Large Maine Employers- The HeART Group
Our employees, and their family members, are the Maine public. Just about every day an employee or spouse contacts us asking about what information is available to them so that they can make an informed decision when choosing a doctor or hospital, researching a disease, or looking to see if their doctor has given them all of their options with sound advice. They want information that is credible, unbiased, understandable and actionable. It is ironic that in today's environment, a consumer can get more information on choosing a television, car or refrigerator than for choosing a doctor or hospital.
This demand for information has grown in recent years from an occasional request every now and then to a sustained demand. In response to these requests, over the past 3 years, we as employers have become vocal advocates at the local and state levels to facilitate the implementation of standardized, regional, state, and national measures to ensure consumer-friendly reporting of performance measures on hospitals, physicians, and other providers of healthcare. We will continue to advocate for transparency of performance measurement information while we continue to develop complementary strategies that form the foundation for true accountability and consumerism in health care.
It is important to set the right context as to why this information is being made available and to clearly explain what the information says and doesn't say. Without going into specific details about each part of the Maine Quality Forum (MQF) web site, we believe that overall it is well designed to create a balanced communication for the consumer. Consumers will be able to get a 360 degree view of the interpretation of the data, and make their own decision on how to use it or not use it.
We believe that, over time, a dialogue of different viewpoints that is made public with the data available will accelerate the discussions that need to take place among all stake holders as public reporting evolves and becomes the norm rather than exception. While we understand that this may be very difficult for those providers and hospitals that are being assessed, we believe that if the data is credible and unbiased, and more than one viewpoint is expressed, then consumers have the right to this information. We need to understand that there are patients out there right now that are being treated in hospitals without the best safety procedures in place or by doctors who are not practicing evidence-based medicine, who would be interested in receiving this information and would benefit from it today. Our biggest challenge is to present this information in a respectful and understandable way so that it is usable by the public.
We believe that the primary drivers of improvements to the health care system will be:
- consumers using valid performance and cost information to choose providers and treatments,
- purchasers building performance expectations into their contracts and benefit designs, and
- providers acting on their desire to improve, supported with better information.
Maine citizens should be able to select hospitals, physicians, physician groups/delivery systems and treatments based upon public reporting of standardized measures for safety and efficacy. We applaud the Maine Quality Forum for advancing this goal and supporting the public dialogue that is taking place.
Peter Hayes, Hannaford Brothers
Frank Johnson, State Employees Health Insurance Program
Steve Gove, Maine Municipal Employees Health Trust
Tom Hopkins, University of Maine System
Maureen Kenney, Bath Iron Works
Maine Medical Association: Geographic Variations
Maine is fortunate to have the best set of hospital inpatient data in the country. This data set, culled from claims data over many years, is comprehensive and can tell us many things. It is, however, based upon claims data and therefore has some important limitations. The credibility from any one hospital can be very small, particularly when broken into specific procedures. Because of the small volume, it frequently is more credible to look at five years of blended averages, rather than relying upon data from one year.
Because of the important work of the Maine Medical Assessment Foundation, the discharge data can be sorted by patient residence and adjusted to account for patients where they reside. This methodology allows for so-called, "small-area variation analysis", and can be used to tell us which areas or regions are receiving more or less care, or particular procedures, compared to other regions.
When reviewing this data showing regional variations, the following points need to be kept in mind:
- There is frequently no professional consensus as to what is the "correct" rate for a given medical procedure.
- When the data is presented by town or region, it tells us little or nothing about an individual hospital or individual physician.
- Variability in the frequency of a medical or surgical intervention can be caused by many factors, including:
- patient preference
- physician preference
- disease incidence in the region
- environmental or demographic factors in the region
- lack of insurance coverage, including coverage for drugs
- lack of professional consensus
- availability of the service or procedure
- state policy has institutionalized some variation in treatment via payment policies.
The Maine Medical Association supports the collection of and appropriate distribution use of such data. The Association believes that such data, although limited, can be of substantial educational value to physicians, patients and policy-makers. But the limitations noted above need to be kept in mind as the data becomes publicly available, as it is also subject to misuse and misinterpretation. The data can tell patients a lot, but most patients will need to continue to rely upon a variety of information in order to be an educated patient.
Maine Hospital Association: Reporting on the Quality of Care
The Maine Hospital Association supports the public reporting of valid quality data to consumers,
as demonstrated by the hospital specific performance report on patient satisfaction and cardiac care
posted on our web site at: www.themha.org/pubs/Caringintroduction.htm.
This quality report shows that participating Maine hospitals collectively score better than 95 percent
of hospitals nationally in how they treat heart attacks and heart failure. The report also shows that
the hospitals collectively score above the national norm 175 times in 16 different categories of patient
satisfaction. We are proud of the consistently high quality care provided in Maine hospitals, which
has been reported as number three in the country by studies published in the Journal of the American
Medical Association in 2000 and updated in 2003. These two articles may be found at:
But, Maine hospitals aren't stopping there. In addition to ongoing statewide quality improvement projects, we are working with the Maine Quality Forum and other interested parties to report an expanded list of hospital-specific quality measures; but true to our commitment to public trust, any information we publish will be:
- Valid, relevant, reliable and simple;
- Well defined, consistently measured and verifiable;
- Easily understood by the public;
- Risk or population adjusted when appropriate;
- Reported by statistically significant differences;
- Limited to comparable data that is accepted by practitioners as measures of quality; and
- Subject to external review for verification.
If these principles are not followed, the reported data may misrepresent the care you receive from Maine physicians and hospitals and mislead you into making the wrong decisions. For example, the Maine Quality Forum only used billing forms to collect this first set of reported information. Claims data provides minimal clinical information because the information collected is limited to the number codes on a billing form. Claims data should be validated with clinical data, at a minimum, and ideally supplemented with true clinical data so that the health care diagnoses, treatments and underlying conditions are all accurately reported.
We believe that everyone in health care, including hospitals, physicians, insurance companies and state government, should take the time and effort necessary to report quality data that is correct and reliable. While we understand that it is faster and easier to collect information from the billing records, as the Maine Quality Forum has done for these initial reports, the billing records do not provide enough accurate clinical information to support the conclusions reported here. This information also does not provide the definitions and the details necessary for physicians and hospitals to make changes and improve the quality of care. We encourage the Maine Quality Forum to consider our principles of public reporting, and because we believe that this initial release of information conflicts with our guiding principles, we very much appreciate the opportunity to share our concerns with you.
Geographic Variation Data
Charts 1-11 report physician admission and treatment decisions for patients hospitalized for one of 11 categories of care, from general medical conditions to surgical procedures on the spine. These rates are reported statewide by 34 geographic areas, some of which have one hospital and relatively few physicians, and some of which are Maine's largest urban areas with more than one hospital and many physicians. Not surprisingly, areas that have a greater concentration of specialty services provide those services to more people, both to residents of that region and to those transferred or referred from other regions. We are also concerned that this information might be misleading because it is collected by patient residence zip code so that a particular geographic region's number includes patients who were not even treated within that region, but were referred or transferred to another region. Most importantly, the chart does not, and cannot, tell us what the "right" rate might be. As a result, we can't tell by looking at this chart whether the physician ordered the most appropriate treatment or not-that is best determined by you and your doctor. Therefore, the Maine Hospital Association believes that quality reports for these conditions should be based on specific measures that are directly related to patient care, rather than on rates of treatment by region.
Chart 12: Care of Chronic Conditions
There are a number of problems with the information shown on the Maine Quality Forum's chart called Ambulatory Care Sensitive Condition Discharges as a Percent of All Discharges by Hospital.
First, the chart implies that hospitals determine who is admitted and why, but only a physician can make the decision to admit you to the hospital.
- As the text explains, small hospitals have very different types of patients than larger hospitals. The larger hospitals have a much more diverse patient population because they offer a wider range of services and receive all of the transfers of complicated and specialty service patients from the smaller hospitals. So, since the smaller hospitals transfer most of their patients in need of specialized services, it is not at all surprising that smaller hospitals have a much larger percentage of patients with chronic conditions.
- There is no known "right" or even "average" rates for this chart, so we don't know what the numbers mean. While it is true that we all try to avoid being hospitalized for any reason, the fact remains that people sometimes need hospital care and there is no known standard for comparison for this chart.
- In recognition of the fact that not all hospitals have patients admitted for the same reasons, researchers who study this information look at the rates of hospital admissions in a geographic region, rather than what percent of a hospital's admissions are people treated for chronic conditions. However, the way this chart is written implies that those hospitals caring for more people with chronic conditions are doing something wrongthis is simply not true.
- In addition, this chart does not account for the differences from one region to another that affect who is hospitalized for what kind of condition, such as the general age of the local residents, income level and environmental conditions such as air quality for people with asthma or other lung diseases. In fact, current research from a government office called the Agency for Healthcare Research and Quality said that for some chronic conditions "differences in socioeconomic status have been shown to explain a substantial-perhaps most-of the variation" from one region to another.
Finally, even though this chart reports statistics about hospital patients, it can only provide insight into the quality of the health care system outside of the hospital. The Maine Quality Forum says that "...a hospital admission shows us that the patient probably did not get care that worked." Fortunately, there are hospitals across the state of Maine to help you, even if you and your doctor are unable keep your chronic medical problem such as blood pressure or diabetes under good control outside of the hospital.
These charts are intended to show variation in the quality of care in Maine hospitals by comparing complication rates among groups of similar hospitals. However, the directions for reading these charts tell us that the results or variations are meaningful only if the entire vertical line for a peer group is outside of the blue dashed lines. This only happens in 3 of the 16 charts. In each case, Peer Group E has slightly lower rates than the state average, which is good news. (Chart 16 Average Severity Adjusted Pneumonia Post Surgery 2001; Chart 17 Average Severity Adjusted Urinary Tract Infections 2001; Chart 24 Average Severity Adjusted Pneumonia Post Surgery 2002) Also, there are no definitions so we don't know what terms like "mechanical complications" mean and the Peer Groups do not compare hospitals of similar size and patient populations. For example, Peer Group E consists of three small rural hospitals that are classified as Critical Access Hospitals. Maine has 5 other Critical Access Hospitals of that same size, but they are listed in Peer Group D.
According to the Maine Quality Forum, variations in hospital medical admission rates are not the result of having more or less people living in the community with certain diseases, such as high blood pressure. We agree that there is variation in hospitalization rates from one community to another and believe that there are many reasons for this variation. These reasons include socioeconomic status, access to effective outpatient management programs, the preference of the physician and the patient, as well as the fact that the more health problems people in the community have, the more likely it is that they will need hospital care. And, these charts do not prove that hospital admission rates are unrelated to the disease burden of a community. This is because looking at just a single condition decreases the chances of showing a direct relationship to hospitalization rates since each condition contributes to the overall rate in such a small and/or indirect way. Using a chart that truly illustrates a community's disease burden by combining multiple chronic conditions, such as diabetes, hypertension, asthma, and high cholesterol, might show a closer association with the hospital admission rates for all medical conditions.
Volume as a Quality Measurement
Although older studies showed some correlation between quality and volume for some types of surgery, more recent research is calling the link into question.
- The Journal of the American Medical Association published two independent studies showing that hospital volume was a poor predictor for identifying hospitals with significantly better or worse quality of care for coronary artery bypass surgery and for the care of very low birth weight infants. (JAMA, January 14, 2004, Vol. 291, No. 2)
- A federal government office called the Agency for Healthcare Research and Quality published a study in 2004 that said hospital volume and other similar measures are "widely acknowledged to be weak surrogates for true quality of care" and that many low-volume hospitals have been shown to achieve excellent outcomes.
- In northern new England, recent work done by the Medicare's Quality Improvement Organization for northern New England found no relationship between volume and quality of care in cardiac catheterization or total hip replacement among all Medicare patients.
- The Maine Quality Forum references the Leapfrog's use of volume as a hospital measure for five surgical procedures and the births of high risk infants, but Leapfrog began working in 2002 to find direct measures of performance for those diagnoses. Dr. Arnold Milstein, Leapfrog's Leaps and Measures Lily Pad chair, said, "It is in the shared interest of hospitals, consumers, and purchasers to be able to measure hospital performance directly to supplement or replace volume-based predictors of performance. With direct measures, hospitals could be recognized based on actual performance, and consumers could make more informed health care choices."
Therefore, the Maine Hospital Association does not endorse volume as a quality measure and recommends that consumers consult with their physician and consider direct quality measures specific to the physician and the hospital when making their health care decisions.
Submitted August 2004
Terrance Sheehan, MD
Chair of the Maine Hospital Association Quality Council
Portions of this web site draw conclusions from the data presented. We believe that the conclusions drawn are accurate and appropriate. Portions of this web site summarize information that Dr. Shubert has collected from his training, nearly 30 years as a practicing physician and his distillation of current expert and consensus opinion.