Key points

Introduction

It is widely recognized that the United States’ (US) healthcare system faces a number of challenges in medical errors, leading to increasing costs, which are unsustainable and threaten the national economy. In November 1999, the Institute of Medicine (IOM) published the landmark report, To Err is Human , which placed the issues of patient safety and medical errors in the US health care system under the national spotlight. This report estimated that medical errors were responsible for up to 98,000 deaths annually in hospitals across the nation, at a cost of $17 billion to $29 billion per year. However, this conservative estimate did not include outpatient medical errors or morbidities from lapses in the quality of medical care.

Quality improvement initiatives must be implemented and reformed at the local level within individual departments, understanding the challenges of health care at a national scale with the challenging movements for large-scale reform. It is imperative that our physician leaders understand the need to reform health care from within, beginning from their own departments, to improve quality and control cost. In this article, we review the quality improvement initiative and analyze the opportunities within the field of neurosurgery for individual neurosurgery departments to integrate initiatives promoting quality improvement and patient safety into their institutional and departmental priorities.

Introduction

It is widely recognized that the United States’ (US) healthcare system faces a number of challenges in medical errors, leading to increasing costs, which are unsustainable and threaten the national economy. In November 1999, the Institute of Medicine (IOM) published the landmark report, To Err is Human , which placed the issues of patient safety and medical errors in the US health care system under the national spotlight. This report estimated that medical errors were responsible for up to 98,000 deaths annually in hospitals across the nation, at a cost of $17 billion to $29 billion per year. However, this conservative estimate did not include outpatient medical errors or morbidities from lapses in the quality of medical care.

Quality improvement initiatives must be implemented and reformed at the local level within individual departments, understanding the challenges of health care at a national scale with the challenging movements for large-scale reform. It is imperative that our physician leaders understand the need to reform health care from within, beginning from their own departments, to improve quality and control cost. In this article, we review the quality improvement initiative and analyze the opportunities within the field of neurosurgery for individual neurosurgery departments to integrate initiatives promoting quality improvement and patient safety into their institutional and departmental priorities.

The national problem

Although the United States is a leader in creating innovative technologies and treatments, the progress has not translated to overall higher quality health care. Since the release of the IOM report in 1999, the National Institutes of Health has doubled its budget and invested more than $32.2 billion to advance medical research. Recently, the McKinsey Global Institute and the Kaiser Family Foundation report that the United States spends more per capita and spends a higher percentage of its national gross domestic product (GDP) on health care than any other country listed under the Organization for Economic Cooperation and Development. In 2007, US health expenditures increased to $2.3 trillion, accounting for nearly 17% of the nation’s GDP, and are expected to reach more than 20% of the nation’s GDP by the end of 2015. Despite these increasing expenditures, the United States fairs poorly compared with other nations in multiple health metrics. The World Health Report 2000 states that despite spending the highest percentage of its GDP on health care, the United States is ranked 37th for its health care performance. The United States fares worse than 46 countries in infant mortality and 48 countries in life expectancy. In a 2003 study by McGlynn and colleagues, roughly only half of all recommended preventative, acute, and chronic care were received by Americans with significant variability based on the medical condition, ranging from 11% to 79% of recommended care. There is a large discrepancy between the quality of care that Americans receive and their cost.

Medical errors and system inefficiencies not only decrease the quality of health care that patients receive but also come at a huge cost to the nation by compromising the nation’s economy, limiting access to health care, and threatening the security of present and future generations. Increasing health care costs threaten the sustainability of government programs like Medicare and force employers to cut coverage or shift part of the financial burden onto their employees. The increasing costs are shifting health care patterns, and hospitals are seeing decreases in admissions and increases in uncompensated care. However, some estimates project that almost 30% of health care costs can be decreased without compromising the quality of health care delivered. Thomson Reuters estimate that wasted health care expenditures account for between $600 million and $850 billion annually, with 40% of wasteful spending attributed to the overuse of unnecessary services or procedures. Of the 6 categories of waste identified in this report, medical errors and unsafe clinical practices accounted for $25 billion to $50 billion annually, an increase from the IOM’s initial annual figure of $17 billion to $29 billion. However, medical errors negatively affect more than mere health care costs and may lead to further readmissions, additional procedures, complications that compromise quality of life, and increase overall mortality.

Now, more than a decade after the IOM To Err is Human report, there seems to be little progress in patient safety reform and quality control to make health care safer, more cost effective, and more assessable for the American public. The obstacles to controlling costs, ensuring patient safety, and improving health care quality are rooted in a highly fragmented and complicated health care system. In addition, the unsustainable health care expenditure growth is fueled by several factors, including technological innovations, for which cost-effectiveness and comparative clinical usefulness and evidence are not readily available, and an expanding aging population with chronic medical conditions who require costlier end-of-life care. With more than 40 million Americans uninsured, equitable access to quality and efficient care also remains elusive.

National initiatives: legislative reform and their challenges

Some national initiatives have been initiated, and several system-wide solutions have been proposed to address health care safety and quality. One of the key recommendations in the IOM’s To Err is Human report included creating a comprehensive national reporting system that is mandatory, validated, and public. In light of the ongoing deficits in patient safety and quality initiatives, there is a need for an adequate and universal system of metrics that can track and follow progress. However, there is still no consensus on which metrics should be focused on or what should be measured. One potential metric is patient outcomes, which examines aspects including patient mortality and morbidity. Another aspect of quality improvement is processes of care: the services and therapies that physicians or hospitals provide to their patients. For example, patients with myocardial infraction treated with aspirin, which has been correlated to improve patient survival, could be a process measure.

With this aim, several different groups have made fragmented progress toward creating process measures to assess a provider’s performance. With more assessable quality metrics, patients will have the ability to identify safer providers, and payers could refuse to reimburse substandard care, pushing providers to prioritize higher quality of care. The National Quality Forum (NQF) uses a consensus development process that lists hundreds of performance metrics, safe practices, and quality frameworks to assess the overall quality of health care. In their 2008 Physician Quality Reporting Initiative (PQRI), the Center for Medicare and Medicaid Services collected data on and proposed 119 different quality metrics of physician performance, ranging from adhering to guidelines for chemotherapy and radiation therapy to blood glucose control for diabetic patients. Another arm of the government, the US Department of Health and Human services, through its Hospital Compare Web site, publishes hospital-specific process of health care quality metrics for surgical, cardiac, and pneumonia treatment ( http://www.hospitalcompare.hhs.gov/ ). In addition to these national organizations, various states and independent groups have also begun collecting and publishing quality metrics, but these efforts remained complicated and fragmented, as shown here.

Despite the move toward improved metrics in patient safety, health care quality metrics have certain limitations. Outcome measures are confounded by the health of a hospital’s patient population. There are also issues of statistical power, because outcome measures may not adequately reflect quality of care between physicians if the comparative sample sizes are too small. Process measures and metrics cannot account for the unquantifiable but still important clinical decisions made in providing quality health care. Some studies show only a weak correlation between process measures and improved clinical outcomes.

National reform is needed to create a uniform and mandatory national reporting system, which promotes accountability through transparency. There have been only fragmented efforts on the state level to require reporting. Throughout the past few years, an increasing number of hospitals have been required to report incidence of medical errors under different state laws. Only 28 states require hospitals to make annual infection rates available to the public. Several states have passed their own safety reform laws to hold hospitals accountable for medical errors, but implementation has been slow. In 2006, California passed patient safety legislation requiring the California Department of Public Health to complete several patient safety provisions. However, in a recent Consumer’s Union report, the California Department of Public Health has been slow to accomplish several key requirements, including creating a hospital-acquired infection protection program, collecting and reporting infection rates from hospitals, reporting medical errors to the public, and conducting inspections to ensure that hospitals are following patient safety policies. The Agency for Healthcare Research and Quality (AHRQ) is the closest national agency that comprehensively aggregates and tracks national progress based on claims from Medicare, hospital data from states, and other sources. However, these data are often dated and presented as a national and state aggregate rather than for specific providers, limiting their usefulness.

Other national priorities have been to introduce payment reform that places a financial incentive for health care quality reform. Through implementing pay-for-performance and bundling payment, the government can provide economic incentives for hospitals to provide better quality care at a lower cost, rather than merely the quantity of procedures. Furthermore, Medicare, as one of the largest payers into the US health care system, is reducing and removing reimbursements for several avoidable hospital-acquired conditions. Although Medicare has made efforts such as these reimbursement changes to realign financial incentives with clinical quality and safety goals, progress has been slow and challenging without clear evidence that these efforts are resulting in improved patient safety and health care quality. For example, the Tax Relief and Health Care Act of 2006 created the 2007 PQRI, a voluntary, Medicare provider quality reporting program. This program offers a bonus payment of up to 1.5% of total Medicare reimbursements for physicians who report various quality measures through medical registries. However, the PQRI has been criticized as “insufficiently funded and overly burdensome,” poorly crafted, without input from all stakeholders, and improperly incentivized, because the rewards do not balance the costs to implement such a reporting program.

With the implementation of the Affordable Care Act (ACA), the United States has shifted the national spotlight to a triple aim focusing on improving quality, experience of care, and decreasing costs. A component of the ACA penalizes hospitals for acquired infection rates and readmission rates to improve the quality of care delivered. Medicare also uses the Value-Based Payment Modifier program to reward or fine physicians based on their quality data. As a provision, the ACA requires the use of PQRI by 2015, and physicians are mandated to report 138 different quality practice measures; those who are unable to comply will face payment reductions. Furthermore, Accountable Care Organizations, which were created to provide financial incentives for provider networks who are able to improve outcomes without higher costs, have increased since the passage of the ACA. Because the ACA is still in its infancy, data on its effectiveness are still being tracked. More time and evidence are needed to elucidate the full effects of the ACA on the quality and cost of health care in the United States.

The local initiative: health care reform from the inside

Issues of patient safety and health care quality initiatives have been under the national spotlight for more than a decade, yet progress has been slow, unwieldy, and challenging. Although the national movement toward patient safety and quality initiatives should be a multidisciplinary endeavor, progress in this movement can and should be initiated locally. As legislators struggle to create patient safety reform on a state and national scale, we as clinicians and leaders in medicine and neurosurgery have our part to improve and reinvent health care. The significant and critical components needed for comprehensive restructuring of the US health care system may be achieved only through the creative insights, interventions, and leadership of the physicians and health care providers working every day in the trenches of the operating room and on the frontlines of medicine. The IOM, in their subsequent report Ensuring Quality Cancer Care , noted that “for many Americans with cancer, there is a wide gulf between what could be construed as the ideal and the reality of their experience with cancer care.” In the same report, the National Cancer Policy Board further addresses the decentralization at the patient and illness level, noting that the “fragmented cancer care system does not ensure access to care, lacks coordination, and is inefficient in its use of recourse” and concluded that “efforts to improve cancer care in many cases will therefore be local or regional and could feasibly originate in a physician’s practices, [or] in a hospital.” With 83% of all national health expenditures categorized under direct clinical care, reform within regional hospitals and individual departments, led by physicians and hospital leaders through a health care reform from within approach, is especially promising, with great potential. The Institute for Healthcare Improvement (IHI), New England Healthcare Institute (NEHI), and Thomson Reuters have all recently published studies addressing specific waste and inefficiencies in clinical care and provided a detailed review of various categories of waste and opportunities to cut spending.

In The Fragmentation of US Healthcare , Elhauge identifies 4 levels of fragmentation. In the broadest level, coverage and access are fragmented across different patient groups. Care for patients can be fragmented over time, when beneficiaries move among different insurers. Similarly, care for a particular patient can be fragmented if there is miscommunication between different hospitals and providers treating the same patient for different conditions. In the narrowest level, care for a certain illness can be fragmented as a patient visits different professions during the course of a hospital stay. For example, care for a patient with a brain tumor may move from a neurosurgeon to the intensive care unit (ICU) hospitalist to a neuro-oncologist and then to a radiation oncologist. Addressing fragmentation at the patient and illness levels can be most effectively addressed at the local level of improving patient safety and developing quality initiatives.

One of the largest costs of national health care spending originates from great regional variations in care and services that are not correlated to significant differences in overall clinical outcomes. Depending on geography, Medicare beneficiaries have been documented to receive wide variations in the intensity of medical care, which includes greater referrals to specialists, office visits, diagnostic tests, and procedures. There is an especially high variation in spending on chronic medical conditions, end-of-life treatment, and medical care delivered at academic medical centers. For example, Medicare spending per patient in 2005 ranged from $5358 in Oregon to greater than $14,000 in Florida. A study of 226 California hospitals revealed that Medicare spending varied from $24,722 to $106,254 per patient per year during the last 2 years of life. However, many studies have found that the variation in demography and health status does not account for the variation in health care expenditures. Many studies have found that increased health care spending is not positively correlated to improved clinical outcomes at the level of states and Hospital Referral Regions. Instead, higher costs are correlated with higher intensities of medical care, including longer ICU stays and more frequent tests and procedures, and, at times, result in decreased quality of medical care based on process-of-care measures and less patient satisfaction. A study analyzing hospital performance for 2712 national hospitals and their spending intensity showed either a zero or negative correlation between quality of care (through process-of-care measures) and spending both among and within regions. Furthermore, a NEHI report estimates that 30% of national health care expenditure or $600 billion in annual savings can be reduced without compromising health care quality, because of unnecessary care.

These challenges and opportunities present an opportunity for improving patient safety, quality initiatives, and efficiency of care on a local and regional level if providers, health care professionals, and individual departments work to implement evidence-based medicine to eliminate avoidable costs within their respective hospitals and departments. Quality initiatives at this narrow local scale within individual departments have huge potential for significant gains, because progress is more easily measured, and efforts are more quickly focused in responding to patient needs and improving safety.

Neurosurgery is in an optimal position in this movement toward improving patient safety, quality initiatives, and health care reform from within. Neurosurgery has always been at the forefront of clinical and technological advances and should continue to lead in this realm of safety and quality. Neurosurgery is inherently high risk, with a low margin of error, and possesses a real potential for catastrophic outcomes. Neurosurgery also requires the close collaboration between a myriad of services, departments, and professionals within every hospital. A single neurosurgical patient may require multiple costly scans and tests, require the coordinated care of a multidisciplinary team, and represent a multitude of opportunities to lead improvements in patient safety and quality initiatives. Because of the high degree of complexity and risks involved, neurosurgery stands in a unique position to incur significant risks and costs, affect many medical processes, and have a significant impact on the quality and safety of medical care. As leaders in the growing movement for patient safety and quality improvements, neurosurgery can make significant contributions in making health care a more integrated, efficient, and safe process. Although there are few published studies that specifically address comprehensive quality improvements in neurosurgery, there are many reports on specific areas in which neurosurgeons can lead health care reform from the inside.

Scope of local quality initiatives

Opportunities in neurosurgery