Susan Birk

ROSEMONT, ILL. — Despite major patient safety strides during the past decade, health care providers need to create more accountability for medical errors and patient safety lapses in order to continue improving, according to Dr. Robert M. Wachter, professor and associate chairman of medicine at the University of California, San Francisco.

At the Joint Commission national conference on quality and patient safety, Dr. Wachter offered his perspectives on the status of patient safety in health care 10 years after the publication of the first Institute of Medicine report on the subject (To Err Is Human: Building a Safer Health System). He and Dr. Peter J. Pronovost of Johns Hopkins University, Baltimore, published an editorial on the topic shortly after the conference (N. Engl. J. Med. 2009;361:1401–6).

Balancing a culture of “no blame” with a culture of accountability remains a key challenge for providers. While it's true that “most errors are committed by caring, competent people trying hard to get it right … the system produces low-quality, unsafe, unreliable care partly because there's been no business case to do otherwise,” said Dr. Wachter, who edits two online publications for the Agency for Healthcare Research and Quality: WebM&M (www.webmm.ahrq.govwww.psnet.ahrq.gov

Dr. Wachter cited the fact that average hand-washing compliance rates continue to hover at only about 50% as an example of the need for more accountability. “I don't believe that is fully a systems problem,” he said. Part of the problem is that “there have been no penalties for transgressions.”

Dr. Wachter also commented on other aspects of patient safety:

▸ Regulation. Health care organizations need regulators to set standards, but the challenge is ensuring that these standards truly help organizations improve safety. Until the Joint Commission developed standards for reading back instructions, “virtually none of us thought of doing that on our own,” he said.

At the same time, “it is extraordinarily difficult to have a set of rules and standards that apply equally in nuanced areas to organizations that are incredibly different in the way they do business, their financial resources, and their capacity,” he said.

For that reason, “regulation is extraordinarily useful to get people moving, but it tends to run out of gas over time,” Dr. Wachter said. To illustrate, he cited the Joint Commission's recent decision to remove adherence to medication reconciliation standards as a requirement for accreditation because organizations struggled to develop appropriate processes.

However, having an “outside organization creating rules and standards we must abide by was extraordinarily important in the first 5 years” after the IOM report, he said. Despite some glitches, “the Joint Commission has improved its processes tremendously” and made an important step in the right direction with the creation of the Center for Transforming Healthcare. (See story on this page.)

▸ Reporting. “The admonition to report everything is silly,” Dr. Wachter said. “Our mistake here was to not be thoughtful about what we are going to do with all of these reports” before requiring them.

However, providers have begun to think more critically about what should be reported and how the data should be used, he said.

State reporting requirements on the 27 “never events” put forth by the National Quality Forum have led to more focused patient safety efforts. “Until the state reporting system, our process [at UCSF] for doing root cause analysis was pretty haphazard and ad lib,” he noted. Now the institution holds a weekly 2-hour root cause analysis meeting.

▸ Information technology. Health care providers have developed a more robust understanding of the role of information technology in patient safety and now realize that it is not a panacea. Improvement efforts are not nearly as effective “if we just do the computer piece but don't educate people,” he said.

Still, “even though we've got plenty of room to go, I think we should all be proud” of what has been accomplished in the past 10 years, he said.

Part of the problem in improving patient safety is that 'there have been no penalties for transgressions.'

Source DR. WACHTER

ROSEMONT, ILL. — Despite major patient safety strides during the past decade, health care providers need to create more accountability for medical errors and patient safety lapses in order to continue improving, according to Dr. Robert M. Wachter, professor and associate chairman of medicine at the University of California, San Francisco.

At the Joint Commission national conference on quality and patient safety, Dr. Wachter offered his perspectives on the status of patient safety in health care 10 years after the publication of the first Institute of Medicine report on the subject (To Err Is Human: Building a Safer Health System). He and Dr. Peter J. Pronovost of Johns Hopkins University, Baltimore, published an editorial on the topic shortly after the conference (N. Engl. J. Med. 2009;361:1401–6).

Balancing a culture of “no blame” with a culture of accountability remains a key challenge for providers. While it's true that “most errors are committed by caring, competent people trying hard to get it right … the system produces low-quality, unsafe, unreliable care partly because there's been no business case to do otherwise,” said Dr. Wachter, who edits two online publications for the Agency for Healthcare Research and Quality: WebM&M (www.webmm.ahrq.govwww.psnet.ahrq.gov

Dr. Wachter cited the fact that average hand-washing compliance rates continue to hover at only about 50% as an example of the need for more accountability. “I don't believe that is fully a systems problem,” he said. Part of the problem is that “there have been no penalties for transgressions.”

Dr. Wachter also commented on other aspects of patient safety:

▸ Regulation. Health care organizations need regulators to set standards, but the challenge is ensuring that these standards truly help organizations improve safety. Until the Joint Commission developed standards for reading back instructions, “virtually none of us thought of doing that on our own,” he said.

At the same time, “it is extraordinarily difficult to have a set of rules and standards that apply equally in nuanced areas to organizations that are incredibly different in the way they do business, their financial resources, and their capacity,” he said.

For that reason, “regulation is extraordinarily useful to get people moving, but it tends to run out of gas over time,” Dr. Wachter said. To illustrate, he cited the Joint Commission's recent decision to remove adherence to medication reconciliation standards as a requirement for accreditation because organizations struggled to develop appropriate processes.

However, having an “outside organization creating rules and standards we must abide by was extraordinarily important in the first 5 years” after the IOM report, he said. Despite some glitches, “the Joint Commission has improved its processes tremendously” and made an important step in the right direction with the creation of the Center for Transforming Healthcare. (See story on this page.)

▸ Reporting. “The admonition to report everything is silly,” Dr. Wachter said. “Our mistake here was to not be thoughtful about what we are going to do with all of these reports” before requiring them.

However, providers have begun to think more critically about what should be reported and how the data should be used, he said.

State reporting requirements on the 27 “never events” put forth by the National Quality Forum have led to more focused patient safety efforts. “Until the state reporting system, our process [at UCSF] for doing root cause analysis was pretty haphazard and ad lib,” he noted. Now the institution holds a weekly 2-hour root cause analysis meeting.

▸ Information technology. Health care providers have developed a more robust understanding of the role of information technology in patient safety and now realize that it is not a panacea. Improvement efforts are not nearly as effective “if we just do the computer piece but don't educate people,” he said.

Still, “even though we've got plenty of room to go, I think we should all be proud” of what has been accomplished in the past 10 years, he said.

Part of the problem in improving patient safety is that 'there have been no penalties for transgressions.'

Source DR. WACHTER

ROSEMONT, ILL. — Despite major patient safety strides during the past decade, health care providers need to create more accountability for medical errors and patient safety lapses in order to continue improving, according to Dr. Robert M. Wachter, professor and associate chairman of medicine at the University of California, San Francisco.

At the Joint Commission national conference on quality and patient safety, Dr. Wachter offered his perspectives on the status of patient safety in health care 10 years after the publication of the first Institute of Medicine report on the subject (To Err Is Human: Building a Safer Health System). He and Dr. Peter J. Pronovost of Johns Hopkins University, Baltimore, published an editorial on the topic shortly after the conference (N. Engl. J. Med. 2009;361:1401–6).

Balancing a culture of “no blame” with a culture of accountability remains a key challenge for providers. While it's true that “most errors are committed by caring, competent people trying hard to get it right … the system produces low-quality, unsafe, unreliable care partly because there's been no business case to do otherwise,” said Dr. Wachter, who edits two online publications for the Agency for Healthcare Research and Quality: WebM&M (www.webmm.ahrq.govwww.psnet.ahrq.gov

Dr. Wachter cited the fact that average hand-washing compliance rates continue to hover at only about 50% as an example of the need for more accountability. “I don't believe that is fully a systems problem,” he said. Part of the problem is that “there have been no penalties for transgressions.”

Dr. Wachter also commented on other aspects of patient safety:

▸ Regulation. Health care organizations need regulators to set standards, but the challenge is ensuring that these standards truly help organizations improve safety. Until the Joint Commission developed standards for reading back instructions, “virtually none of us thought of doing that on our own,” he said.

At the same time, “it is extraordinarily difficult to have a set of rules and standards that apply equally in nuanced areas to organizations that are incredibly different in the way they do business, their financial resources, and their capacity,” he said.

For that reason, “regulation is extraordinarily useful to get people moving, but it tends to run out of gas over time,” Dr. Wachter said. To illustrate, he cited the Joint Commission's recent decision to remove adherence to medication reconciliation standards as a requirement for accreditation because organizations struggled to develop appropriate processes.

However, having an “outside organization creating rules and standards we must abide by was extraordinarily important in the first 5 years” after the IOM report, he said. Despite some glitches, “the Joint Commission has improved its processes tremendously” and made an important step in the right direction with the creation of the Center for Transforming Healthcare. (See story on this page.)

▸ Reporting. “The admonition to report everything is silly,” Dr. Wachter said. “Our mistake here was to not be thoughtful about what we are going to do with all of these reports” before requiring them.

However, providers have begun to think more critically about what should be reported and how the data should be used, he said.

State reporting requirements on the 27 “never events” put forth by the National Quality Forum have led to more focused patient safety efforts. “Until the state reporting system, our process [at UCSF] for doing root cause analysis was pretty haphazard and ad lib,” he noted. Now the institution holds a weekly 2-hour root cause analysis meeting.

▸ Information technology. Health care providers have developed a more robust understanding of the role of information technology in patient safety and now realize that it is not a panacea. Improvement efforts are not nearly as effective “if we just do the computer piece but don't educate people,” he said.

Still, “even though we've got plenty of room to go, I think we should all be proud” of what has been accomplished in the past 10 years, he said.

Part of the problem in improving patient safety is that 'there have been no penalties for transgressions.'

Source DR. WACHTER

ROSEMONT, ILL. — In an effort to help health care providers make lasting improvements in quality and safety, the Joint Commission has established the Center for Transforming Healthcare to disseminate data and lessons from leading health care organizations that have successfully implemented robust process-improvement methods developed by other industries.

The Joint Commission's center, which will function separately from the accreditation process, is developing a Web-based tool and other resources to help guide organizations through process improvement.

“The aim is to deliver this to accredited organizations at no extra cost,” Dr. Mark R. Chassin said at the Joint Commission national conference on quality and patient safety.

Health care providers have expressed a desire for information from the Joint Commission on effective solutions to safety and quality problems. “What I hear from our customers is: 'Don't keep telling us only about the problems—tell us how we can get better,'” he said.

Health care providers can make major and durable improvements in patient safety and quality by adopting “robust process-improvement” tools that are widely used by high-reliability industries such as commercial aviation and nuclear energy, where adverse events are far less common than in health care, Dr. Chassin said.

The Joint Commission does not plan to require the use of these tools as a condition for accreditation. However, emerging evidence indicates that these methodologies—including the Lean, Six Sigma, Toyota Production System, and GE Change Acceleration Process models—“work just as well when applied to our very nasty safety and quality problems as they do in all of the other very successful business and administrative processes where they've been tried,” Dr. Chassin said. “I am firmly convinced that the tools of robust process improvement are an incredibly important vehicle for getting us much farther down the road.”

With that in mind, “we are collaborating with physicians, nurse leaders, and managers of hospitals and health systems where Lean and Six Sigma are already working—organizations that have already made the investment and have mastered those tools. And we are deploying teams from those institutions to solve the most difficult quality and safety problems facing all of American health care,” Dr. Chassin explained. “Our job at the Joint Commission is to build the knowledge database, compiling all of that learning across all of those organizations, and to spread it to other organizations.”

The center's first project, devoted to hand hygiene, is a collaborative effort with several institutions nationwide. Using high-reliability strategies, these organizations documented average hand-washing rates below 50% at their institutions, rates much lower than previously believed. A range of solutions tailored to specific causes of noncompliance are now being tested.

The second project, which will focus on breakdowns in handoff communications, has several different participant organizations across the country.

The third project, which will target wrong-site surgery, will be a collaboration with Rhode Island Hospital (Providence) and Newport (R.I.) Hospital on the development and testing of a universal protocol for avoiding such errors.

High-reliability industries manage risks far more effectively than do health care providers because these industries have “a set of tools and principles that allows them to look very hard at their processes and perfect them, and then a culture that wraps around those improvement tools [and] that allows those nearly perfect processes to continue at high levels of safety for long periods of time,” Dr. Chassin said.

This type of firmly embedded culture, currently absent in health care, begins with the rigorous identification of problem root causes. Health care providers generally do a good job of defining problems and measuring outcomes, but they often gloss over the critical step of identifying exactly why a process is not working, he said. In order to develop effective, durable interventions, “you have to understand the specific causes of the problem where you're trying to fix it.”

“You can have the best technical solution … but if nobody uses it and everybody hates it, it will have no impact,” Dr. Chassin said. To deal with that problem, robust process improvement incorporates explicit change-management principles and tools into the process at the very beginning.

High-reliability organizations often automate processes after they have perfected them, but automation is not always possible in health care, he noted. “What we are charged with if we're going to get improvement that is sustained is changing the behavior of the individuals that work in the health care delivery system and maintaining that changed behavior over long periods of time.”

The Joint Commission Center for Transforming Healthcare has received support from the American Hospital Association, BD, Ecolab, GE Healthcare, Johnson & Johnson, the Federation of American Hospitals, and Hospira.

For more information, go to www.centerfortransforminghealthcare.org

'Our job at the Joint Commission is to [compile] all of that learning … and to spread it to other organizations.'

Source DR. CHASSIN

ROSEMONT, ILL. — In an effort to help health care providers make lasting improvements in quality and safety, the Joint Commission has established the Center for Transforming Healthcare to disseminate data and lessons from leading health care organizations that have successfully implemented robust process-improvement methods developed by other industries.

The Joint Commission's center, which will function separately from the accreditation process, is developing a Web-based tool and other resources to help guide organizations through process improvement.

“The aim is to deliver this to accredited organizations at no extra cost,” Dr. Mark R. Chassin said at the Joint Commission national conference on quality and patient safety.

Health care providers have expressed a desire for information from the Joint Commission on effective solutions to safety and quality problems. “What I hear from our customers is: 'Don't keep telling us only about the problems—tell us how we can get better,'” he said.

Health care providers can make major and durable improvements in patient safety and quality by adopting “robust process-improvement” tools that are widely used by high-reliability industries such as commercial aviation and nuclear energy, where adverse events are far less common than in health care, Dr. Chassin said.

The Joint Commission does not plan to require the use of these tools as a condition for accreditation. However, emerging evidence indicates that these methodologies—including the Lean, Six Sigma, Toyota Production System, and GE Change Acceleration Process models—“work just as well when applied to our very nasty safety and quality problems as they do in all of the other very successful business and administrative processes where they've been tried,” Dr. Chassin said. “I am firmly convinced that the tools of robust process improvement are an incredibly important vehicle for getting us much farther down the road.”

With that in mind, “we are collaborating with physicians, nurse leaders, and managers of hospitals and health systems where Lean and Six Sigma are already working—organizations that have already made the investment and have mastered those tools. And we are deploying teams from those institutions to solve the most difficult quality and safety problems facing all of American health care,” Dr. Chassin explained. “Our job at the Joint Commission is to build the knowledge database, compiling all of that learning across all of those organizations, and to spread it to other organizations.”

The center's first project, devoted to hand hygiene, is a collaborative effort with several institutions nationwide. Using high-reliability strategies, these organizations documented average hand-washing rates below 50% at their institutions, rates much lower than previously believed. A range of solutions tailored to specific causes of noncompliance are now being tested.

The second project, which will focus on breakdowns in handoff communications, has several different participant organizations across the country.

The third project, which will target wrong-site surgery, will be a collaboration with Rhode Island Hospital (Providence) and Newport (R.I.) Hospital on the development and testing of a universal protocol for avoiding such errors.

High-reliability industries manage risks far more effectively than do health care providers because these industries have “a set of tools and principles that allows them to look very hard at their processes and perfect them, and then a culture that wraps around those improvement tools [and] that allows those nearly perfect processes to continue at high levels of safety for long periods of time,” Dr. Chassin said.

This type of firmly embedded culture, currently absent in health care, begins with the rigorous identification of problem root causes. Health care providers generally do a good job of defining problems and measuring outcomes, but they often gloss over the critical step of identifying exactly why a process is not working, he said. In order to develop effective, durable interventions, “you have to understand the specific causes of the problem where you're trying to fix it.”

“You can have the best technical solution … but if nobody uses it and everybody hates it, it will have no impact,” Dr. Chassin said. To deal with that problem, robust process improvement incorporates explicit change-management principles and tools into the process at the very beginning.

High-reliability organizations often automate processes after they have perfected them, but automation is not always possible in health care, he noted. “What we are charged with if we're going to get improvement that is sustained is changing the behavior of the individuals that work in the health care delivery system and maintaining that changed behavior over long periods of time.”

The Joint Commission Center for Transforming Healthcare has received support from the American Hospital Association, BD, Ecolab, GE Healthcare, Johnson & Johnson, the Federation of American Hospitals, and Hospira.

For more information, go to www.centerfortransforminghealthcare.org

'Our job at the Joint Commission is to [compile] all of that learning … and to spread it to other organizations.'

Source DR. CHASSIN

ROSEMONT, ILL. — In an effort to help health care providers make lasting improvements in quality and safety, the Joint Commission has established the Center for Transforming Healthcare to disseminate data and lessons from leading health care organizations that have successfully implemented robust process-improvement methods developed by other industries.

The Joint Commission's center, which will function separately from the accreditation process, is developing a Web-based tool and other resources to help guide organizations through process improvement.

“The aim is to deliver this to accredited organizations at no extra cost,” Dr. Mark R. Chassin said at the Joint Commission national conference on quality and patient safety.

Health care providers have expressed a desire for information from the Joint Commission on effective solutions to safety and quality problems. “What I hear from our customers is: 'Don't keep telling us only about the problems—tell us how we can get better,'” he said.

Health care providers can make major and durable improvements in patient safety and quality by adopting “robust process-improvement” tools that are widely used by high-reliability industries such as commercial aviation and nuclear energy, where adverse events are far less common than in health care, Dr. Chassin said.

The Joint Commission does not plan to require the use of these tools as a condition for accreditation. However, emerging evidence indicates that these methodologies—including the Lean, Six Sigma, Toyota Production System, and GE Change Acceleration Process models—“work just as well when applied to our very nasty safety and quality problems as they do in all of the other very successful business and administrative processes where they've been tried,” Dr. Chassin said. “I am firmly convinced that the tools of robust process improvement are an incredibly important vehicle for getting us much farther down the road.”

With that in mind, “we are collaborating with physicians, nurse leaders, and managers of hospitals and health systems where Lean and Six Sigma are already working—organizations that have already made the investment and have mastered those tools. And we are deploying teams from those institutions to solve the most difficult quality and safety problems facing all of American health care,” Dr. Chassin explained. “Our job at the Joint Commission is to build the knowledge database, compiling all of that learning across all of those organizations, and to spread it to other organizations.”

The center's first project, devoted to hand hygiene, is a collaborative effort with several institutions nationwide. Using high-reliability strategies, these organizations documented average hand-washing rates below 50% at their institutions, rates much lower than previously believed. A range of solutions tailored to specific causes of noncompliance are now being tested.

The second project, which will focus on breakdowns in handoff communications, has several different participant organizations across the country.

The third project, which will target wrong-site surgery, will be a collaboration with Rhode Island Hospital (Providence) and Newport (R.I.) Hospital on the development and testing of a universal protocol for avoiding such errors.

High-reliability industries manage risks far more effectively than do health care providers because these industries have “a set of tools and principles that allows them to look very hard at their processes and perfect them, and then a culture that wraps around those improvement tools [and] that allows those nearly perfect processes to continue at high levels of safety for long periods of time,” Dr. Chassin said.

This type of firmly embedded culture, currently absent in health care, begins with the rigorous identification of problem root causes. Health care providers generally do a good job of defining problems and measuring outcomes, but they often gloss over the critical step of identifying exactly why a process is not working, he said. In order to develop effective, durable interventions, “you have to understand the specific causes of the problem where you're trying to fix it.”

“You can have the best technical solution … but if nobody uses it and everybody hates it, it will have no impact,” Dr. Chassin said. To deal with that problem, robust process improvement incorporates explicit change-management principles and tools into the process at the very beginning.

High-reliability organizations often automate processes after they have perfected them, but automation is not always possible in health care, he noted. “What we are charged with if we're going to get improvement that is sustained is changing the behavior of the individuals that work in the health care delivery system and maintaining that changed behavior over long periods of time.”

The Joint Commission Center for Transforming Healthcare has received support from the American Hospital Association, BD, Ecolab, GE Healthcare, Johnson & Johnson, the Federation of American Hospitals, and Hospira.

For more information, go to www.centerfortransforminghealthcare.org

'Our job at the Joint Commission is to [compile] all of that learning … and to spread it to other organizations.'

Source DR. CHASSIN

CHICAGO — A primary care delivery model for older patients with multiple chronic illnesses increased physician understanding of the patients' clinical conditions and improved communication with patients and families, in a randomized trial at eight primary care practices.

The study findings, presented in a poster at the annual research meeting of AcademyHealth, add to a growing body of evidence that the model can improve outcomes, reduce costs, and enhance the quality of care for chronically ill older adults.

In the Guided Care model—an initiative developed by the Johns Hopkins Bloomberg School of Public Health, Baltimore—a Guided Care nurse works with three or four primary care physicians and a targeted population of 50-60 patients. The nurse receives additional training in patient education and coaching and in chronic disease management.

The nurse also develops a comprehensive care plan for each patient based on medical conditions, the home environment, and individual patient goals; monitors patients monthly; coordinates transitions between providers and sites of care; educates and supports caregivers; keeps an electronic health record; and provides physicians with detailed updates.

“Physicians don't have a lot of time to do these things for every one of their complex patients,” Jill Marsteller, Ph.D., noted in an interview. “The nurse helps very much in terms of having a close personal relationship with these people who are so complex, and can provide them with the guidance that they need to access community resources and help them keep track of all the different visits.” The nurse also summarizes the information for the physician, she said, and in so doing, “is really helping the primary care physician as a partner in the care of this patient.”

The nurse visits the patient's home when Guided Care begins, making a connection that can yield valuable insights that might not come out in a medical interview. The patient who reports difficulty sleeping, for example, may be found during the home visit to have a kitchen stocked with caffeinated soft drinks.

A randomized trial of Guided Care—one aspect of which was reported in the poster presented at the meeting—has shown that this heightened attention to patients and support for physicians improves outcomes and increases patient satisfaction with their care. In the trial, 49 primary care physicians at eight community-based medical practices in the Baltimore and Washington D.C. region and 904 of their patients aged 65 years or older with multiple comorbidities were randomly assigned to Guided Care or usual care. Although the patients chosen for the study had multiple chronic illnesses, the study did not include patients who were severely ill or near death.

After 6 months, patients receiving Guided Care were twice as likely as were patients receiving usual care to rate the quality of their care as high (J. Gerontol. A Biol. Sci. Med. Sci. 2008;63:321-7). Caregivers of Guided Care patients, particularly those who spent 14 or more hours weekly caring for a family member, reported less “strain” and depression than did caregivers of usual care patients (J. Gerontol. A Biol. Sci. Med. Sci. 2009; 64:785-91). After 8 months, Guided Care patients spent 24% fewer days in the hospital, and had 29% fewer home health visits and 15% fewer emergency department visits (Am. J. Manag. Care 2009; 15:555-9).

The most recent phase of the study, presented at the AcademyHealth meeting, focused on physician satisfaction and perceptions after participating in the project for 1 year.

“Compared to the physicians in the control group, the physicians in Guided Care rated their satisfaction with patient/family communication and their knowledge of their chronically ill patients' clinical conditions significantly higher,” Ms. Marsteller and her colleagues reported.

On a six-point scale ranging from “very dissatisfied” to “very satisfied,” physicians in the control group gave mean ratings of 4.25 and 3.94, at baseline and at 1 year, respectively, for satisfaction with patient/family communication, while physicians in the Guided Care group gave mean ratings of 4.03 and 4.40. On a four-point scale measuring clinical knowledge of patients, with responses ranging from “definitely not” to “definitely,” physicians in the control group gave mean ratings of 2.70 and 2.77 at baseline and 1 year, respectively, while physicians in the Guided Care group gave mean ratings of 2.85 and 3.17.

Although the physicians who participated in the Guided Care group also reported greater satisfaction than did those in the usual care group on other measures, differences between the two groups did not reach statistical significance on these dimensions, which included satisfaction with management of chronic care and care coordination activities, time spent managing patients, personal knowledge of patients, and written information sent to specialists. The lack of significant results in these dimensions probably reflects the limited number of physicians who participated in the study. “We expect that after 2 and 3 years, we will begin to see a stronger effect,” said Ms. Marsteller of Johns Hopkins University's Bloomberg School of Public Health.

The study was funded by the John A. Hartford Foundation and the Roger C. Lipitz Center for Integrated Health Care of the Bloomberg School of Public Health.

The main study, of which this study is a part, also received support from the Agency for Healthcare Research and Quality, the National Institute on Aging, the Jacob and Valeria Langeloth Foundation, Kaiser-Permanente Mid-Atlantic, and Johns Hopkins Health Care.

More information about Guided Care is available at www.guidedcare.org

CHICAGO — A primary care delivery model for older patients with multiple chronic illnesses increased physician understanding of the patients' clinical conditions and improved communication with patients and families, in a randomized trial at eight primary care practices.

The study findings, presented in a poster at the annual research meeting of AcademyHealth, add to a growing body of evidence that the model can improve outcomes, reduce costs, and enhance the quality of care for chronically ill older adults.

In the Guided Care model—an initiative developed by the Johns Hopkins Bloomberg School of Public Health, Baltimore—a Guided Care nurse works with three or four primary care physicians and a targeted population of 50-60 patients. The nurse receives additional training in patient education and coaching and in chronic disease management.

The nurse also develops a comprehensive care plan for each patient based on medical conditions, the home environment, and individual patient goals; monitors patients monthly; coordinates transitions between providers and sites of care; educates and supports caregivers; keeps an electronic health record; and provides physicians with detailed updates.

“Physicians don't have a lot of time to do these things for every one of their complex patients,” Jill Marsteller, Ph.D., noted in an interview. “The nurse helps very much in terms of having a close personal relationship with these people who are so complex, and can provide them with the guidance that they need to access community resources and help them keep track of all the different visits.” The nurse also summarizes the information for the physician, she said, and in so doing, “is really helping the primary care physician as a partner in the care of this patient.”

The nurse visits the patient's home when Guided Care begins, making a connection that can yield valuable insights that might not come out in a medical interview. The patient who reports difficulty sleeping, for example, may be found during the home visit to have a kitchen stocked with caffeinated soft drinks.

A randomized trial of Guided Care—one aspect of which was reported in the poster presented at the meeting—has shown that this heightened attention to patients and support for physicians improves outcomes and increases patient satisfaction with their care. In the trial, 49 primary care physicians at eight community-based medical practices in the Baltimore and Washington D.C. region and 904 of their patients aged 65 years or older with multiple comorbidities were randomly assigned to Guided Care or usual care. Although the patients chosen for the study had multiple chronic illnesses, the study did not include patients who were severely ill or near death.

After 6 months, patients receiving Guided Care were twice as likely as were patients receiving usual care to rate the quality of their care as high (J. Gerontol. A Biol. Sci. Med. Sci. 2008;63:321-7). Caregivers of Guided Care patients, particularly those who spent 14 or more hours weekly caring for a family member, reported less “strain” and depression than did caregivers of usual care patients (J. Gerontol. A Biol. Sci. Med. Sci. 2009; 64:785-91). After 8 months, Guided Care patients spent 24% fewer days in the hospital, and had 29% fewer home health visits and 15% fewer emergency department visits (Am. J. Manag. Care 2009; 15:555-9).

The most recent phase of the study, presented at the AcademyHealth meeting, focused on physician satisfaction and perceptions after participating in the project for 1 year.

“Compared to the physicians in the control group, the physicians in Guided Care rated their satisfaction with patient/family communication and their knowledge of their chronically ill patients' clinical conditions significantly higher,” Ms. Marsteller and her colleagues reported.

On a six-point scale ranging from “very dissatisfied” to “very satisfied,” physicians in the control group gave mean ratings of 4.25 and 3.94, at baseline and at 1 year, respectively, for satisfaction with patient/family communication, while physicians in the Guided Care group gave mean ratings of 4.03 and 4.40. On a four-point scale measuring clinical knowledge of patients, with responses ranging from “definitely not” to “definitely,” physicians in the control group gave mean ratings of 2.70 and 2.77 at baseline and 1 year, respectively, while physicians in the Guided Care group gave mean ratings of 2.85 and 3.17.

Although the physicians who participated in the Guided Care group also reported greater satisfaction than did those in the usual care group on other measures, differences between the two groups did not reach statistical significance on these dimensions, which included satisfaction with management of chronic care and care coordination activities, time spent managing patients, personal knowledge of patients, and written information sent to specialists. The lack of significant results in these dimensions probably reflects the limited number of physicians who participated in the study. “We expect that after 2 and 3 years, we will begin to see a stronger effect,” said Ms. Marsteller of Johns Hopkins University's Bloomberg School of Public Health.

The study was funded by the John A. Hartford Foundation and the Roger C. Lipitz Center for Integrated Health Care of the Bloomberg School of Public Health.

The main study, of which this study is a part, also received support from the Agency for Healthcare Research and Quality, the National Institute on Aging, the Jacob and Valeria Langeloth Foundation, Kaiser-Permanente Mid-Atlantic, and Johns Hopkins Health Care.

More information about Guided Care is available at www.guidedcare.org

CHICAGO — A primary care delivery model for older patients with multiple chronic illnesses increased physician understanding of the patients' clinical conditions and improved communication with patients and families, in a randomized trial at eight primary care practices.

The study findings, presented in a poster at the annual research meeting of AcademyHealth, add to a growing body of evidence that the model can improve outcomes, reduce costs, and enhance the quality of care for chronically ill older adults.

In the Guided Care model—an initiative developed by the Johns Hopkins Bloomberg School of Public Health, Baltimore—a Guided Care nurse works with three or four primary care physicians and a targeted population of 50-60 patients. The nurse receives additional training in patient education and coaching and in chronic disease management.

The nurse also develops a comprehensive care plan for each patient based on medical conditions, the home environment, and individual patient goals; monitors patients monthly; coordinates transitions between providers and sites of care; educates and supports caregivers; keeps an electronic health record; and provides physicians with detailed updates.

“Physicians don't have a lot of time to do these things for every one of their complex patients,” Jill Marsteller, Ph.D., noted in an interview. “The nurse helps very much in terms of having a close personal relationship with these people who are so complex, and can provide them with the guidance that they need to access community resources and help them keep track of all the different visits.” The nurse also summarizes the information for the physician, she said, and in so doing, “is really helping the primary care physician as a partner in the care of this patient.”

The nurse visits the patient's home when Guided Care begins, making a connection that can yield valuable insights that might not come out in a medical interview. The patient who reports difficulty sleeping, for example, may be found during the home visit to have a kitchen stocked with caffeinated soft drinks.

A randomized trial of Guided Care—one aspect of which was reported in the poster presented at the meeting—has shown that this heightened attention to patients and support for physicians improves outcomes and increases patient satisfaction with their care. In the trial, 49 primary care physicians at eight community-based medical practices in the Baltimore and Washington D.C. region and 904 of their patients aged 65 years or older with multiple comorbidities were randomly assigned to Guided Care or usual care. Although the patients chosen for the study had multiple chronic illnesses, the study did not include patients who were severely ill or near death.

After 6 months, patients receiving Guided Care were twice as likely as were patients receiving usual care to rate the quality of their care as high (J. Gerontol. A Biol. Sci. Med. Sci. 2008;63:321-7). Caregivers of Guided Care patients, particularly those who spent 14 or more hours weekly caring for a family member, reported less “strain” and depression than did caregivers of usual care patients (J. Gerontol. A Biol. Sci. Med. Sci. 2009; 64:785-91). After 8 months, Guided Care patients spent 24% fewer days in the hospital, and had 29% fewer home health visits and 15% fewer emergency department visits (Am. J. Manag. Care 2009; 15:555-9).

The most recent phase of the study, presented at the AcademyHealth meeting, focused on physician satisfaction and perceptions after participating in the project for 1 year.

“Compared to the physicians in the control group, the physicians in Guided Care rated their satisfaction with patient/family communication and their knowledge of their chronically ill patients' clinical conditions significantly higher,” Ms. Marsteller and her colleagues reported.

On a six-point scale ranging from “very dissatisfied” to “very satisfied,” physicians in the control group gave mean ratings of 4.25 and 3.94, at baseline and at 1 year, respectively, for satisfaction with patient/family communication, while physicians in the Guided Care group gave mean ratings of 4.03 and 4.40. On a four-point scale measuring clinical knowledge of patients, with responses ranging from “definitely not” to “definitely,” physicians in the control group gave mean ratings of 2.70 and 2.77 at baseline and 1 year, respectively, while physicians in the Guided Care group gave mean ratings of 2.85 and 3.17.

Although the physicians who participated in the Guided Care group also reported greater satisfaction than did those in the usual care group on other measures, differences between the two groups did not reach statistical significance on these dimensions, which included satisfaction with management of chronic care and care coordination activities, time spent managing patients, personal knowledge of patients, and written information sent to specialists. The lack of significant results in these dimensions probably reflects the limited number of physicians who participated in the study. “We expect that after 2 and 3 years, we will begin to see a stronger effect,” said Ms. Marsteller of Johns Hopkins University's Bloomberg School of Public Health.

The study was funded by the John A. Hartford Foundation and the Roger C. Lipitz Center for Integrated Health Care of the Bloomberg School of Public Health.

The main study, of which this study is a part, also received support from the Agency for Healthcare Research and Quality, the National Institute on Aging, the Jacob and Valeria Langeloth Foundation, Kaiser-Permanente Mid-Atlantic, and Johns Hopkins Health Care.

More information about Guided Care is available at www.guidedcare.org

CHICAGO — The Medicare Physician Group Practice Demonstration achieved modest cost savings and quality enhancements in the project's first 2 performance years, researchers reported at the annual research meeting of AcademyHealth. Data released in August reinforce that finding.

The project involves 10 large, geographically diverse physician group practices with a total of 5,000 physicians caring for 200,000 Medicare fee-for-service beneficiaries. The practices include multispecialty groups, integrated delivery systems, faculty groups, and a physician network.

During each year of the project, each group was retroactively assigned a population of Medicare beneficiaries, with an average of 20,000 patients per group (range 10,000-37,000). Each group was held accountable for total Part A and Part B expenditures for these patients.

Patients had complete freedom of choice in providers and were not required to receive care through the participating group practice. However, only patients who received most of their outpatient evaluation and management for the year from the group practice were assigned to the group. Groups that kept increases in expenditures below 2 percentage points of their target growth rate shared up to 80% of the savings; Medicare retained 20%.

The group practices assumed all business risks associated with investments related to their participation in the demonstration, and there was no guarantee of savings.

“Savings are a function of the ability of the group to control growth in Medicare spending as well as changes in [health] status of their assigned population over time relative to their local market,” explained John Pilotte, a senior research analyst at the Centers for Medicare and Medicaid Services. The groups were free to make whatever investments and enhancements they felt were necessary to reach their quality and efficiency goals.

In the first year of the demonstration, two participating group practices earned a total performance payment of $7.3 million and two lost a total of $1.5 million, Gregory Pope of RTI International in Waltham, Mass., a nonprofit research and development firm working with the CMS, reported at the meeting. In the second year, four groups shared a total payment of $13.8 million and one lost $2 million. Savings to Medicare totaled $677,000 and $1.6 million for the first and second years, respectively.

Results for the third year were announced in August; five physician groups will receive performance payments totaling $25.3 million as part of their share of $32.3 million of savings generated for the Medicare Trust Funds in that year, the CMS announced.

Quality was assessed by the groups' adherence to 27 measures as indicated by Medicare claims and clinical records data. The measures covered heart failure, diabetes, coronary artery disease, hypertension, and preventive care.

In the third year, all 10 groups achieved benchmark performance on at least 28 of the 32 measures reported, according to the CMS. Two groups—Geisinger Clinic in Danville, Pa., and Park Nicollet Health Services in St. Louis Park, Minn.—achieved benchmark performance on all 32 performance measures.

Over the first 3 years of the demonstration, the physician groups increased their quality scores an average of 10 percentage points on 10 diabetes measures, 11 points on 10 heart failure measures, 6 points on 7 coronary artery disease measures, 10 points on 2 cancer screening measures, and 1 percentage point on 3 hypertension measures.

Additional research is needed to determine the keys to success, according to Mr. Pilotte of the CMS. “Trying to figure out how to make this work in a program that processes over 1 billion claims each year is not a small feat. … It takes a while to get these projects up and running both from our side of the house and the provider side.”

Although the group practices generally have sophisticated health information management systems and dedicated information technology leadership, “even that doesn't seem to be enough to control growth in expenditures.”

One key lesson learned so far during the demonstration is that “leadership and champions within the organization are really important,” Mr. Pilotte said. “All of these groups have someone who is on point for monitoring and reporting the quality metrics to us every year and developing mechanisms … to be able to capture the information.”

Another lesson learned is the importance of having quality measures consistent with clinical practice and high-quality care in order to achieve physician buy-in. “That's why we spent a fair amount of time early on with these physician groups on which measures we were going to use and to gain their support, because it really wouldn't be possible without them,” he said.

For more information, visit www.cms.hhs.gov/DemoProjectsEvalRpts/MD/list.asp

Joyce Frieden contributed to this report.

CHICAGO — The Medicare Physician Group Practice Demonstration achieved modest cost savings and quality enhancements in the project's first 2 performance years, researchers reported at the annual research meeting of AcademyHealth. Data released in August reinforce that finding.

The project involves 10 large, geographically diverse physician group practices with a total of 5,000 physicians caring for 200,000 Medicare fee-for-service beneficiaries. The practices include multispecialty groups, integrated delivery systems, faculty groups, and a physician network.

During each year of the project, each group was retroactively assigned a population of Medicare beneficiaries, with an average of 20,000 patients per group (range 10,000-37,000). Each group was held accountable for total Part A and Part B expenditures for these patients.

Patients had complete freedom of choice in providers and were not required to receive care through the participating group practice. However, only patients who received most of their outpatient evaluation and management for the year from the group practice were assigned to the group. Groups that kept increases in expenditures below 2 percentage points of their target growth rate shared up to 80% of the savings; Medicare retained 20%.

The group practices assumed all business risks associated with investments related to their participation in the demonstration, and there was no guarantee of savings.

“Savings are a function of the ability of the group to control growth in Medicare spending as well as changes in [health] status of their assigned population over time relative to their local market,” explained John Pilotte, a senior research analyst at the Centers for Medicare and Medicaid Services. The groups were free to make whatever investments and enhancements they felt were necessary to reach their quality and efficiency goals.

In the first year of the demonstration, two participating group practices earned a total performance payment of $7.3 million and two lost a total of $1.5 million, Gregory Pope of RTI International in Waltham, Mass., a nonprofit research and development firm working with the CMS, reported at the meeting. In the second year, four groups shared a total payment of $13.8 million and one lost $2 million. Savings to Medicare totaled $677,000 and $1.6 million for the first and second years, respectively.

Results for the third year were announced in August; five physician groups will receive performance payments totaling $25.3 million as part of their share of $32.3 million of savings generated for the Medicare Trust Funds in that year, the CMS announced.

Quality was assessed by the groups' adherence to 27 measures as indicated by Medicare claims and clinical records data. The measures covered heart failure, diabetes, coronary artery disease, hypertension, and preventive care.

In the third year, all 10 groups achieved benchmark performance on at least 28 of the 32 measures reported, according to the CMS. Two groups—Geisinger Clinic in Danville, Pa., and Park Nicollet Health Services in St. Louis Park, Minn.—achieved benchmark performance on all 32 performance measures.

Over the first 3 years of the demonstration, the physician groups increased their quality scores an average of 10 percentage points on 10 diabetes measures, 11 points on 10 heart failure measures, 6 points on 7 coronary artery disease measures, 10 points on 2 cancer screening measures, and 1 percentage point on 3 hypertension measures.

Additional research is needed to determine the keys to success, according to Mr. Pilotte of the CMS. “Trying to figure out how to make this work in a program that processes over 1 billion claims each year is not a small feat. … It takes a while to get these projects up and running both from our side of the house and the provider side.”

Although the group practices generally have sophisticated health information management systems and dedicated information technology leadership, “even that doesn't seem to be enough to control growth in expenditures.”

One key lesson learned so far during the demonstration is that “leadership and champions within the organization are really important,” Mr. Pilotte said. “All of these groups have someone who is on point for monitoring and reporting the quality metrics to us every year and developing mechanisms … to be able to capture the information.”

Another lesson learned is the importance of having quality measures consistent with clinical practice and high-quality care in order to achieve physician buy-in. “That's why we spent a fair amount of time early on with these physician groups on which measures we were going to use and to gain their support, because it really wouldn't be possible without them,” he said.

For more information, visit www.cms.hhs.gov/DemoProjectsEvalRpts/MD/list.asp

Joyce Frieden contributed to this report.

CHICAGO — The Medicare Physician Group Practice Demonstration achieved modest cost savings and quality enhancements in the project's first 2 performance years, researchers reported at the annual research meeting of AcademyHealth. Data released in August reinforce that finding.

The project involves 10 large, geographically diverse physician group practices with a total of 5,000 physicians caring for 200,000 Medicare fee-for-service beneficiaries. The practices include multispecialty groups, integrated delivery systems, faculty groups, and a physician network.

During each year of the project, each group was retroactively assigned a population of Medicare beneficiaries, with an average of 20,000 patients per group (range 10,000-37,000). Each group was held accountable for total Part A and Part B expenditures for these patients.

Patients had complete freedom of choice in providers and were not required to receive care through the participating group practice. However, only patients who received most of their outpatient evaluation and management for the year from the group practice were assigned to the group. Groups that kept increases in expenditures below 2 percentage points of their target growth rate shared up to 80% of the savings; Medicare retained 20%.

The group practices assumed all business risks associated with investments related to their participation in the demonstration, and there was no guarantee of savings.

“Savings are a function of the ability of the group to control growth in Medicare spending as well as changes in [health] status of their assigned population over time relative to their local market,” explained John Pilotte, a senior research analyst at the Centers for Medicare and Medicaid Services. The groups were free to make whatever investments and enhancements they felt were necessary to reach their quality and efficiency goals.

In the first year of the demonstration, two participating group practices earned a total performance payment of $7.3 million and two lost a total of $1.5 million, Gregory Pope of RTI International in Waltham, Mass., a nonprofit research and development firm working with the CMS, reported at the meeting. In the second year, four groups shared a total payment of $13.8 million and one lost $2 million. Savings to Medicare totaled $677,000 and $1.6 million for the first and second years, respectively.

Results for the third year were announced in August; five physician groups will receive performance payments totaling $25.3 million as part of their share of $32.3 million of savings generated for the Medicare Trust Funds in that year, the CMS announced.

Quality was assessed by the groups' adherence to 27 measures as indicated by Medicare claims and clinical records data. The measures covered heart failure, diabetes, coronary artery disease, hypertension, and preventive care.

In the third year, all 10 groups achieved benchmark performance on at least 28 of the 32 measures reported, according to the CMS. Two groups—Geisinger Clinic in Danville, Pa., and Park Nicollet Health Services in St. Louis Park, Minn.—achieved benchmark performance on all 32 performance measures.

Over the first 3 years of the demonstration, the physician groups increased their quality scores an average of 10 percentage points on 10 diabetes measures, 11 points on 10 heart failure measures, 6 points on 7 coronary artery disease measures, 10 points on 2 cancer screening measures, and 1 percentage point on 3 hypertension measures.

Additional research is needed to determine the keys to success, according to Mr. Pilotte of the CMS. “Trying to figure out how to make this work in a program that processes over 1 billion claims each year is not a small feat. … It takes a while to get these projects up and running both from our side of the house and the provider side.”

Although the group practices generally have sophisticated health information management systems and dedicated information technology leadership, “even that doesn't seem to be enough to control growth in expenditures.”

One key lesson learned so far during the demonstration is that “leadership and champions within the organization are really important,” Mr. Pilotte said. “All of these groups have someone who is on point for monitoring and reporting the quality metrics to us every year and developing mechanisms … to be able to capture the information.”

Another lesson learned is the importance of having quality measures consistent with clinical practice and high-quality care in order to achieve physician buy-in. “That's why we spent a fair amount of time early on with these physician groups on which measures we were going to use and to gain their support, because it really wouldn't be possible without them,” he said.

For more information, visit www.cms.hhs.gov/DemoProjectsEvalRpts/MD/list.asp

Joyce Frieden contributed to this report.

CHICAGO — The Medicare Physician Group Practice Demonstration achieved modest cost savings and quality enhancements in the project's first 2 performance years, researchers reported at the annual research meeting of AcademyHealth. Data released in August reinforce that finding.

The project involves 10 large, geographically diverse physician group practices with a total of 5,000 physicians caring for 200,000 Medicare fee-for-service beneficiaries.

During each year of the project, each group was retroactively assigned a population of Medicare beneficiaries, with an average of 20,000 patients per group (range 10,000-37,000). Each group was held accountable for total Part A and Part B expenditures for these patients.

Patients had complete freedom of choice in providers and were not required to receive care through the participating group practice. However, only patients who received most of their outpatient evaluation and management for the year from the group practice were assigned to the group. Groups that kept increases in expenditures below 2 percentage points of their target growth rate shared up to 80% of the savings; Medicare retained 20%.

"Savings are a function of the ability of the group to control growth in Medicare spending as well as changes in [health] status of their assigned population over time relative to their local market," explained John Pilotte, a senior research analyst at the Centers for Medicare and Medicaid Services.

In the first year of the demonstration, two participating group practices earned a total performance payment of $7.3 million and two lost a total of $1.5 million, Gregory Pope of RTI International in Waltham, Mass., a nonprofit research and development firm working with the CMS, reported at the meeting. In the second year, four groups shared a total payment of $13.8 million and one lost $2 million. Savings to Medicare totaled $677,000 and $1.6 million for the first and second years, respectively.

Results for the third year were announced in August; five physician groups will receive performance payments totaling $25.3 million as part of their share of $32.3 million of savings generated for the Medicare Trust Funds in that year, the CMS announced.

Quality was assessed by the groups' adherence to 27 measures as indicated by Medicare claims and clinical records data. Two group practices complied with 10 of the quality markers in performance year one, while five groups complied with all 27 quality markers in the second year, said Musetta Leung of RTI International.

Second-year performance data indicated significant improvements, she said.

In the third year, all 10 groups achieved benchmark performance on at least 28 of the 32 measures reported, according to the CMS. Two groups achieved benchmark performance on all 32 performance measures.

Over the first 3 years of the demonstration, the physician groups increased their quality scores an average of 10 percentage points on 10 diabetes measures, 11 points on 10 heart failure measures, 6 points on 7 coronary artery disease measures, 10 points on 2 cancer screening measures, and 1 percentage point on 3 hypertension measures.

Additional research is needed to determine the keys to success, according to Mr. Pilotte of the CMS. The group practices generally have sophisticated health information management systems and dedicated information technology leadership, but "even that doesn't seem to be enough to control growth in expenditures.

Joyce Frieden contributed to this report.

CHICAGO — The Medicare Physician Group Practice Demonstration achieved modest cost savings and quality enhancements in the project's first 2 performance years, researchers reported at the annual research meeting of AcademyHealth. Data released in August reinforce that finding.

The project involves 10 large, geographically diverse physician group practices with a total of 5,000 physicians caring for 200,000 Medicare fee-for-service beneficiaries.

During each year of the project, each group was retroactively assigned a population of Medicare beneficiaries, with an average of 20,000 patients per group (range 10,000-37,000). Each group was held accountable for total Part A and Part B expenditures for these patients.

Patients had complete freedom of choice in providers and were not required to receive care through the participating group practice. However, only patients who received most of their outpatient evaluation and management for the year from the group practice were assigned to the group. Groups that kept increases in expenditures below 2 percentage points of their target growth rate shared up to 80% of the savings; Medicare retained 20%.

"Savings are a function of the ability of the group to control growth in Medicare spending as well as changes in [health] status of their assigned population over time relative to their local market," explained John Pilotte, a senior research analyst at the Centers for Medicare and Medicaid Services.

In the first year of the demonstration, two participating group practices earned a total performance payment of $7.3 million and two lost a total of $1.5 million, Gregory Pope of RTI International in Waltham, Mass., a nonprofit research and development firm working with the CMS, reported at the meeting. In the second year, four groups shared a total payment of $13.8 million and one lost $2 million. Savings to Medicare totaled $677,000 and $1.6 million for the first and second years, respectively.

Results for the third year were announced in August; five physician groups will receive performance payments totaling $25.3 million as part of their share of $32.3 million of savings generated for the Medicare Trust Funds in that year, the CMS announced.

Quality was assessed by the groups' adherence to 27 measures as indicated by Medicare claims and clinical records data. Two group practices complied with 10 of the quality markers in performance year one, while five groups complied with all 27 quality markers in the second year, said Musetta Leung of RTI International.

Second-year performance data indicated significant improvements, she said.

In the third year, all 10 groups achieved benchmark performance on at least 28 of the 32 measures reported, according to the CMS. Two groups achieved benchmark performance on all 32 performance measures.

Over the first 3 years of the demonstration, the physician groups increased their quality scores an average of 10 percentage points on 10 diabetes measures, 11 points on 10 heart failure measures, 6 points on 7 coronary artery disease measures, 10 points on 2 cancer screening measures, and 1 percentage point on 3 hypertension measures.

Additional research is needed to determine the keys to success, according to Mr. Pilotte of the CMS. The group practices generally have sophisticated health information management systems and dedicated information technology leadership, but "even that doesn't seem to be enough to control growth in expenditures.

Joyce Frieden contributed to this report.

CHICAGO — The Medicare Physician Group Practice Demonstration achieved modest cost savings and quality enhancements in the project's first 2 performance years, researchers reported at the annual research meeting of AcademyHealth. Data released in August reinforce that finding.

The project involves 10 large, geographically diverse physician group practices with a total of 5,000 physicians caring for 200,000 Medicare fee-for-service beneficiaries.

During each year of the project, each group was retroactively assigned a population of Medicare beneficiaries, with an average of 20,000 patients per group (range 10,000-37,000). Each group was held accountable for total Part A and Part B expenditures for these patients.

Patients had complete freedom of choice in providers and were not required to receive care through the participating group practice. However, only patients who received most of their outpatient evaluation and management for the year from the group practice were assigned to the group. Groups that kept increases in expenditures below 2 percentage points of their target growth rate shared up to 80% of the savings; Medicare retained 20%.

"Savings are a function of the ability of the group to control growth in Medicare spending as well as changes in [health] status of their assigned population over time relative to their local market," explained John Pilotte, a senior research analyst at the Centers for Medicare and Medicaid Services.

In the first year of the demonstration, two participating group practices earned a total performance payment of $7.3 million and two lost a total of $1.5 million, Gregory Pope of RTI International in Waltham, Mass., a nonprofit research and development firm working with the CMS, reported at the meeting. In the second year, four groups shared a total payment of $13.8 million and one lost $2 million. Savings to Medicare totaled $677,000 and $1.6 million for the first and second years, respectively.

Results for the third year were announced in August; five physician groups will receive performance payments totaling $25.3 million as part of their share of $32.3 million of savings generated for the Medicare Trust Funds in that year, the CMS announced.

Quality was assessed by the groups' adherence to 27 measures as indicated by Medicare claims and clinical records data. Two group practices complied with 10 of the quality markers in performance year one, while five groups complied with all 27 quality markers in the second year, said Musetta Leung of RTI International.

Second-year performance data indicated significant improvements, she said.

In the third year, all 10 groups achieved benchmark performance on at least 28 of the 32 measures reported, according to the CMS. Two groups achieved benchmark performance on all 32 performance measures.

Over the first 3 years of the demonstration, the physician groups increased their quality scores an average of 10 percentage points on 10 diabetes measures, 11 points on 10 heart failure measures, 6 points on 7 coronary artery disease measures, 10 points on 2 cancer screening measures, and 1 percentage point on 3 hypertension measures.

Additional research is needed to determine the keys to success, according to Mr. Pilotte of the CMS. The group practices generally have sophisticated health information management systems and dedicated information technology leadership, but "even that doesn't seem to be enough to control growth in expenditures.

Joyce Frieden contributed to this report.

CHICAGO — The Medicare Physician Group Practice Demonstration achieved modest cost savings and quality enhancements in the project's first 2 performance years, researchers reported at the annual research meeting of AcademyHealth. Data released in August reinforce that finding.

The project involves 10 large, geographically diverse physician group practices with a total of 5,000 physicians caring for 200,000 Medicare fee-for-service beneficiaries. The practices include multispecialty groups, integrated delivery systems, faculty groups, and a physician network.

During each year of the project, each group was retroactively assigned a population of Medicare beneficiaries, with an average of 20,000 patients per group (range 10,000–37,000). Each group was held accountable for total Part A and Part B expenditures for these patients.

Patients had complete freedom of choice in providers and were not required to receive care through the participating group practice. However, only patients who received most of their outpatient evaluation and management for the year from the group practice were assigned to the group. Groups that kept increases in expenditures below 2 percentage points of their target growth rate shared up to 80% of the savings; Medicare retained 20%.

The group practices assumed all business risks associated with investments related to their participation in the demonstration, and there was no guarantee of savings.

“Savings are a function of the ability of the group to control growth in Medicare spending as well as changes in [health] status of their assigned population over time relative to their local market,” explained John Pilotte, a senior research analyst at the Centers for Medicare and Medicaid Services.

The groups were free to make whatever investments and enhancements that they felt were necessary to reach their quality and efficiency goals.

In the first year of the demonstration, two participating group practices earned a total performance payment of $7.3 million and two lost a total of $1.5 million, Gregory Pope of RTI International in Waltham, Mass., a nonprofit research and development firm working with the CMS, reported at the meeting.

In the second year of the project, four groups shared a total payment of $13.8 million and one lost $2 million. Savings to Medicare totaled $677,000 and $1.6 million for the first and second years, respectively.

Results for the third year were announced in August; five physician groups will receive performance payments totaling $25.3 million as part of their share of $32.3 million of savings generated for the Medicare Trust Funds in that year, the CMS announced.

Quality was assessed by the groups' adherence to 27 measures as indicated by Medicare claims and clinical records data. The measures, developed by the CMS in collaboration with the American Medical Association and the National Committee for Quality Assurance, covered heart failure, diabetes, coronary artery disease, hypertension, and preventive care.

Two group practices complied with 10 of the quality markers in performance year one, while five groups complied with all 27 quality markers in the second year, said Musetta Leung of RTI International.

In the second year, all of the group practices met all of their quality targets for heart failure and coronary artery disease.

Achieving the diabetes-related quality measures remained a challenge. Still, second-year performance data indicated significant improvements, Ms. Leung said.

In the project's third year, all 10 groups achieved benchmark performance on at least 28 of the 32 measures reported, according to the CMS. Two groups—Geisinger Clinic in Danville, Pa., and Park Nicollet Health Services in St. Louis Park, Minn.—achieved benchmark performance on all of the 32 performance measures.

Over the first 3 years of the demonstration, the physician groups increased their quality scores an average of 10 percentage points on 10 diabetes measures, 11 points on 10 heart failure measures, 6 points on 7 coronary artery disease measures, 10 points on 2 cancer screening measures, and 1 percentage point on 3 hypertension measures.

Additional research is needed to determine the keys to success, according to Mr. Pilotte of the CMS. “Trying to figure out how to make this work in a program that processes over 1 billion claims each year is not a small feat. …It takes a while to get these projects up and running both from our side of the house and the provider side.”

Although the group practices generally have sophisticated health information management systems and dedicated information technology leadership, “even that doesn't seem to be enough to control growth in expenditures. …There are probably other things going on that we haven't fully identified that are necessary to be successful.”

Overall, “the results show we're moving in the right direction, but bringing in expenditure growth under target is challenging under the existing target-setting methodology even for these large organizations,” he said.

One key lesson learned so far during the demonstration is that “leadership and champions within the organization are really important,” Mr. Pilotte said. “All of these groups have someone who is on point for monitoring and reporting the quality metrics to us every year and developing mechanisms … to be able to capture the information.”

Another lesson learned is the importance of having quality measures consistent with clinical practice and high-quality care in order to achieve physician buy-in.

“That's why we spent a fair amount of time early on with these physician groups on which measures we were going to use and to gain their support, because it really wouldn't be possible without them,” he said.

For more information, visit www.cms.hhs.gov/DemoProjectsEvalRpts/MD/list.asp

Joyce Frieden contributed to this report.

CHICAGO — The Medicare Physician Group Practice Demonstration achieved modest cost savings and quality enhancements in the project's first 2 performance years, researchers reported at the annual research meeting of AcademyHealth. Data released in August reinforce that finding.

The project involves 10 large, geographically diverse physician group practices with a total of 5,000 physicians caring for 200,000 Medicare fee-for-service beneficiaries. The practices include multispecialty groups, integrated delivery systems, faculty groups, and a physician network.

During each year of the project, each group was retroactively assigned a population of Medicare beneficiaries, with an average of 20,000 patients per group (range 10,000–37,000). Each group was held accountable for total Part A and Part B expenditures for these patients.

Patients had complete freedom of choice in providers and were not required to receive care through the participating group practice. However, only patients who received most of their outpatient evaluation and management for the year from the group practice were assigned to the group. Groups that kept increases in expenditures below 2 percentage points of their target growth rate shared up to 80% of the savings; Medicare retained 20%.

The group practices assumed all business risks associated with investments related to their participation in the demonstration, and there was no guarantee of savings.

“Savings are a function of the ability of the group to control growth in Medicare spending as well as changes in [health] status of their assigned population over time relative to their local market,” explained John Pilotte, a senior research analyst at the Centers for Medicare and Medicaid Services.

The groups were free to make whatever investments and enhancements that they felt were necessary to reach their quality and efficiency goals.

In the first year of the demonstration, two participating group practices earned a total performance payment of $7.3 million and two lost a total of $1.5 million, Gregory Pope of RTI International in Waltham, Mass., a nonprofit research and development firm working with the CMS, reported at the meeting.

In the second year of the project, four groups shared a total payment of $13.8 million and one lost $2 million. Savings to Medicare totaled $677,000 and $1.6 million for the first and second years, respectively.

Results for the third year were announced in August; five physician groups will receive performance payments totaling $25.3 million as part of their share of $32.3 million of savings generated for the Medicare Trust Funds in that year, the CMS announced.

Quality was assessed by the groups' adherence to 27 measures as indicated by Medicare claims and clinical records data. The measures, developed by the CMS in collaboration with the American Medical Association and the National Committee for Quality Assurance, covered heart failure, diabetes, coronary artery disease, hypertension, and preventive care.

Two group practices complied with 10 of the quality markers in performance year one, while five groups complied with all 27 quality markers in the second year, said Musetta Leung of RTI International.

In the second year, all of the group practices met all of their quality targets for heart failure and coronary artery disease.

Achieving the diabetes-related quality measures remained a challenge. Still, second-year performance data indicated significant improvements, Ms. Leung said.

In the project's third year, all 10 groups achieved benchmark performance on at least 28 of the 32 measures reported, according to the CMS. Two groups—Geisinger Clinic in Danville, Pa., and Park Nicollet Health Services in St. Louis Park, Minn.—achieved benchmark performance on all of the 32 performance measures.

Over the first 3 years of the demonstration, the physician groups increased their quality scores an average of 10 percentage points on 10 diabetes measures, 11 points on 10 heart failure measures, 6 points on 7 coronary artery disease measures, 10 points on 2 cancer screening measures, and 1 percentage point on 3 hypertension measures.

Additional research is needed to determine the keys to success, according to Mr. Pilotte of the CMS. “Trying to figure out how to make this work in a program that processes over 1 billion claims each year is not a small feat. …It takes a while to get these projects up and running both from our side of the house and the provider side.”

Although the group practices generally have sophisticated health information management systems and dedicated information technology leadership, “even that doesn't seem to be enough to control growth in expenditures. …There are probably other things going on that we haven't fully identified that are necessary to be successful.”

Overall, “the results show we're moving in the right direction, but bringing in expenditure growth under target is challenging under the existing target-setting methodology even for these large organizations,” he said.

One key lesson learned so far during the demonstration is that “leadership and champions within the organization are really important,” Mr. Pilotte said. “All of these groups have someone who is on point for monitoring and reporting the quality metrics to us every year and developing mechanisms … to be able to capture the information.”

Another lesson learned is the importance of having quality measures consistent with clinical practice and high-quality care in order to achieve physician buy-in.

“That's why we spent a fair amount of time early on with these physician groups on which measures we were going to use and to gain their support, because it really wouldn't be possible without them,” he said.

For more information, visit www.cms.hhs.gov/DemoProjectsEvalRpts/MD/list.asp

Joyce Frieden contributed to this report.

CHICAGO — The Medicare Physician Group Practice Demonstration achieved modest cost savings and quality enhancements in the project's first 2 performance years, researchers reported at the annual research meeting of AcademyHealth. Data released in August reinforce that finding.

The project involves 10 large, geographically diverse physician group practices with a total of 5,000 physicians caring for 200,000 Medicare fee-for-service beneficiaries. The practices include multispecialty groups, integrated delivery systems, faculty groups, and a physician network.

During each year of the project, each group was retroactively assigned a population of Medicare beneficiaries, with an average of 20,000 patients per group (range 10,000–37,000). Each group was held accountable for total Part A and Part B expenditures for these patients.

Patients had complete freedom of choice in providers and were not required to receive care through the participating group practice. However, only patients who received most of their outpatient evaluation and management for the year from the group practice were assigned to the group. Groups that kept increases in expenditures below 2 percentage points of their target growth rate shared up to 80% of the savings; Medicare retained 20%.

The group practices assumed all business risks associated with investments related to their participation in the demonstration, and there was no guarantee of savings.

“Savings are a function of the ability of the group to control growth in Medicare spending as well as changes in [health] status of their assigned population over time relative to their local market,” explained John Pilotte, a senior research analyst at the Centers for Medicare and Medicaid Services.

The groups were free to make whatever investments and enhancements that they felt were necessary to reach their quality and efficiency goals.

In the first year of the demonstration, two participating group practices earned a total performance payment of $7.3 million and two lost a total of $1.5 million, Gregory Pope of RTI International in Waltham, Mass., a nonprofit research and development firm working with the CMS, reported at the meeting.

In the second year of the project, four groups shared a total payment of $13.8 million and one lost $2 million. Savings to Medicare totaled $677,000 and $1.6 million for the first and second years, respectively.

Results for the third year were announced in August; five physician groups will receive performance payments totaling $25.3 million as part of their share of $32.3 million of savings generated for the Medicare Trust Funds in that year, the CMS announced.

Quality was assessed by the groups' adherence to 27 measures as indicated by Medicare claims and clinical records data. The measures, developed by the CMS in collaboration with the American Medical Association and the National Committee for Quality Assurance, covered heart failure, diabetes, coronary artery disease, hypertension, and preventive care.

Two group practices complied with 10 of the quality markers in performance year one, while five groups complied with all 27 quality markers in the second year, said Musetta Leung of RTI International.

In the second year, all of the group practices met all of their quality targets for heart failure and coronary artery disease.

Achieving the diabetes-related quality measures remained a challenge. Still, second-year performance data indicated significant improvements, Ms. Leung said.

In the project's third year, all 10 groups achieved benchmark performance on at least 28 of the 32 measures reported, according to the CMS. Two groups—Geisinger Clinic in Danville, Pa., and Park Nicollet Health Services in St. Louis Park, Minn.—achieved benchmark performance on all of the 32 performance measures.

Over the first 3 years of the demonstration, the physician groups increased their quality scores an average of 10 percentage points on 10 diabetes measures, 11 points on 10 heart failure measures, 6 points on 7 coronary artery disease measures, 10 points on 2 cancer screening measures, and 1 percentage point on 3 hypertension measures.

Additional research is needed to determine the keys to success, according to Mr. Pilotte of the CMS. “Trying to figure out how to make this work in a program that processes over 1 billion claims each year is not a small feat. …It takes a while to get these projects up and running both from our side of the house and the provider side.”

Although the group practices generally have sophisticated health information management systems and dedicated information technology leadership, “even that doesn't seem to be enough to control growth in expenditures. …There are probably other things going on that we haven't fully identified that are necessary to be successful.”

Overall, “the results show we're moving in the right direction, but bringing in expenditure growth under target is challenging under the existing target-setting methodology even for these large organizations,” he said.

One key lesson learned so far during the demonstration is that “leadership and champions within the organization are really important,” Mr. Pilotte said. “All of these groups have someone who is on point for monitoring and reporting the quality metrics to us every year and developing mechanisms … to be able to capture the information.”

Another lesson learned is the importance of having quality measures consistent with clinical practice and high-quality care in order to achieve physician buy-in.

“That's why we spent a fair amount of time early on with these physician groups on which measures we were going to use and to gain their support, because it really wouldn't be possible without them,” he said.

For more information, visit www.cms.hhs.gov/DemoProjectsEvalRpts/MD/list.asp

Joyce Frieden contributed to this report.

CHICAGO — The Medicare Physician Group Practice Demonstration achieved modest cost savings and quality enhancements in the ongoing project's first 2 performance years, researchers reported at the annual research meeting of AcademyHealth. Data released in August reinforce that finding.

The project involves 10 large, geographically diverse physician group practices with a total of 5,000 physicians caring for 200,000 Medicare fee-for-service beneficiaries. The practices include multispecialty groups, integrated delivery systems, faculty groups, and a physician network.

During each year of the project, each group was retroactively assigned a population of Medicare beneficiaries, with an average of 20,000 patients per group (range, 10,000-37,000). Each group was held accountable for total Part A and Part B expenditures for these patients.

Patients had complete freedom of choice in providers and were not required to receive care through the participating group practice. However, only patients who received most of their outpatient evaluation and management for the year from the group practice were assigned to the group. Groups that kept increases in expenditures below 2 percentage points of their target growth rate shared up to 80% of the savings; Medicare retained 20%.

The group practices assumed all business risks associated with investments related to their participation in the demonstration, and there was no guarantee of savings. “Savings are a function of the ability of the group to control growth in Medicare spending as well as changes in [health] status of their assigned population over time relative to their local market,” explained John Pilotte, a senior research analyst at the Centers for Medicare and Medicaid Services. The groups were free to make whatever investments and enhancements they felt were necessary to reach their quality and efficiency goals.

In the first year of the demonstration, two participating group practices earned a total performance payment of $7.3 million and two lost a total of $1.5 million, Gregory Pope of RTI International in Waltham, Mass., a nonprofit research and development firm working with the CMS, reported at the meeting. In the second year, four groups shared a total payment of $13.8 million and one lost $2 million. Savings to Medicare totaled $677,000 and $1.6 million for the first and second years, respectively.

Results for the third year were announced in August; five physician groups will receive performance payments totaling $25.3 million as part of their share of $32.3 million of savings generated for the Medicare Trust Funds in that year, the CMS announced.

Quality was assessed by the groups' adherence to 27 measures as indicated by Medicare claims and clinical records data. The measures, developed by the CMS in collaboration with the American Medical Association and the National Committee for Quality Assurance, covered heart failure, diabetes, coronary artery disease, hypertension, and preventive care.

Two practices complied with 10 of the quality markers in performance year 1, whereas five groups complied with all 27 quality markers in the second year, said Musetta Leung of RTI International.

In the second year, all group practices met all of their quality targets for heart failure and coronary artery disease. Achieving the diabetes-related quality measures remained a challenge. Still, second-year performance data indicated significant improvements, she said.

In the third year, all 10 groups achieved benchmark performance on at least 28 of the 32 measures reported, according to the CMS. Two groups—Geisinger Clinic in Danville, Pa., and Park Nicollet Health Services in St. Louis Park, Minn.—achieved benchmark performance on all 32 performance measures.

Over the first 3 years of the demonstration, the physician groups increased their quality scores an average of 10 percentage points on 10 diabetes measures, 11 points on 10 heart failure measures, 6 points on 7 coronary artery disease measures, 10 points on 2 cancer screening measures, and 1 percentage point on 3 hypertension measures.

“Leadership and champions within the organization are really important,” said Mr. Pilotte of CMS.

CHICAGO — The Medicare Physician Group Practice Demonstration achieved modest cost savings and quality enhancements in the ongoing project's first 2 performance years, researchers reported at the annual research meeting of AcademyHealth. Data released in August reinforce that finding.

The project involves 10 large, geographically diverse physician group practices with a total of 5,000 physicians caring for 200,000 Medicare fee-for-service beneficiaries. The practices include multispecialty groups, integrated delivery systems, faculty groups, and a physician network.

During each year of the project, each group was retroactively assigned a population of Medicare beneficiaries, with an average of 20,000 patients per group (range, 10,000-37,000). Each group was held accountable for total Part A and Part B expenditures for these patients.

Patients had complete freedom of choice in providers and were not required to receive care through the participating group practice. However, only patients who received most of their outpatient evaluation and management for the year from the group practice were assigned to the group. Groups that kept increases in expenditures below 2 percentage points of their target growth rate shared up to 80% of the savings; Medicare retained 20%.

The group practices assumed all business risks associated with investments related to their participation in the demonstration, and there was no guarantee of savings. “Savings are a function of the ability of the group to control growth in Medicare spending as well as changes in [health] status of their assigned population over time relative to their local market,” explained John Pilotte, a senior research analyst at the Centers for Medicare and Medicaid Services. The groups were free to make whatever investments and enhancements they felt were necessary to reach their quality and efficiency goals.

In the first year of the demonstration, two participating group practices earned a total performance payment of $7.3 million and two lost a total of $1.5 million, Gregory Pope of RTI International in Waltham, Mass., a nonprofit research and development firm working with the CMS, reported at the meeting. In the second year, four groups shared a total payment of $13.8 million and one lost $2 million. Savings to Medicare totaled $677,000 and $1.6 million for the first and second years, respectively.

Results for the third year were announced in August; five physician groups will receive performance payments totaling $25.3 million as part of their share of $32.3 million of savings generated for the Medicare Trust Funds in that year, the CMS announced.

Quality was assessed by the groups' adherence to 27 measures as indicated by Medicare claims and clinical records data. The measures, developed by the CMS in collaboration with the American Medical Association and the National Committee for Quality Assurance, covered heart failure, diabetes, coronary artery disease, hypertension, and preventive care.

Two practices complied with 10 of the quality markers in performance year 1, whereas five groups complied with all 27 quality markers in the second year, said Musetta Leung of RTI International.

In the second year, all group practices met all of their quality targets for heart failure and coronary artery disease. Achieving the diabetes-related quality measures remained a challenge. Still, second-year performance data indicated significant improvements, she said.

In the third year, all 10 groups achieved benchmark performance on at least 28 of the 32 measures reported, according to the CMS. Two groups—Geisinger Clinic in Danville, Pa., and Park Nicollet Health Services in St. Louis Park, Minn.—achieved benchmark performance on all 32 performance measures.

Over the first 3 years of the demonstration, the physician groups increased their quality scores an average of 10 percentage points on 10 diabetes measures, 11 points on 10 heart failure measures, 6 points on 7 coronary artery disease measures, 10 points on 2 cancer screening measures, and 1 percentage point on 3 hypertension measures.

“Leadership and champions within the organization are really important,” said Mr. Pilotte of CMS.

CHICAGO — The Medicare Physician Group Practice Demonstration achieved modest cost savings and quality enhancements in the ongoing project's first 2 performance years, researchers reported at the annual research meeting of AcademyHealth. Data released in August reinforce that finding.

The project involves 10 large, geographically diverse physician group practices with a total of 5,000 physicians caring for 200,000 Medicare fee-for-service beneficiaries. The practices include multispecialty groups, integrated delivery systems, faculty groups, and a physician network.

During each year of the project, each group was retroactively assigned a population of Medicare beneficiaries, with an average of 20,000 patients per group (range, 10,000-37,000). Each group was held accountable for total Part A and Part B expenditures for these patients.

Patients had complete freedom of choice in providers and were not required to receive care through the participating group practice. However, only patients who received most of their outpatient evaluation and management for the year from the group practice were assigned to the group. Groups that kept increases in expenditures below 2 percentage points of their target growth rate shared up to 80% of the savings; Medicare retained 20%.

The group practices assumed all business risks associated with investments related to their participation in the demonstration, and there was no guarantee of savings. “Savings are a function of the ability of the group to control growth in Medicare spending as well as changes in [health] status of their assigned population over time relative to their local market,” explained John Pilotte, a senior research analyst at the Centers for Medicare and Medicaid Services. The groups were free to make whatever investments and enhancements they felt were necessary to reach their quality and efficiency goals.

In the first year of the demonstration, two participating group practices earned a total performance payment of $7.3 million and two lost a total of $1.5 million, Gregory Pope of RTI International in Waltham, Mass., a nonprofit research and development firm working with the CMS, reported at the meeting. In the second year, four groups shared a total payment of $13.8 million and one lost $2 million. Savings to Medicare totaled $677,000 and $1.6 million for the first and second years, respectively.

Results for the third year were announced in August; five physician groups will receive performance payments totaling $25.3 million as part of their share of $32.3 million of savings generated for the Medicare Trust Funds in that year, the CMS announced.

Quality was assessed by the groups' adherence to 27 measures as indicated by Medicare claims and clinical records data. The measures, developed by the CMS in collaboration with the American Medical Association and the National Committee for Quality Assurance, covered heart failure, diabetes, coronary artery disease, hypertension, and preventive care.

Two practices complied with 10 of the quality markers in performance year 1, whereas five groups complied with all 27 quality markers in the second year, said Musetta Leung of RTI International.

In the second year, all group practices met all of their quality targets for heart failure and coronary artery disease. Achieving the diabetes-related quality measures remained a challenge. Still, second-year performance data indicated significant improvements, she said.

In the third year, all 10 groups achieved benchmark performance on at least 28 of the 32 measures reported, according to the CMS. Two groups—Geisinger Clinic in Danville, Pa., and Park Nicollet Health Services in St. Louis Park, Minn.—achieved benchmark performance on all 32 performance measures.

Over the first 3 years of the demonstration, the physician groups increased their quality scores an average of 10 percentage points on 10 diabetes measures, 11 points on 10 heart failure measures, 6 points on 7 coronary artery disease measures, 10 points on 2 cancer screening measures, and 1 percentage point on 3 hypertension measures.

“Leadership and champions within the organization are really important,” said Mr. Pilotte of CMS.

CHICAGO — Increases in the availability of magnetic resonance imaging are significantly associated with increases in utilization of lower back MRI and lower back pain surgery, a study of 832,000 episodes of treatment among Medicare recipients has shown.

Patients in geographic areas with the highest quartile of MRI availability were 15% more likely to receive lower back MRI within 30 days of an initial doctor visit and 10% more likely to receive lower back MRI within a year, compared with patients living in areas with the lowest quartile of MRI availability, according to Jacqueline Baras Shreibati, a medical student at Stanford (Calif.) University, and Laurence C. Baker, Ph.D., professor of health research and policy at Stanford. These patients also were significantly more likely to undergo surgery for their ailments, they reported at the annual research meeting of AcademyHealth.

“These results raise concerns that the widespread expansion of MRI may adversely impact quality of care for low back pain patients,” they stated. “The rapid expansion in the number of MRI scanners in the United States has enabled more patients to receive cutting-edge imaging that can produce valuable diagnostic information. However, for patients with low back pain, the use of MRI is controversial. Spinal abnormalities detected by MRI often do not correlate with symptoms and can lead to unnecessary interventions, including surgery, which in many patients is of uncertain efficacy.”

The researchers used claims from a 20% sample of Medicare beneficiaries from 1998-2005. Cohorts were developed of patients with a new episode of care for low back pain in 1999, 2002, and 2005, years for which data were available on the number of MRI units per million people in U.S. metropolitan statistical areas. Patients were assigned to an MRI quartile based on their metropolitan statistical area of residence. The researchers examined the impact of MRI availability on the receipt of low back pain MRI and surgery within 30, 90, 180, or 365 days of the initial visit.

Among all low back pain episodes of care, 18% resulted in MRI and 4% resulted in low back pain surgery within a year of the initial visit. The authors reported no conflicts of interest.

CHICAGO — Increases in the availability of magnetic resonance imaging are significantly associated with increases in utilization of lower back MRI and lower back pain surgery, a study of 832,000 episodes of treatment among Medicare recipients has shown.

Patients in geographic areas with the highest quartile of MRI availability were 15% more likely to receive lower back MRI within 30 days of an initial doctor visit and 10% more likely to receive lower back MRI within a year, compared with patients living in areas with the lowest quartile of MRI availability, according to Jacqueline Baras Shreibati, a medical student at Stanford (Calif.) University, and Laurence C. Baker, Ph.D., professor of health research and policy at Stanford. These patients also were significantly more likely to undergo surgery for their ailments, they reported at the annual research meeting of AcademyHealth.

“These results raise concerns that the widespread expansion of MRI may adversely impact quality of care for low back pain patients,” they stated. “The rapid expansion in the number of MRI scanners in the United States has enabled more patients to receive cutting-edge imaging that can produce valuable diagnostic information. However, for patients with low back pain, the use of MRI is controversial. Spinal abnormalities detected by MRI often do not correlate with symptoms and can lead to unnecessary interventions, including surgery, which in many patients is of uncertain efficacy.”

The researchers used claims from a 20% sample of Medicare beneficiaries from 1998-2005. Cohorts were developed of patients with a new episode of care for low back pain in 1999, 2002, and 2005, years for which data were available on the number of MRI units per million people in U.S. metropolitan statistical areas. Patients were assigned to an MRI quartile based on their metropolitan statistical area of residence. The researchers examined the impact of MRI availability on the receipt of low back pain MRI and surgery within 30, 90, 180, or 365 days of the initial visit.

Among all low back pain episodes of care, 18% resulted in MRI and 4% resulted in low back pain surgery within a year of the initial visit. The authors reported no conflicts of interest.

CHICAGO — Increases in the availability of magnetic resonance imaging are significantly associated with increases in utilization of lower back MRI and lower back pain surgery, a study of 832,000 episodes of treatment among Medicare recipients has shown.

Patients in geographic areas with the highest quartile of MRI availability were 15% more likely to receive lower back MRI within 30 days of an initial doctor visit and 10% more likely to receive lower back MRI within a year, compared with patients living in areas with the lowest quartile of MRI availability, according to Jacqueline Baras Shreibati, a medical student at Stanford (Calif.) University, and Laurence C. Baker, Ph.D., professor of health research and policy at Stanford. These patients also were significantly more likely to undergo surgery for their ailments, they reported at the annual research meeting of AcademyHealth.

“These results raise concerns that the widespread expansion of MRI may adversely impact quality of care for low back pain patients,” they stated. “The rapid expansion in the number of MRI scanners in the United States has enabled more patients to receive cutting-edge imaging that can produce valuable diagnostic information. However, for patients with low back pain, the use of MRI is controversial. Spinal abnormalities detected by MRI often do not correlate with symptoms and can lead to unnecessary interventions, including surgery, which in many patients is of uncertain efficacy.”

The researchers used claims from a 20% sample of Medicare beneficiaries from 1998-2005. Cohorts were developed of patients with a new episode of care for low back pain in 1999, 2002, and 2005, years for which data were available on the number of MRI units per million people in U.S. metropolitan statistical areas. Patients were assigned to an MRI quartile based on their metropolitan statistical area of residence. The researchers examined the impact of MRI availability on the receipt of low back pain MRI and surgery within 30, 90, 180, or 365 days of the initial visit.

Among all low back pain episodes of care, 18% resulted in MRI and 4% resulted in low back pain surgery within a year of the initial visit. The authors reported no conflicts of interest.

CHICAGO — A blood test for a protein associated with colorectal cancer can detect adenomas and colorectal cancer, according to two studies of a total of 370 patients.

The test, the first of its kind, holds promise for early disease detection and surveillance, said Dr. Nadir Arber of Tel Aviv Medical Center, Israel, at the annual Digestive Disease Week.

“This is a simple blood test measuring the levels of CD24 protein [a cell surface protein and P-selectin ligand] in peripheral blood lymphocytes (PBLs), and we can successfully distinguish healthy subjects from patients with colorectal neoplasm,” Dr. Arber reported at a research forum that was sponsored by the AGA Institute.

The findings provide further substantiation that CD24 levels are significantly elevated in the majority of patients with adenomas and colorectal cancer (CRC), he said.

Previous research by Dr. Arber and his colleagues with both animal and human cancer cell lines confirmed the overexpression of CD24 in the colonic mucosa as an early event in CRC carcinogenesis, and identified the protein as a potential biomarker for early CRC detection and a target for therapy (Gastroenterology 2006;131:630-9).

The low level of public compliance with current CRC screening techniques underscores the need for a noninvasive test, Dr. Arber said.

Analyses of PBLs for expression of CD24 detected CRC in a pilot study of 203 consecutive subjects with a sensitivity and specificity of 70.5% and 83.3%, respectively. The test also distinguished patients with adenomas from normal patients with a sensitivity and specificity of 84.2% and 73.5%, respectively (confidence interval 95%).

An external third-party evaluation of 143 blood samples from this population yielded a lower specificity of 65% for normal versus CRC patients and a specificity of 76.7% for normal versus adenoma patients. Dr. Arber noted in an interview that the somewhat lower specificity could be attributed to potential degradation of the protein during storage and transportation.

Patients completed a detailed questionnaire, provided a blood sample, and underwent a colonoscopy. PBLs were isolated and analyzed with Western blot, a technique that detects levels of a protein using antibodies specific to the target protein. Sensitivity and specificity for CD24 were calculated using receiver operating characteristic curves.

In a second validation study of an independent sample of 167 subjects, the blood test yielded improved values for the detection of CRC (sensitivity 92.3%; specificity 83.8%). The values for the detection of normal versus CRC and adenoma patients were 77.1% and 86.8%, respectively.

Dr. Arber said that a goal of further research is to collect data on CD24 levels and polyp size.

When asked what additional research would be needed before the test could be widely offered for CRC detection and surveillance, Dr. Arber said he is focusing on increasing the test's negative predictive values and is exploring whether there are certain subpopulations for whom the test is not predictive.

In its current form, the test, based on Western blot analysis, can be performed in any hospital, Dr. Arber said. He added that he and his colleagues are developing an ELISA (enzyme-linked immunosorbent assay) kit designed to facilitate use of the test in any laboratory worldwide.

Dr. Arber disclosed that he is chief scientist at Micromedic Technologies Ltd., which supported this research. Dr. Arber also is on the review panel for GI View Ltd., which develops gastrointestinal diagnostic devices, and has received research support from Pfizer.

The test can be performed in any hospital, Dr. Nadir Arber said.

Source Courtesy Dr. Nadir Arber

CHICAGO — A blood test for a protein associated with colorectal cancer can detect adenomas and colorectal cancer, according to two studies of a total of 370 patients.

The test, the first of its kind, holds promise for early disease detection and surveillance, said Dr. Nadir Arber of Tel Aviv Medical Center, Israel, at the annual Digestive Disease Week.

“This is a simple blood test measuring the levels of CD24 protein [a cell surface protein and P-selectin ligand] in peripheral blood lymphocytes (PBLs), and we can successfully distinguish healthy subjects from patients with colorectal neoplasm,” Dr. Arber reported at a research forum that was sponsored by the AGA Institute.

The findings provide further substantiation that CD24 levels are significantly elevated in the majority of patients with adenomas and colorectal cancer (CRC), he said.

Previous research by Dr. Arber and his colleagues with both animal and human cancer cell lines confirmed the overexpression of CD24 in the colonic mucosa as an early event in CRC carcinogenesis, and identified the protein as a potential biomarker for early CRC detection and a target for therapy (Gastroenterology 2006;131:630-9).

The low level of public compliance with current CRC screening techniques underscores the need for a noninvasive test, Dr. Arber said.

Analyses of PBLs for expression of CD24 detected CRC in a pilot study of 203 consecutive subjects with a sensitivity and specificity of 70.5% and 83.3%, respectively. The test also distinguished patients with adenomas from normal patients with a sensitivity and specificity of 84.2% and 73.5%, respectively (confidence interval 95%).

An external third-party evaluation of 143 blood samples from this population yielded a lower specificity of 65% for normal versus CRC patients and a specificity of 76.7% for normal versus adenoma patients. Dr. Arber noted in an interview that the somewhat lower specificity could be attributed to potential degradation of the protein during storage and transportation.

Patients completed a detailed questionnaire, provided a blood sample, and underwent a colonoscopy. PBLs were isolated and analyzed with Western blot, a technique that detects levels of a protein using antibodies specific to the target protein. Sensitivity and specificity for CD24 were calculated using receiver operating characteristic curves.

In a second validation study of an independent sample of 167 subjects, the blood test yielded improved values for the detection of CRC (sensitivity 92.3%; specificity 83.8%). The values for the detection of normal versus CRC and adenoma patients were 77.1% and 86.8%, respectively.

Dr. Arber said that a goal of further research is to collect data on CD24 levels and polyp size.

When asked what additional research would be needed before the test could be widely offered for CRC detection and surveillance, Dr. Arber said he is focusing on increasing the test's negative predictive values and is exploring whether there are certain subpopulations for whom the test is not predictive.

In its current form, the test, based on Western blot analysis, can be performed in any hospital, Dr. Arber said. He added that he and his colleagues are developing an ELISA (enzyme-linked immunosorbent assay) kit designed to facilitate use of the test in any laboratory worldwide.

Dr. Arber disclosed that he is chief scientist at Micromedic Technologies Ltd., which supported this research. Dr. Arber also is on the review panel for GI View Ltd., which develops gastrointestinal diagnostic devices, and has received research support from Pfizer.

The test can be performed in any hospital, Dr. Nadir Arber said.

Source Courtesy Dr. Nadir Arber

CHICAGO — A blood test for a protein associated with colorectal cancer can detect adenomas and colorectal cancer, according to two studies of a total of 370 patients.

The test, the first of its kind, holds promise for early disease detection and surveillance, said Dr. Nadir Arber of Tel Aviv Medical Center, Israel, at the annual Digestive Disease Week.

“This is a simple blood test measuring the levels of CD24 protein [a cell surface protein and P-selectin ligand] in peripheral blood lymphocytes (PBLs), and we can successfully distinguish healthy subjects from patients with colorectal neoplasm,” Dr. Arber reported at a research forum that was sponsored by the AGA Institute.

The findings provide further substantiation that CD24 levels are significantly elevated in the majority of patients with adenomas and colorectal cancer (CRC), he said.

Previous research by Dr. Arber and his colleagues with both animal and human cancer cell lines confirmed the overexpression of CD24 in the colonic mucosa as an early event in CRC carcinogenesis, and identified the protein as a potential biomarker for early CRC detection and a target for therapy (Gastroenterology 2006;131:630-9).

The low level of public compliance with current CRC screening techniques underscores the need for a noninvasive test, Dr. Arber said.

Analyses of PBLs for expression of CD24 detected CRC in a pilot study of 203 consecutive subjects with a sensitivity and specificity of 70.5% and 83.3%, respectively. The test also distinguished patients with adenomas from normal patients with a sensitivity and specificity of 84.2% and 73.5%, respectively (confidence interval 95%).

An external third-party evaluation of 143 blood samples from this population yielded a lower specificity of 65% for normal versus CRC patients and a specificity of 76.7% for normal versus adenoma patients. Dr. Arber noted in an interview that the somewhat lower specificity could be attributed to potential degradation of the protein during storage and transportation.

Patients completed a detailed questionnaire, provided a blood sample, and underwent a colonoscopy. PBLs were isolated and analyzed with Western blot, a technique that detects levels of a protein using antibodies specific to the target protein. Sensitivity and specificity for CD24 were calculated using receiver operating characteristic curves.

In a second validation study of an independent sample of 167 subjects, the blood test yielded improved values for the detection of CRC (sensitivity 92.3%; specificity 83.8%). The values for the detection of normal versus CRC and adenoma patients were 77.1% and 86.8%, respectively.

Dr. Arber said that a goal of further research is to collect data on CD24 levels and polyp size.

When asked what additional research would be needed before the test could be widely offered for CRC detection and surveillance, Dr. Arber said he is focusing on increasing the test's negative predictive values and is exploring whether there are certain subpopulations for whom the test is not predictive.

In its current form, the test, based on Western blot analysis, can be performed in any hospital, Dr. Arber said. He added that he and his colleagues are developing an ELISA (enzyme-linked immunosorbent assay) kit designed to facilitate use of the test in any laboratory worldwide.

Dr. Arber disclosed that he is chief scientist at Micromedic Technologies Ltd., which supported this research. Dr. Arber also is on the review panel for GI View Ltd., which develops gastrointestinal diagnostic devices, and has received research support from Pfizer.

The test can be performed in any hospital, Dr. Nadir Arber said.

Source Courtesy Dr. Nadir Arber

CHICAGO — Uterus-sparing surgery was a safe alternative to concurrent hysterectomy for many women undergoing surgery for pelvic organ prolapse, based on mean follow-ups of 5 years.

Favorable outcomes can be achieved with uterine preservation, and women aged 40-60 years who are free of vaginal and uterine disease should know about this option, Dr. Elisabetta Costantini of the University of Perugia (Italy) and her colleagues wrote in a poster presented at the annual meeting of the American Urological Association. Leaving the uterus intact has been thought to introduce the risk for repeat surgery, yet none of the patients in this study required additional surgery.

Hysterocolposacropexy was performed in 47 women with symptomatic pelvic organ prolapse; 40 had abdominal procedures and 7 had laparoscopic procedures. Patients were followed up at 1, 3, 6, and 12 months after surgery and then yearly for a mean of 5 years (range, 12-141 months). Outcome measures included anatomical and physical examinations, assessments of urodynamics, and patient responses to questionnaires.

Sexual activity was maintained in 28 of 29 (96%) patients following surgery. None of the patients required repeat surgery for recurrent prolapse, and 83% reported long-term satisfaction with their procedures. However, anatomical examinations indicated cystocele of grade 2 or higher in six women (12.8%) and rectocele of grade 2 or higher in four (8.5%). Postoperative voiding symptoms persisted in 3 of 33 (9.1%) patients, and postoperative storage symptoms persisted in 6 of 32 (18.8%) patients. Two patients reported de novo urgency, and four patients showed de novo urinary incontinence (three with stress UI and one with urge UI). None of the patients developed pelvic neoplasms.

For younger patients, an option is to place only one posterior mesh; however, it is preferable for patients to plan not to conceive again, Dr. Costantini said during a press conference. “We should always advise them about the risks of pregnancy and delivery and the need for a long-term follow-up to rule out malignant disease.”

CHICAGO — Uterus-sparing surgery was a safe alternative to concurrent hysterectomy for many women undergoing surgery for pelvic organ prolapse, based on mean follow-ups of 5 years.

Favorable outcomes can be achieved with uterine preservation, and women aged 40-60 years who are free of vaginal and uterine disease should know about this option, Dr. Elisabetta Costantini of the University of Perugia (Italy) and her colleagues wrote in a poster presented at the annual meeting of the American Urological Association. Leaving the uterus intact has been thought to introduce the risk for repeat surgery, yet none of the patients in this study required additional surgery.

Hysterocolposacropexy was performed in 47 women with symptomatic pelvic organ prolapse; 40 had abdominal procedures and 7 had laparoscopic procedures. Patients were followed up at 1, 3, 6, and 12 months after surgery and then yearly for a mean of 5 years (range, 12-141 months). Outcome measures included anatomical and physical examinations, assessments of urodynamics, and patient responses to questionnaires.

Sexual activity was maintained in 28 of 29 (96%) patients following surgery. None of the patients required repeat surgery for recurrent prolapse, and 83% reported long-term satisfaction with their procedures. However, anatomical examinations indicated cystocele of grade 2 or higher in six women (12.8%) and rectocele of grade 2 or higher in four (8.5%). Postoperative voiding symptoms persisted in 3 of 33 (9.1%) patients, and postoperative storage symptoms persisted in 6 of 32 (18.8%) patients. Two patients reported de novo urgency, and four patients showed de novo urinary incontinence (three with stress UI and one with urge UI). None of the patients developed pelvic neoplasms.

For younger patients, an option is to place only one posterior mesh; however, it is preferable for patients to plan not to conceive again, Dr. Costantini said during a press conference. “We should always advise them about the risks of pregnancy and delivery and the need for a long-term follow-up to rule out malignant disease.”

CHICAGO — Uterus-sparing surgery was a safe alternative to concurrent hysterectomy for many women undergoing surgery for pelvic organ prolapse, based on mean follow-ups of 5 years.

Favorable outcomes can be achieved with uterine preservation, and women aged 40-60 years who are free of vaginal and uterine disease should know about this option, Dr. Elisabetta Costantini of the University of Perugia (Italy) and her colleagues wrote in a poster presented at the annual meeting of the American Urological Association. Leaving the uterus intact has been thought to introduce the risk for repeat surgery, yet none of the patients in this study required additional surgery.

Hysterocolposacropexy was performed in 47 women with symptomatic pelvic organ prolapse; 40 had abdominal procedures and 7 had laparoscopic procedures. Patients were followed up at 1, 3, 6, and 12 months after surgery and then yearly for a mean of 5 years (range, 12-141 months). Outcome measures included anatomical and physical examinations, assessments of urodynamics, and patient responses to questionnaires.

Sexual activity was maintained in 28 of 29 (96%) patients following surgery. None of the patients required repeat surgery for recurrent prolapse, and 83% reported long-term satisfaction with their procedures. However, anatomical examinations indicated cystocele of grade 2 or higher in six women (12.8%) and rectocele of grade 2 or higher in four (8.5%). Postoperative voiding symptoms persisted in 3 of 33 (9.1%) patients, and postoperative storage symptoms persisted in 6 of 32 (18.8%) patients. Two patients reported de novo urgency, and four patients showed de novo urinary incontinence (three with stress UI and one with urge UI). None of the patients developed pelvic neoplasms.

For younger patients, an option is to place only one posterior mesh; however, it is preferable for patients to plan not to conceive again, Dr. Costantini said during a press conference. “We should always advise them about the risks of pregnancy and delivery and the need for a long-term follow-up to rule out malignant disease.”