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A Profile at State and National Levels

Stephen F. Jencks, MD, MPH; Timothy Cuerdon, PhD; Dale R. Burwen, MD, MPH; Barbara Fleming, MD, PhD; Peter M. Houck, MD; Annette E. Kussmaul, MD, MPH; David S. Nilasena, MD, MSPH, MS; Diana L. Ordin, MD, MPH; David R. Arday, MD, MPH

JAMA. 2000;284:1670-1676.

ABSTRACT
Context  Despite condition-specific and managed care–specific reports, no systematic program has been developed for monitoring the quality of medical care provided to Medicare beneficiaries.

Objective  To create a monitoring system for a range of measures of clinical performance that supports quality improvement and provides repeated, reliable estimates at the national and state levels for fee-for-service (FFS) Medicare beneficiaries.

Design, Setting, and Participants  National study of repeated, cross-sectional observational data collected in 1997-1999 on all Medicare FFS beneficiaries or on a representative sample of beneficiaries with a particular condition. Data were collected using medical record abstraction for inpatient care, analysis of Medicare claims for some ambulatory services, and surveys for immunization rates. Separate samples were drawn for each topic for each state.

Main Outcome Measures  Beneficiary patients' receipt of 24 process-of-care measures related to primary prevention, secondary prevention, or treatment of 6 medical conditions (acute myocardial infarction, breast cancer, diabetes mellitus, heart failure, pneumonia, and stroke) for which there is strong scientific evidence and professional consensus that the process of care either directly improves outcomes or is a necessary step in a chain of care that does so.

Results  Across all states for all measures, the percentage of patients receiving appropriate care in the median state ranged from a high of 95% (avoidance of sublingual nifedipine for patients with acute stroke) to a low of 11% (patients with pneumonia screened for pneumococcal immunization status before discharge). The median performance on an indicator is 69% (patients discharged with heart failure diagnosis who received angiotensin-converting enzyme inhibitors; diabetic patients having an eye examination in the last 2 years). Some states (particularly less populous states and those in the Northeast) consistently ranked high in relative performance while others (particularly more populous states and those in the Southeast) consistently ranked low.

Conclusions  It is possible to assemble information on a diverse set of clinical performance measures that represent performance on the range of services in a health insurance program. These findings indicate substantial opportunities to improve the care delivered to Medicare beneficiaries and urgently invite a partnership among practitioners, hospitals, health plans, and purchasers to achieve that improvement.

INTRODUCTION

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As concern grows that attempts to control the cost of health care will crowd out quality, evidence has also emerged that quality of care is and has been far more uneven than previously recognized. The public health report entitled Healthy People 2010¹ showed wide gaps between public health performance goals and actual achievements on many measures, including some delivered by the fee-for-service (FFS) health care system. Reviews, most notably by Schuster et al,² showed that there were major gaps in acute, chronic, and preventive care almost everywhere that studies have been done. More recently, a report from the Institute of Medicine showed serious problems of harm to patients from medical errors.³ This kind of evidence was reflected in the recommendation of a recent presidential commission that quality of health care should become a major national priority.⁴ Despite condition-specific and managed care–specific reports, there has been no systematic program for monitoring the quality of medical care provided to FFS Medicare beneficiaries.

Except for the clinical measures of the Health Plan Employer Data and Information Set (HEDIS)⁵ and the Diabetes Quality Improvement Project (DQIP)⁶ there is no clinical quality measure set in general national use. About 4 years ago, the Health Care Financing Administration (HCFA) began to implement a program to measure and track the quality of the care for which Medicare pays. Simultaneously, HCFA committed to using its peer review organization (PRO) contractors to systematically promote improved performance on the quality measures tracked under this program using a voluntary, collaborative, and nonpunitive educational strategy.⁷

This article describes the 24 initial measures used in this program and reports the baseline values measured in 1997-1999. The Medicare measurement system we developed includes most of the HEDIS clinical measures, but it addresses more conditions, measures more elements of care, and measures the care delivered to the 85% of Medicare beneficiaries who are covered under FFS. The sampling frame provides state-level results to target PRO activities, evaluate PRO and HCFA effectiveness in improving care, and create a national picture of care under Medicare FFS.

Even though purchasers and beneficiaries are primarily interested in outcomes, we focused on measuring processes of care critical to outcomes rather than on measuring outcomes themselves. Five reasons drove this choice: (1) in comparison to outcomes of care, there is more consensus on appropriate processes of care and the target rates (nearly 100%); (2) measuring processes of care generally does not require the risk adjustment that has been so controversial in comparisons of outcomes; (3) it is easier for providers, practitioners, and plans to identify and fix the reasons why critical processes of care were not carried out than to determine why outcomes are not optimal; (4) many important outcomes take years; and (5) because significant, achievable improvements in outcomes are generally much smaller in relative terms than improvements in processes, unrealistic sample sizes are necessary to measure significant improvements in outcomes. While we report only process measures here, HCFA intends to track outcomes, risk-adjusted when possible, at the national level for the targeted conditions.

METHODS

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Clinical Topic and Measure Selection

The clinical topics were selected using 5 criteria: (1) the disease is prevalent and a major source of morbidity or mortality in the Medicare population; (2) there is strong scientific evidence and practitioner consensus that there are processes of care that can substantially improve outcomes; (3) reliably measuring the delivery of these processes is feasible; (4) there is a substantial "performance gap" between current performance and desirable performance; and (5) there is at least anecdotal evidence that PROs can intervene effectively to improve performance on the measures. Using these criteria, we adopted or developed 24 process-of-care measures (Table 1) relating to primary prevention, secondary prevention, or treatment of acute myocardial infarction (AMI), breast cancer, diabetes mellitus, heart failure, pneumonia, and stroke.

View this table: [in this window] [in a new window] Table 1. Quality Indicators for Care of Medicare Beneficiaries

Measures

Each measure is based on professionally developed, widely accepted practice guidelines that were translated into measures either as part of a larger partnership (HEDIS and DQIP) or national public health surveillance effort (Behavioral Risk Factor Surveillance System [BRFSS]) or by HCFA staff in consultation with experts and relevant professional groups. Whenever possible, we used measures that have wide acceptance and have been used and tested. The detailed measure specifications and the scientific evidence supporting each of these measures is summarized on the HCFA Web site.⁸

Acute Myocardial Infarction. We updated and/or expanded measures that had been used for the Medicare Cooperative Cardiovascular Project.^9-10

Heart Failure. We created measures based on treatment recommendations from the American College of Cardiology/American Heart Association and the Agency for Healthcare Research and Quality, which were reviewed by clinical expert technical advisory panels and extensively field tested by PROs.

Stroke. We adapted measures based on treatment recommendations from the American College of Chest Physicians, the American Heart Association, the National Stroke Association, and the American Academy of Neurology; the measures were reviewed by clinical expert technical advisory panels and extensively field tested by PROs.

Treatment of Pneumonia. We used measures developed in collaboration with the American Thoracic Society, the Infectious Diseases Society of America, and the Centers for Disease Control and Prevention; the measures were reviewed by clinical expert technical advisory panels and extensively field tested by PROs.

Prevention of Pneumonia We used outpatient immunization measures in the BRFSS, which correspond both to the HEDIS system and to commitments that HCFA has made to Congress under the Government Performance and Results Act and inpatient measures corresponding to recommendations of the Advisory Committee on Immunization Practices.

Breast Cancer. We adopted the breast cancer screening measure used in HEDIS,⁵ which measures the percentage of women aged 52 to 69 years who have received a mammogram in the past 2 years.

Diabetes. We selected those measures developed by the DQIP that can be computed from claims data. Indicators based on chart abstraction were not included because a representative sample of office records is not currently available to PROs.

Data Sources and Sampling Frame

In all measures except immunization status, the denominator or sampling frame is patients enrolled in FFS Medicare, and Medicare+Choice (managed care) plan members are excluded. All states in the United States were sampled, plus the District of Columbia and Puerto Rico.

Inpatient Measures (AMI, Heart Failure, Atrial Fibrillation, Stroke, Treatment of Pneumonia). We sampled from Medicare hospital claims data in each state for each condition. The discharges were eligible for selection only if the principal diagnosis met the criteria for the target condition, except for stroke prevention, for which we accepted any diagnosis of atrial fibrillation. We sampled the discharges for a 6-month period within each state. For a third of the states, this period was from April to October 1998; for another third of the states, July to December 1998; and for the remaining states, October 1998 to March 1999. We sampled up to 850 discharges for AMI, pneumonia, and stroke, and up to 900 discharges for heart failure and used a census of all discharges for states with fewer than the targeted number of discharges during the period. The universe of eligible claims was first sorted by age, race, sex, and hospital, and cases were then sampled systematically from a random starting point. Data for the performance measures were abstracted from the hospital medical records by 2 clinical data abstraction centers (which are administratively independent of individual PROs) using computerized abstraction tools with explicit criteria that were developed and tested specifically for these measures. The abstraction tools collected information on contraindications to the treatment process being studied. Informed consent was not required because the data were collected for administration of the Medicare program, not for research, and access to these data is given to the program by law.

Influenza and Pneumococcal Immunization Rates. We used the BRFSS,¹¹ which is coordinated by the Centers for Disease Control and Prevention and carried out by state health departments, to estimate statewide vaccination coverage. The BRFSS is a random-digit-dialed telephone survey of the noninstitutionalized adult population, and the estimates are for all persons older than 65 years; the national sample is 26,469 for this age group, with a median state sample of 430 in 1997 (estimated from the 1997 BRFSS Public Use Data File¹²). The estimates therefore differ from those for other samples by including beneficiaries who are enrolled in managed care and excluding persons younger than 65 years old. Rate estimates reported here are from the 1997 survey. Screening for or administration of influenza and pneumococcal vaccine for inpatients with pneumonia was ascertained from nursing and physician notes and other information in the medical record.

Breast Cancer (Mammography). The denominator was all women aged 52 to 69 years who were enrolled in Medicare FFS in both 1997 and 1998. Whether a mammogram had been performed in the 2 years was determined by whether Medicare had paid a claim for a diagnostic or screening mammogram in that period.

Diabetes. The denominator was all FFS beneficiaries aged 18 to 75 years who had 2 outpatient claims or 1 inpatient claim with a diagnosis of diabetes mellitus during a 1-year period starting January 1998-July 1998, with the start date determined by the date when the PRO's contract began in that state. Whether a service had been provided was determined by whether Medicare had paid a claim for the service.

Statistical Methods

For the inpatient measures, patients found to have a clinical contraindication to the process of care were either included as having received appropriate care (heart failure measures) or excluded from both the numerator and denominator (other appropriateness of care measures). Reliability was calculated as the percentage agreement on an indicator for 2 blinded, independent abstractions at different abstraction centers. Performance was calculated at the state level for each of the measures. For 22 measures, results were calculated as the percentage of patients receiving appropriate care; for time to angioplasty or thrombolytic therapy, the result was calculated as the median number of minutes from arrival at the hospital to beginning of angioplasty or thrombolytic agent instillation. We primarily direct our attention to variation among states (including the District of Columbia and Puerto Rico). We therefore calculated, for each measure, performance of the median state rather than a national average. We also calculated the rank of each state on each performance measure and then calculated the average rank for each state across the 22 measures (we excluded time to angioplasty and time to thrombolytic therapy from this calculation because the sample size was too small in many states) and the SD of the 22 ranks for each state. We mapped the distribution of average ranks to display geographic patterns.

RESULTS

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Across the 4 inpatient conditions we obtained 94.3% to 99.2% of sampled records (median, 95.3%). The reliability of measures based on medical record abstraction ranged from 80% to 95% with a median interrater reliability of 90%. Table 2 shows the number of charts in the denominator of each rate in 2 ways: the individual rate or time number is formatted in a type that reflects the number of charts used; the Table 1 also provides the median number of charts across all states. Even though more than 700 records were obtained for each condition in most states, the number of patients who qualified for a particular indicator was rarely even half that number and sometimes much less. Table 2 shows 3 kinds of results: (1) the performance of the median state on each measure, (2) the average of each state's performance ranks across the 22 measures, and (3) the rank of each state among all states based on this average rank. More detailed results are available at the HCFA Web site.⁸

View this table: [in this window] [in a new window] Table 2. Rank and Performance on Medicare Quality Indicators by State*

The performance rates in the median state for each of the 22 rate measures range from a high of 95% (avoidance of sublingual nifedipine in acute stroke) to a low of 11% (patients with pneumonia screened for pneumococcal immunization status before discharge). When performance indicators are ranked by the rate in the median state, the median performance is 69% (patients discharged with heart failure diagnosis who received angiotensin-converting enzyme inhibitors; diabetic patients having an eye examination in the last 2 years). The range of rates for each measure also varies widely across the states, from a low of a 13-percentage point range for avoidance of sublingual nifedipine for patients with acute stroke (Nevada, 86%; Wyoming, 100%) to a high of a 54-percentage point range for antibiotic administered within 8 hours of hospital arrival to patients with an admission diagnosis of pneumonia (Puerto Rico, 38%; Montana, 93%). The median of the ranges for performance indicators (other than time to angioplasty and thrombolytic therapy) is 33 percentage points and the median interquartile range is 8 percentage points. Table 2 shows the performance of each state on each quality measure.

Table 2 also shows the average of the ranking of each state compared with other states on all of the performance measures (except time to angioplasty and thrombolytic therapy) and the SD of these rankings; these averages of rankings range from 10 to 48 because no state is consistently at the top or bottom. Based on the average of the rankings, Table 2 shows the state's rank among all states and areas (range, 1-52). Figure 1 shows that the rankings tend to follow a geographic pattern with northern and less populous states more likely to rank high than southern and more populous states.

View larger version (16K): [in this window] [in a new window] Figure. Average State Rank on 22 Medicare Performance Measures Puerto Rico (not shown) is in the fourth quartile.

COMMENT

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Implications

Previous studies have reported results using some of the individual measures reported here,^1-4,10 and HEDIS provides a picture (albeit more limited) of care in Medicare managed care, but we believe that this is the first study to provide a broad picture of quality of care in FFS Medicare and the first to include data that have been verified by chart abstraction of a national sample for several conditions. This study provides strong evidence of a substantial opportunity to improve the care delivered to Medicare beneficiaries. Available data suggest that providing the services measured here could each save hundreds to thousands of lives a year, but more precise estimates of the effect of such improvement on beneficiary health are beyond the scope of this study.

The differences in average performance among states and regions are modest compared with the overall need for improvement. Nevertheless, the data suggest real underlying geographic differences in the way care is delivered to the Medicare FFS population. They also suggest that variations among states on individual measures are part of a larger pattern and not simply local variation. We do not yet understand the reasons for these differences or whether aspects of the systems in high-performing states can be easily replicated in low-performing states.

Limitations and Qualifications

These measures give a somewhat unbalanced picture of Medicare services. They overrepresent inpatient and preventive services, underrepresent ambulatory care, and scarcely represent interventional procedures at all.

This article is generally limited to care delivered in FFS Medicare. Nationally, about 85% of Medicare beneficiaries are cared for under FFS and about 15% under managed care, but in Arizona, California, Florida, and Pennsylvania more than 25% of beneficiaries are enrolled in managed care. Comparing HEDIS data from managed care with this FFS data presents technical problems that we have not yet solved because denominators and/or measure definitions differ in the 2 systems. However, the data reported here for FFS do not differ dramatically from the HEDIS data reported for Medicare managed care.¹³

This article is limited to national- and state-level information. Information on individual practitioners and providers requires a different and more efficient data collection and reporting system designed to collect such voluminous data. Even with practitioner- and provider-level data, many practitioners and providers treat too few patients with particular conditions to generate a meaningful sample size, and it will remain difficult to determine which practitioner is responsible for delivering the process of care that is measured.

We must also consider the extent to which these measures fairly represent quality of care for the services and population addressed. There are 2 concerns: the validity of the measures as representations of quality of care and the accuracy of the data.

Each of the measures is based on both strong science and professional consensus that delivering the service would either improve outcomes or be necessary to services that would improve outcomes. Nevertheless, for almost all of the services, there are circumstances in which delivering them would be inappropriate. For the inpatient measures, we included the major contraindications in our abstraction and computational algorithms, but there are likely to be unusual circumstances that account for a few cases of undelivered care. The measures are designed to credit care as appropriate if there is doubt, and we know from PRO field experience with the measures that valid, unmeasured contraindications are not frequent.

Small numbers are a problem for some inpatient measures, such as time to angioplasty and thrombolytic therapy, because a relatively small number of the beneficiaries in our sample received these services in some states. However, the effect of small denominators is to increase the variation among states, not to bias the median downward. We use surveys for influenza and pneumococcal immunization rates because many influenza immunizations are delivered without claims being submitted to Medicare, and because there is no immediately feasible way to accurately determine pneumococcal immunization status from existing Medicare claims data files. Surveys, of course, may have recall and sampling bias, but this does not appear to be a major problem for the other measures.

If interrater reliability is 90%, the accuracy of the individual abstractor is about 95% (each rater accounts for about half of disagreements between raters). The range of reliabilities is about 80% to 95%, suggesting that, even for the most unreliable measure, abstraction errors would not account for a performance level below 90%.

Future Steps

We believe that this article and the tracking system behind it establish a mechanism for HCFA to move beyond its historical focus on individual cases and providers and to take responsibility as a purchaser for the care delivered to the population of Medicare beneficiaries. Although it is customary to speak of holding providers, practitioners, and health plans accountable for the care they provide, it is at least as important to hold purchasers, whether Medicare or Medicaid or commercial or government employers, accountable for the quality of the care they purchase, because they are making continual and important decisions that potentially balance quality against expenditures. As required by the Government Performance and Results Act, HCFA is beginning to assume this responsibility by reporting some of these measures to Congress as part of its annual budget submission.

HCFA intends to extend the Medicare clinical performance tracking system in 3 ways. First, for those measures based on medical record abstraction, we are now collecting a continuous sample large enough to provide accurate trending of national data every few months, although too small to provide state-level estimates more than every few years. Second, we will collect enough data to make accurate state-level estimates every 3 years (synchronous with PRO contract cycles). This will allow us to evaluate the success of each PRO in meeting its major contractual requirement, which is to improve statewide performance on the measures. Third, we will extend the system to include other settings, such as nursing homes, home health agencies, and other providers and to include other clinical priorities.

Obviously, pervasive gaps between what is being done and what could be done invite us to consider what policies might lead to improvements. A future article will describe the quality improvement strategy that HCFA is pursuing to improve performance on these and other measures. Recent reports^3-4 have emphasized the importance of focusing on system failure rather than practitioner failure to working to close these performance gaps. The United States has poured enormous resources into practitioner training and very little into improving processes in the systems within which those practitioners work, and it is time to redress that balance. Available evidence suggests that, at least for preventive services, systems changes are more effective than either provider or patient education in improving provision of services.¹⁴

The data should also remind us of the need for partnership among HCFA, beneficiaries, practitioners, providers, and health plans to achieve improvements. The HCFA PROs are charged with promoting improvement. They now have performance-based contracts with more than $200 million a year for improving performance on the measures reported. Their contracts hold them accountable for successful promotion of improvement, and there is good evidence that they can contribute to significant improvement in care.¹⁰ Nevertheless, neither HCFA nor PROs deliver care. They can only provide technical assistance to practitioners, providers, and plans; take steps that will make it easier for practitioners and providers to deliver and for beneficiaries to receive needed care; and serve as conveners for partnerships among local stakeholders. Only practitioners and providers can make such systems changes as putting appropriate standing orders in place, installing failure-resistant information systems, and designing processes that deliver critical services within the optimum window of time. Segmenting improvement efforts according to payment source is inefficient and counterproductive. Partnerships among all of the stakeholders, regardless of source of payment, can make improvement possible and are urgently needed.

AUTHOR INFORMATION

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Funding/Support: All funding for this work was provided by the Health Care Financing Administration.

Disclaimer: The opinions herein are the authors' and not necessarily those of the Health Care Financing Administration.

Acknowledgment: The authors especially thank Joyce V. Kelly, PhD, who coordinates the national PRO quality improvement efforts and Jeffrey Kang, MD, MPH, without whom this work would not have been possible. We also thank the following individuals: Robert Peterson, Stephanie Monroe, PhD, and Edwin D. Huff, PhD, MA, for work on the sampling and sample validation for the inpatient measures; Marjorie Bedinger and James Michael, MS, for validation of the analytic code and production of the inpatient measures; Cynthia G. Wark, RN, MSN, Martha J. Radford, MD, Harlan M. Krumholz, MD, Deron Galusha, MS, and Jennifer Lewis, BSN, for work on the acute myocardial infarction measures; D. Jo DeBuhr, Edward P. Havranek, MD, Harlan M. Krumholz, MD, Frederick A. Masoudi, MD, and Debra Ralston for work on heart failure measurements; Wato Nsa, MD, PhD, Hui Jiang, MS, Dale Bratzler, DO, MPH, Claudette Shook, RN, for work on the pneumonia measurements; Marian Brenton, MPA, Marc Hendel, MS, June Wilwert, RN, Timothy Kresowik, MD, and Rebecca Hemann, BLS, for work on the stroke measurements; Lawrence La Voie, PhD, Rebecca Rogers, and Gary E. Thoni for production of the mammography measurements; David Nicewander for work on the diabetes measurements; and Kelly Westfall and Pam Wolfe, MA, MS, for creating Figure 1.

Corresponding Author and Reprints: Stephen F. Jencks, MD, MPH, S3-02-01, Health Care Financing Administration, 7500 Security Blvd, Baltimore, MD 21244.

Author Affiliations: Health Care Financing Administration, Baltimore, Md.

REFERENCES

Jump to Section  • Top  • Introduction  • Methods  • Results  • Comment  • Author information  • References

1. US Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. Washington, DC: US Dept of Health and Human Services; 2000. 2. Schuster MA, McGlynn EA, Brook RH. How good is the quality of health care in the United States? Milbank Q. 1998;76:517-563. FULL TEXT | ISI | PUBMED 3. Kohn LT, ed, Corrigan JM, ed, Donaldson MS, ed. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999. 4. Quality First: Better Health Care for All Americans. Washington, DC: The President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry; 1998. 5. National Committee for Quality Assurance. HEDIS 1999, Volume 2: Technical Specifications. Washington, DC: National Committee for Quality Assurance; 1998. 6. Fleming B. Quality of Care—National Projects: Diabetes Quality Improvement Project (DQIP). Health Care Financing Administration, 1999. Available at: http://www.hcfa.gov/quality/3l.htm. Verified September 12, 2000. 7. Jencks SF, Wilensky GR. The health care quality improvement initiative: a new approach to quality assurance in Medicare. JAMA. 1992;268:900-904. FREE FULL TEXT 8. Health Care Financing Administration. Quality of Care—PRO Priorities: National Clinical Topics (Task 1). Health Care Financing Administration, 2000. Available at: http://www.hcfa.gov/quality/11a.htm. Verified September 12, 2000. 9. Ellerbeck EF, Jencks SF, Radford MJ, et al. Quality of care for Medicare patients with acute myocardial infarction. JAMA. 1995;273:1509-1514. FREE FULL TEXT 10. Marciniak TA, Ellerbeck EF, Radford MJ, et al. Improving the quality of care for Medicare patients with acute myocardial infarction. JAMA. 1998;279:1351-1357. FREE FULL TEXT 11. Centers for Disease Control and Prevention. Influenza and pneumococcal immunization rates among adults age greater than or equal to 65 years—United States. MMWR Morb Mortal Wkly Rep. 1998;47:797-805. PUBMED 12. National Center for Chronic Disease Prevention and Health Promotion. Behavioral Risk Factor Surveillance System, 1997 Survey Data. Atlanta, Ga: US Dept of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention; 1999. CD-ROM Series 1, No. 3. 13. Health Care Financing Administration: Health Care Compare Health Care Financing Administration, 2000. Available at: http://www.medicare.gov/mphCompare/home.asp. Verified September 12, 2000. 14. Shekelle P, Stone E, Breuder T. Interventions That Increase the Utilization of Medicare-Funded Preventive Services for Persons Age 65 and Older. Baltimore, Md: US Dept of Health and Human Services, Health Care Financing Administration; 2000.

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Ann Fam Med 2006;4:541-547.
ABSTRACT | FULL TEXT  

Development of a contemporary bleeding risk model for elderly warfarin recipients.
Shireman et al.
Chest 2006;130:1390-1396.
ABSTRACT | FULL TEXT  

National surveillance of emergency department visits for outpatient adverse drug events.
Budnitz et al.
JAMA 2006;296:1858-1866.
ABSTRACT | FULL TEXT  

Recent Trends in the Care of Patients With Non-ST-Segment Elevation Acute Coronary Syndromes: Insights From the CRUSADE Initiative.
Mehta et al.
Arch Intern Med 2006;166:2027-2034.
ABSTRACT | FULL TEXT  

Agreement of Immunosuppression Regimens Described in Medicare Pharmacy Claims with the Organ Procurement and Transplantation Network Survey
Stirnemann et al.
J. Am. Soc. Nephrol. 2006;17:2299-2306.
ABSTRACT | FULL TEXT  

Antibiotic Timing and Diagnostic Uncertainty in Medicare Patients With Pneumonia: Is it Reasonable to Expect All Patients to Receive Antibiotics Within 4 Hours?
Metersky et al.
Chest 2006;130:16-21.
ABSTRACT | FULL TEXT  

Quality of care for patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease.
Lindenauer et al.
ANN INTERN MED 2006;144:894-903.
ABSTRACT | FULL TEXT  

Primary Prevention of Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council: Cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline.
Goldstein et al.
Circulation 2006;113:e873-e923.
ABSTRACT | FULL TEXT  

Primary Prevention of Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council: Cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline.
Goldstein et al.
Stroke 2006;37:1583-1633.
ABSTRACT | FULL TEXT  

The Pre-Hospital Electrocardiogram and Time to Reperfusion in Patients With Acute Myocardial Infarction, 2000-2002: Findings From the National Registry of Myocardial Infarction-4
Curtis et al.
J Am Coll Cardiol 2006;47:1544-1552.
ABSTRACT | FULL TEXT  

Regionalization of ST-Segment Elevation Acute Coronary Syndromes Care: Putting a National Policy in Proper Perspective
Rathore et al.
J Am Coll Cardiol 2006;47:1346-1349.
ABSTRACT | FULL TEXT  

Translating the Results of Randomized Trials into Clinical Practice: The Challenge of Warfarin Candidacy Among Hospitalized Elderly Patients With Atrial Fibrillation
Hylek et al.
Stroke 2006;37:1075-1080.
ABSTRACT | FULL TEXT  

An Intervention to Overcome Clinical Inertia and Improve Diabetes Mellitus Control in a Primary Care Setting: Improving Primary Care of African Americans With Diabetes (IPCAAD) 8.
Ziemer et al.
Arch Intern Med 2006;166:507-513.
ABSTRACT | FULL TEXT  

Volume, quality of care, and outcome in pneumonia.
Lindenauer et al.
ANN INTERN MED 2006;144:262-269.
ABSTRACT | FULL TEXT  

Coming Together to Achieve Quality Cardiovascular Care
Douglas et al.
Circulation 2006;113:607-608.
FULL TEXT  

Hospital Improvement in Time to Reperfusion in Patients With Acute Myocardial Infarction, 1999 to 2002
McNamara et al.
J Am Coll Cardiol 2006;47:45-51.
ABSTRACT | FULL TEXT  

Coming Together to Achieve Quality Cardiovascular Care
Douglas et al.
J Am Coll Cardiol 2006;47:266-267.
FULL TEXT  

Quality of Care of Medicare Patients With Diabetes in a Metropolitan Fee-for-Service Primary Care Integrated Delivery System
Hollander et al.
American Journal of Medical Quality 2005;20:344-352.
ABSTRACT  

Guideline-Based Standardized Care Is Associated With Substantially Lower Mortality in Medicare Patients With Acute Myocardial Infarction: The American College of Cardiology's Guidelines Applied in Practice (GAP) Projects in Michigan
Eagle et al.
J Am Coll Cardiol 2005;46:1242-1248.
ABSTRACT | FULL TEXT  

An Endocrinologist-Supported Intervention Aimed at Providers Improves Diabetes Management in a Primary Care Site: Improving Primary Care of African Americans with Diabetes (IPCAAD) 7
Phillips et al.
Diabetes Care 2005;28:2352-2360.
ABSTRACT | FULL TEXT  

{beta}2-Adrenergic Receptor Genotype and Survival Among Patients Receiving {beta}-Blocker Therapy After an Acute Coronary Syndrome
Lanfear et al.
JAMA 2005;294:1526-1533.
ABSTRACT | FULL TEXT  

Aspirin Use in Older Patients With Heart Failure and Coronary Artery Disease: National Prescription Patterns and Relationship With Outcomes
Masoudi et al.
J Am Coll Cardiol 2005;46:955-962.
ABSTRACT | FULL TEXT  

Moving beyond Round Pegs and Square Holes: Restructuring Medicare To Improve Chronic Care
Wolff and Boult
ANN INTERN MED 2005;143:439-445.
ABSTRACT | FULL TEXT  

Feasibility and Effectiveness of System Redesign for Diabetes Care Management in Rural Areas: The Eastern North Carolina Experience
Bray et al.
The Diabetes Educator 2005;31:712-718.
ABSTRACT | FULL TEXT  

Understanding variation in quality of antibiotic use for community-acquired pneumonia: effect of patient, professional and hospital factors
Schouten et al.
J Antimicrob Chemother 2005;56:575-582.
ABSTRACT | FULL TEXT  

FAMILY MEDICINE LEGISLATIVE ADVOCACY: OUR POWERFUL MESSAGE
Kruse
Ann Fam Med 2005;3:468-469.
FULL TEXT  

Trends in the Quality of Care and Racial Disparities in Medicare Managed Care
Trivedi et al.
NEJM 2005;353:692-700.
ABSTRACT | FULL TEXT  

Quality of Care Is Associated with Survival in Vulnerable Older Patients
Higashi et al.
ANN INTERN MED 2005;143:274-281.
ABSTRACT | FULL TEXT  

Improving the Quality of Hospital Care in America
Romano
NEJM 2005;353:302-304.
FULL TEXT  

The Cost-Quality Trade-Off: Need for Data Quality Standards for Studies That Impact Clinical Practice and Health Policy
Malin and Keating
JCO 2005;23:4581-4584.
FULL TEXT  

Identification of Patients With Diabetes From the Text of Physician Notes in the Electronic Medical Record
Turchin et al.
Diabetes Care 2005;28:1794-1795.
FULL TEXT  

Do Quality Improvement Organizations Improve the Quality of Hospital Care for Medicare Beneficiaries?
Snyder and Anderson
JAMA 2005;293:2900-2907.
ABSTRACT | FULL TEXT  

In defence of current treatment options: where are we now?
Voller
Eur Heart J Suppl 2005;7:E4-E9.
FULL TEXT  

Acute Stroke Care in the US: Results from 4 Pilot Prototypes of the Paul Coverdell National Acute Stroke Registry
The Paul Coverdell Prototype Registries Writing Gr
Stroke 2005;36:1232-1240.
ABSTRACT | FULL TEXT  

Pursuing integration of performance measures into electronic medical records: beta-adrenergic receptor antagonist medications
Weiner et al.
Qual Saf Health Care 2005;14:99-106.
ABSTRACT | FULL TEXT  

Long-term Outcomes of Regional Variations in Intensity of Invasive vs Medical Management of Medicare Patients With Acute Myocardial Infarction
Stukel et al.
JAMA 2005;293:1329-1337.
ABSTRACT | FULL TEXT  

Disparities And Quality Improvement: Federal Policy Levers
Lurie et al.
Health Aff (Millwood) 2005;24:354-364.
ABSTRACT | FULL TEXT  

Systematic Review: The Relationship between Clinical Experience and Quality of Health Care
Choudhry et al.
ANN INTERN MED 2005;142:260-273.
ABSTRACT | FULL TEXT  

Trends in implantable cardioverter-defibrillator racial disparity: The importance of geography
Groeneveld et al.
J Am Coll Cardiol 2005;45:72-78.
ABSTRACT | FULL TEXT  

Heart Failure Disease Management Programs: Not a Class Effect
Fonarow
Circulation 2004;110:3506-3508.
FULL TEXT  

Use of Cancer Performance Measures in Population Health: A Macro-level Perspective
Clauser
J Natl Cancer Inst Monogr 2004;2004:142-154.
ABSTRACT | FULL TEXT  

Combined Anticoagulant-Antiplatelet Use and Major Bleeding Events in Elderly Atrial Fibrillation Patients
Shireman et al.
Stroke 2004;35:2362-2367.
ABSTRACT | FULL TEXT  

Randomized, Controlled Evaluation of Short- and Long-Term Benefits of Heart Failure Disease Management Within a Diverse Provider Network: The SPAN-CHF Trial
Kimmelstiel et al.
Circulation 2004;110:1450-1455.
ABSTRACT | FULL TEXT  

Quality of in-hospital care in acute coronary syndromes: it is time to close the gap
Gaspoz
Int J Qual Health Care 2004;16:273-274.
FULL TEXT  

Hospital Quality Improvement Activities and the Effects of Interventions on Pneumonia: A Multistate Study of Medicare Beneficiaries
Weingarten et al.
American Journal of Medical Quality 2004;19:157-165.
ABSTRACT  

Limited Impact of a Multicenter Intervention To Improve the Quality and Efficiency of Pneumonia Care
Halm et al.
Chest 2004;126:100-107.
ABSTRACT | FULL TEXT  

Medicare Patients with Cardiovascular Disease Have a High Prevalence of Chronic Kidney Disease and a High Rate of Progression to End-Stage Renal Disease
McClellan et al.
J. Am. Soc. Nephrol. 2004;15:1912-1919.
ABSTRACT | FULL TEXT  

Stroke Care Delivery in Institutions Participating in the Registry of the Canadian Stroke Network
Kapral et al.
Stroke 2004;35:1756-1762.
ABSTRACT | FULL TEXT  

Provider and Hospital Characteristics Associated With Geographic Variation in the Evaluation and Management of Elderly Patients With Heart Failure
Havranek et al.
Arch Intern Med 2004;164:1186-1191.
ABSTRACT | FULL TEXT  

Outpatient utilization of angiotensin-converting enzyme inhibitors among heart failure patients after hospital discharge
Butler et al.
J Am Coll Cardiol 2004;43:2036-2043.
ABSTRACT | FULL TEXT  

Outcomes and the quality of care for patients hospitalized with heart failure
Luthi et al.
Int J Qual Health Care 2004;16:201-210.
ABSTRACT | FULL TEXT  

Pitfalls of Converting Practice Guidelines Into Quality Measures: Lessons Learned From a VA Performance Measure
Walter et al.
JAMA 2004;291:2466-2470.
ABSTRACT | FULL TEXT  

Improving Health Care Systems Performance: A Human Factors Approach
Silver et al.
American Journal of Medical Quality 2004;19:93-102.
ABSTRACT  

Are Low-Income Elderly Patients at Risk for Poor Diabetes Care?
McCall et al.
Diabetes Care 2004;27:1060-1065.
ABSTRACT | FULL TEXT  

The Sensitivity of Medicare Billing Claims Data for Monitoring Mammography Use by Elderly Women
Mouchawar et al.
Med Care Res Rev 2004;61:116-127.
ABSTRACT  

Data feedback efforts in quality improvement: lessons learned from US hospitals
Bradley et al.
Qual Saf Health Care 2004;13:26-31.
ABSTRACT | FULL TEXT  

Is readmission to hospital an indicator of poor process of care for patients with heart failure?
Luthi et al.
Qual Saf Health Care 2004;13:46-51.
ABSTRACT | FULL TEXT  

Get With the Guidelines for Cardiovascular Secondary Prevention: Pilot Results
LaBresh et al.
Arch Intern Med 2004;164:203-209.
ABSTRACT | FULL TEXT  

Paying Physicians for High-Quality Care
Epstein et al.
NEJM 2004;350:406-410.
FULL TEXT  

Variations in Diabetes Care and the Influence of Office Systems
Ellerbeck et al.
American Journal of Medical Quality 2004;19:12-18.
ABSTRACT  

Little Time for Diabetes Management in the Primary Care Setting
Barnes et al.
The Diabetes Educator 2004;30:126-135.
 

Acute Ischemic Stroke in Hospitalized Medicare Patients: Evaluation and Treatment
Roychoudhury et al.
Stroke 2004;35 :e22-e23.
ABSTRACT | FULL TEXT  

Reducing clinical variations with clinical pathways: do pathways work?
Panella et al.
Int J Qual Health Care 2003;15:509-521.
ABSTRACT | FULL TEXT  

Racial Variation in the Control of Diabetes Among Elderly Medicare Managed Care Beneficiaries
McBean et al.
Diabetes Care 2003;26:3250-3256.
ABSTRACT | FULL TEXT  

Doctors and managers: poor relationships may be damaging patients--what can be done?
Edwards
Qual Saf Health Care 2003;12:i21-24.
ABSTRACT | FULL TEXT  

Statewide Assessment of Hospital-Based Stroke Prevention and Treatment Services in North Carolina: Changes Over the Last 5 Years
Camilo and Goldstein
Stroke 2003;34:2945-2950.
ABSTRACT | FULL TEXT  

The Quality of Medical Care Provided to Vulnerable Community-Dwelling Older Patients
Wenger et al.
ANN INTERN MED 2003;139:740-747.
ABSTRACT | FULL TEXT