000
EXHIBIT D.
Incidence
Acute Strol
and Preval
of Chronic
Stroke, Ea
Ontario, 1
81
249
Population
250,345
248,748
163,914
166,248
65
649
378
432
Aged 25-44 males
Aged 25-44 females
Aged 45-64 males
Aged 45-64 females
Aged 65+ males
Aged 65+ females
Total
267
1,464
1,166
80,077
112,581
1,140
1,568
4,312
1,021,913
3,525
(continued)
Capstone Cases
570
(continued from previous page)
10. What is the relative risk of acute stroke of being male versus
female aged 45 to 64?
11. What is the prevalence ratio of chronic stroke (male to female)
among those 65 and older?
12. Assume that 97 percent of the 3,525 acute stroke cases survive
the initial attack. Of these survivors, 3,031 require hospitalization,
211 die within seven days, and another 281 die within 28 days.
What are the seven-day and 28-day case fatality rates for the
3,525 acute stroke survivors?
13. Exhibit D.4 illustrates the concepts of undermet and overmet
need. For each risk factor, or stroke sequelae, QHPRU listed the
kind of intervention that would be effective, and the proportion
of people with these risk factors for whom this intervention
would be appropriate. This is summarized in Exhibit D.5. Use this
exhibit as a template to calculate the number of people at risk
and the number of people for whom each intervention would be
appropriate.
14. QHPRU estimates of the provision of various risk factor
interventions is summarized in Exhibit D.6. Use this as a template
to calculate the gap between services needed and services
provided in Eastern Ontario.
15. Is there overmet need for any intervention?
16. For which two interventions is the undermet need the largest?
EXHIBIT D.4
Overmet and
Undermet Need
11
Overmet Need
Undermet Need
Services Provided
Estimated
Population
Need
Services Provided
Capstone Cases
571
is
(continued from previous page)
ale)
# Who Should
Receive
Intervention
Hypertension
vive
zation,
EXHIBIT D.5
Interven-
tions for
Hypertension
ys.
e
t
Obesity
Low physical activity
Smoking
the
% at Risk with
Indications for
Type Intervention Intervention # at Risk
Non-pharmacologic 100% of
hypertensives
Pharmacologic
70%
(hypertensives who
smoke with high
cholesterol)
Non-pharmacologic 100% of the obese
Non-pharmacologic 100%
Non-pharmacologic 100% of smokers
Pharmacologic 95% (those without
adverse reactions)
Non-pharmacologic 100%
fasting lipoprotein
Non-pharmacologic 70% (those with
dietary
dietary indications)
Pharmacologic 20% (those with
pharmacologic
indications)
lon
this
Hypercholesterolemia
sk
be
plate
Heavy alcohol
consumption
Non-pharmacologic 100%
Diabetes mellitus
Atrial fibrillation
Non-pharmacologic 94.9% (diabetics
with cardiovascular
disease)
Pharmacologic 44.9% (diabetics
with hypertension)
Pharmacologic 100%
Non-pharmacologic 100%
Pharmacologic 100%
Surgical
22% % TIAs with
275% carotid
stenosis)
Transient ischemic
attack
Ischemic heart disease
Non-pharmacologic 100%
Pharmacologic 100%
Source: With permission from Hunter DJW, Spasoff RA, Dorland JL, Purdue MPH, Bains N.
Determining the Need and Provision of Health Services for Stroke in Eastern Ontario: An Epi-
demiologic Approach to Needs Assessment. Health Information Partnership, Eastern Ontario
Region, 2000.
The following types of interventions were recommended for some
of the 3,419 acute stroke survivors: (a) hospitalization (88.65 per-
cent); (b) surgical intervention (i.e. carotid endarterectomy, 4 percent
of acute stroke survivors); C) thrombolytic therapy (11 percent of
(continued)
CAPSTONE CASE E: QUALITY OF CARE IN SEVEN
BOSTON HOSPITALS
By Steven T. Fleming
The Affordable Care Act initiated a hospital value-based purchasing
(VBP) program at the Centers for Medicare & Medicaid Services (CMS)
that rewards acute care hospitals with incentive payments for the qual-
ity of care they provide to Medicare patients. The Hospital Compare
program collects various structure, process, and outcome indicators
for quality of care that are used by the VBP program. This case study
compares seven Boston hospitals in terms of these indicators.
Brigham and Women’s Hospital is a 777-bed teaching hospital
associated with the Harvard Medical School that ranks highly for the
quality of medical care and has deep historical roots dating back to the
early nineteenth century. Brigham and Women’s Faulkner Hospital is
a 150-bed community teaching hospital founded in 1900 and located
in southwest Boston. Tufts Medical Center is a 415-bed teaching hos-
pital affiliated with Tufts School of Medicine and located in downtown
Boston. New England Baptist hospital is a 140-bed hospital with a
national reputation for the treatment of orthopedic and musculoskel-
etal conditions. Boston Medical Center is a 496-bed academic medical
center location in the South End neighborhood of Boston, Beth Israel
Deaconess Hospital is an 81-bed teaching hospital associated with the
Harvard Medical School. Massachusetts General Hospital is the larg.
est and oldest hospital in New England. It is a 950-bed medical center
consistently ranked highly on the quality of care and reputation of the
16 clinical specialties.
Avedis Donabedian (1980) has proposed that quality of care can
be measured along three different dimensions: structure, process,
and outcome. Measures of structure relate to personnel, facilities, and
their configurations. Indicators such as fire code compliance, facility
cleanliness, physician licensure, and the ratio of RNs to total nurses
would be considered measures of structure. This information is readily
obtained from existing documents and inspection reports. One major
disadvantage of these measures is the assumption that the capacity
to provide care (structure) translates into the actual processes of care,
which translates into favorable outcomes. Process measures refer to
(continued)
Capstone Cases
575
(continued from previous page)
what is actually done to the patient, that is, the sequence and coordi-
nation of activities. These include the technical aspects of care, or the
science of care (i.e., activities of professionals) as well as the interper-
sonal aspects of care or the art of care (i.e., how patients are treated).
Process measures tend to be easier to collect than outcome measures,
less time dependent, and less dependent on expensive patient follow-
d purchasing
Services (CMS)
ents for the qual
ital Compare
ne indicators
his case study
up. The medical record does track some but not all aspects of process
of care. Process of care measures do depend on agreed upon criteria
for care. Outcome measures refer to the net changes in health status
as a result of care. It is multidimensional and may include general
health status indicators as well as adverse outcomes of care such as
infections, complications, mortality, and readmissions.
cators.
ng hospital
highly for the
ting back to the
er Hospital is
and located
teaching hos-
in downtown
ital with a
QUESTIONS
1. Exhibit E.1 lists seven structure measures for the seven Boston
hospitals. Which hospitals lack some measures that are
presumably indicative of the capacity to provide care?
2. Exhibit E.2 is a nonexhaustive list of some process of care
measures used by the VBP. These measures are criteria deemed
to be important for patient care. They document the percent of a
sample of patients in which each measure is satisfied compared
to Massachusetts and national averages. Why are these measures
called process of care measures?
3. Compare Brigham and Women’s Hospital to state and national
averages.
musculoskel
demic medical
n. Beth Israel
ciated with the
il is the larg.
edical center
utation of the
of care can
process,
facilities, and
Healthcare-associated infections (HAI) are adverse outcomes of
care that are presumably associated with quality. These measures
use a standardized infection ratio (SIR) to adjust for differences in the
characteristics of patients using the hospital. They take into account
type of patient care location, procedure, number of patients admitted
with methicillin-resistant Staphylococcus aureus (MRSA) or C. difficile,
nce, facility
otal nurses
laboratory methods, hospital affiliation with a medical school, and
tion is readily
One major
?e capacity
bed size of the patient care location. The SIR is somewhat similar to
the standardized mortality ratio (SMR) of the indirect method of age-
adjusted mortality in that we calculate the expected number of infec-
tions based on national benchmarks and adjustments. A confidence
sses of care
es refer to
(continued)
Cardiac
Surgery
Registry
Stroke
Care
Registry
Nursing
Care
Registry
Multispecialty
Surgical
Registry
Receive
Lab Results
Electronically
Track Pts’ Lab
Results, Tests,
and Referrals
General
Surgery
Registry
lospitals
Y
Y
Y
Y
Y
Brigham and Women’s Hospital
Y
Y
Y
Y
Y
?
Tufts Medical Center
Y
Y
?
Y
Y
Y
Y
Brigham and Women’s Faulkner Hospital
N
Y
Y
Y
Y
Y
?
N
Y
N
New England Baptist
Y
N
N
Y
Boston Medical Center
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Beth Israel Deaconess Medical Center
Y
Y
Y
Y
Y
Y
Y
Massachusetts General Hospital
Note: ? = unavailable data.
Source: Medicare.gov (2014b).
erta
Brigham
and
Women’s
Tufts
Medical
Center
B & W
Faulkner
Hospital
NE Baptist
Hospital
Boston
Medical
Center
Beth
Israel
Mass. Mass. Nation
General Average Avera
Hospital
89
94
100
98
100
100
100
100
100
100
100
94
100
99
100
100
99
100
NA
94
100
95
96
failure patients given discharge instructions
ailure patients given an evaluation of left
lar systolic (LVS) function
ure patients given ACE inhibitor or ARB
tricular systolic dysfunction (LVSD
patients whose initial emergency
culture was performed prior to
ation of the first hospital dose of
99 93
98
100
100
97
98
97
98
100
100
100
NA
94
95
91
ents given the most appropriate
5)
95
98
100
98
93
97
97
g surgery who got an antibiotic
vithin one hour before surgery)
tose preventive antibiotics
right time (within 24 hours
99
100
100
98
97
99
99
England Baptist
er Hospital
Y
N
Y
Electronically
?
Results Te
and Referral
Boston Medical Center
Y
Y
N
?
Y
N
Y
Y
Y
Y
Beth Israel Deaconess Medical Center
Y
Y
Y
Y
?
Y
Massachusetts General Hospital
Y
y
Y
Y
Y
Y
Y
Y
Y
Y
N
Note:? = unavailable data.
Source: Medicare.gov (2014b).
N
continued)
Y
Y
y
Y
?
Y
Y
Y
Criteria
Brigham
and
Women’s
EXHIBIT E.2
Timely and
Effective Care
Criteria (Not
Exhaustive
List)
Tufts
Medical
Center
B&W
Faulkner
Hospital
NE Baptist
Hospital
Boston
Medical
Center
Beth
Israel
Mass. Mass. National
General Average Average
Hospital
94
94
100
98
100
100
100
100
89
100
100
100
94
100
99
100
100
(continued from previous page)
99
99
99
100
NA
94
100
95
96
97
93
98
100
100
97
98
97
98
98
100
100
100
NA
94
95
91
97
95
95
98
100
98
93
97
97
97
97
99
100
100
98
97
99
99
99
99
Heart failure patients given discharge instructions
Heart failure patients given an evaluation of left
ventricular systolic (LVS) function
Heart failure patients given ACE inhibitor or ARB
for left ventricular systolic dysfunction (LVSD)
Pneumonia patients whose initial emergency
room blood culture was performed prior to
the administration of the first hospital dose of
antibiotics
Pneumonia patients given the most appropriate
initial antibiotic(s)
Outpatients having surgery who got an antibiotic
at the right time (within one hour before surgery)
Surgery patients whose preventive antibiotics
were stopped at the right time (within 24 hours
after surgery)
Patients who got treatment at the right time
(within 24 hours before or after their surgery) to
help prevent blood clots after certain types of
surgery
Surgery patients who were taking heart drugs
called beta blockers before coming to the
hospital, who were kept on the beta blockers
during the period just before and after their
surgery
Surgery patients who were given the right kind of
antibiotic to help prevent infection
Surgery patients whose urinary catheters were
removed on the first or second day after surgery
100
99
99
98
100
100
98
99
98
100
99
100
99
98
100
99
98
97
100
100
99
100
99
100
99
99
99
98
98
100
97
97
100
97
97
97
(continued)
???????? ?? ????
????????
TUTO
?????? ??????
??
(continued from previous page)
97
92
82
National
Average Average
Mass.
athued from previous page
Interval is estimated around the
tich is 1.0 for each infection measure. If
had lewer infections than expected. If the lower confidenc
258 than 1.0, the hospital is better than the nation
86
93
87
ser than 1.0, then the hospital is worse than the national average
Mass.
General
Hospital
confidence intervals include 1.0, then the hospitals infection rate is
because it had more infections than expected. If the upper and lower
95
99
97
esame (neither better nor worse) as the US average (Medicare.gov
0
will.
91
88
Boston
Medical
Center
100
100
93
QUESTIONS
NE Baptist
Hospital
. Exhibit E.3 summarizes central line and catheter-associated
infections for each hospital. Use Exhibit E.3 as a template to
calculate the SiR for each hospital.
Indicate whether each hospital is better, worse, or the same as the
98
93
10
5
United States average.
B & W
Faulkner
Hospital
NA
NA
98
Central Line-Associated Bloodstream Infections
Tufts
Medical
Center
97
91
65
EXH
Cen
and
Infe
Hospitals
Actual Expected SIR
Cases Cases
Lower
CI
Upper Compare
CI to US
Brigham
and
Women’s
?
100
95
91
Brigham and
22
Women’s Hospital
41.578
0.331
0.801
Tufts Medical
Center
10
26.655
0.18
0.69
Brigham and
Women’s Faulkner
0
1.744
Hospital
New England
NA
2.115
Ischemic stroke patients who received medicine
known to prevent complications caused by blood
clots within two days of arriving at the hospital
Ischemic or hemorrhagic stroke patients who
received treatment to keep blood clots from
forming anywhere in the body within two days of
Patients who got treatment to prevent blood clots
on the day of or day after hospital admission or
arriving at the hospital
surgery
antist
1
Baston Medical
1.333
Source: Medicare.gov (2014b).
6to’o
White
3
4.18
24.067
Criteria
beaconess Medical
0.026
15
Passachusetts
eneral Hospital
30.307
0.364
0.277
List)
EXHIBIT E.2
Timely and
Effective Care
Criteria (Not
Exhaustive
(continued)
38
0.816
(continued)
66.796
Capstone Cases
579
(continued from previous page)
which is 1.0 for each infection measure. If the upper confidence limit is
interval is estimated around the SIR and compared to the national SIR,
less than 1.o, the hospital is better than the national average because
it had fewer infections than expected. If the lower confidence limit is
greater than 1.0, then the hospital is worse than the national average
because it had more infections than expected. If the upper and lower
confidence intervals include 1.0, then the hospitals infection rate is
the same (neither better nor worse) as the US average (Medicare.gov
2014).
QUESTIONS
4. Exhibit E.3 summarizes central line and catheter-associated
infections for each hospital. Use Exhibit E.3 as a template to
calculate the SIR for each hospital.
5. Indicate whether each hospital is better, worse, or the same as the
United States average.
Central Line-Associated Bloodstream Infections
EXHIBIT E.3
Central Line
and Catheter
Infections
Actual Expected SIR
Cases Cases
Lower Upper Compare
CI ?? to US
Hospitals
Brigham and
Women’s Hospital
22
41.578
0.801
0.331
0.18
26.655
0.69
10
Tufts Medical
Center
NA
2.115
0
1.744
Brigham and
Women’s Faulkner
Hospital
4.18
0.019
1
1.333
New England
Baptist
0.026 0.364
Boston Medical
3
24.067
Center
0.816
30.307
0.277
15
Source: Medicare.gov (2014b).
Beth Israel
Deaconess Medical
Center
0.403
0.781
66.796
38
Massachusetts
General Hospital
(table continued on next page)
(continued)
(4
(continued from previous page)
EXHIBIT E.3
Central Line
and Catheter
Infections
(continued)
??
CI
Catheter-Associated Urinary Tract Infections
Actual Expected SIR
Lower
Hospitals
Cases Cases
CI
Brigham and
60.273
1.186 1.817
Women’s Hospital
Upper Compare
to US
Br
W
89
Th
C
37
22.699
1.148
2.247
Tufts Medical
Center
c
3
B
?
3.326
0.186
2.636
Brigham and
Women’s Faulkner
Hospital
H
N
2
1.641
0.148
4.403
New England
Baptist
E
31
25.753
0.818
1.709
Boston Medical
Center
73
38.408
1.49
2.39
Beth Israel
Deaconess Medical
Center
200
86.371
2.006
2.66
Massachusetts
General Hospital
Source: Medicare.gov (2014b).
6. Exhibit E.4 summarizes surgical site infections for colon su…
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