Improving health care quality in Texas and the Baylor Health Care System

According to a recent article, Texas is in the lowest quartile of states in its delivery of health care to patients >65 years of age (1). Physicians may wonder how these statistics came about and how Baylor Health Care System (BHCS) is trying to improve health care quality. This article begins by defining quality. It then discusses the performance measures and the sixth scope of work, which are key in the state ranking mentioned above, and closes by outlining some of BHCS's efforts in quality improvement.

A DEFINITION OF QUALITY

As recently as 4 years ago, physicians believed that quality in health care meant doing the right thing correctly (2). However, this discussion focuses on the widely accepted definition of quality offered by the Institute of Medicine 10 years ago: “Quality is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (2). As noted by David Shipon, MD, and David Nash, MD, applying this definition entails measuring health care and implementing interventions based on the measurements as a way to improve care (3). The Health Care Financing Administration (HCFA) takes the measurements from the states and hospital systems and compares them nationally.

BACKGROUND FOR THE RECENT STATE RANKING

For the past 16 years, HCFA has funded numerous quality management programs based upon Medicare beneficiaries, known as the first through sixth scope of work. The current contract with HCFA and the peer review organizations is the sixth scope of work, and it focuses on 6 clinical areas—acute myocar- dial infarction and congestive heart failure, atrial fibrillation, thromboembolic stroke, community-acquired pneumonia, breast cancer, and diabetes mellitus—with a total of 22 quality indicators. These quality indicators serve as performance measures and not as guidelines for practitioners. They are similar to the measures used by the Joint Commission on Accreditation of Health- care Organizations.

Overall, Texas ranked 45th out of 52 states (including Puerto Rico) in the performance measures based on the clinical indicators; data on the individual measures are provided in the Table.The Texas peer review organization—the Texas Medical Foundation—is working with the hospital systems, administrators, and practitioners to improve the quality of care.

Table.

Percentage of Texas Medicare patients receiving appropriate care based on the sixth scope of work compared with the national median^*

	Performance (% patients receiving appropriate care)
Scope of work	Texas	Median	Texas rank
1.	Acute myocardial infarction and congestive heart failure
a. Aspirin given within 24 hours of admission	78%	84%	45
b. Aspirin prescribed on discharge	84%	85%	32
c. Beta-blockers given within 24 hours of admission	51%	64%	49
d. Beta-blockers prescribed on discharge	58%	72%	48
e. ACE inhibitor prescribed on discharge for patients with LVEF <40% (AMI)	63%	71%	44
f. Counseling given on nicotine cessation during hospitalization	19%	40%	52
g. Time to delivery of thrombolytic therapy (min)†	39	40	20
h. Time to percutaneous transluminal coronary angioplasty (min)†	85	20	NA
i. Assessment of LVEF	64%	65%	39
j. ACE inhibitor prescribed at discharge for patients with LVEF <40% (HF)	62%	69%	44
2. Atrial fibrillation
a. Warfarin prescribed on discharge‡	45%	55%	49
3. Thromboembolic stroke
a. Antithrombotic prescribed at discharge‡	72%	83%	52
b. Avoidance of sublingual nifedipine§	90%	95%	47
4. Community-acquired pneumonia
a. Antibiotic given within 8 hours of arrival at hospital	80%	85%	44
b. Antibiotics consistent with recommendations	80%	79%	19
c. Blood cultures drawn (if done) before antibiotic given	84%	82%	23
d. Screening of patients and administration of influenza vaccine if needed	12% s, 68% v	14% s, 66% v	36, 18
e. Screening of patients and administration of pneumococcal vaccine if needed	8% s, 44% v	11% s, 46% v	40, 31
5. Breast cancer
a. Mammography at least every 2 years	51%	56%	44
6. Diabetes mellitus
a. Hemoglobin A1C levels at least every year	73%	71%	21
b. Eye examination at least every 2 years	68%	69%	31
c. Lipid profile at least every 2 years	66%	57%	4

*Adapted from reference 1. The first three were examined in an inpatient setting and the last three in any setting.

†Values are in minutes rather than percentages.

‡Applies to patients with acute stroke or transient ischemia attack.

§Applies to patients with acute stroke.

ACE indicates angiotensin-converting enzyme; AMI, acute myocardial infarction; HF, heart failure; LVEF, left ventricular ejection fraction; NA, not available; s, screened; v, vaccinated.

RELATED QUALITY IMPROVEMENT EFFORTS AT BHCS

BHCS is evaluating baseline data in several of the clinical areas in the sixth scope of work. For community-acquired pneumonia, BHCS is pursuing a baseline evaluation study of its 5 major hospitals with physician champions on a system and local hospital level. The goal is to highlight the areas where the hospital excels as well as offer a forum for physician leaders, quality care coordinators, and administrators to propose new initiatives to improve the delivery of medicine.

BHCS is participating with 14 other health care systems across the nation to evaluate the clinical indicators for acute myocardial infarction and congestive heart failure as well. Once again, a physician champion at the system level along with physician champions from individual hospitals are evaluating the data and implementing new strategies for patient care from the moment a patient enters the emergency department to the day he or she is discharged.

Other studies on the horizon include a systemwide evaluation of the use of anticoagulants in patients with atrial fibrillation and an evaluation of the delivery of health care to the diabetic patient.

Quality improvement at BHCS is not the work of only a few. It requires the support of everyone—from health care practitioners (physicians, nurses, care coordinators, technicians, pharmacists, dietitians, and respiratory therapists) and administrators to unit clerical assistants, medical records personnel, and the engineering department. With all of us working together, we can become the symbol of good health care not only in North Texas but also in the nation. Let us work together on these clinical indicators.