Leaders: Research Pioneer Shines Light on Quality Improvement

Dr. Peter K. Lindenauer is used to making headlines with his research on hospital quality of care. Dr. Lindenauer, who directs the Center for Quality of Care Research at Baystate Medical Center in Springfield, Mass., led the research team that uncovered significant variations in how physicians care for patients with acute exacerbations of chronic obstructive pulmonary disease (Ann. Intern. Med. 2006;144:894-903). The following year, he and his colleagues at Baystate published research showing that patients cared for by hospitalists have slightly shorter lengths of stay without related increases in mortality or readmission (N. Engl. J. Med. 2007;357:2589-600). These days, Dr. Lindenauer, who is also an associate professor of medicine at Tufts University, Boston, is devoting much of his time to HOMERUN, the Hospital Medicine Re-engineering Outcomes Research Network, which was started by hospitalists and is being funded in part by the Association of American Medical Colleges.

Dr. Lindenauer, a member of the Hospitalist News editorial advisory board, shared his thoughts on the state of quality improvement in U.S. hospitals and offered some advice to hospitalists considering research projects.

Hospitalist News: What general areas are ripe for quality improvement research projects at the academic and community hospital levels?

Dr. Lindenauer: One natural place for hospitalists to focus on is developing and evaluating strategies for translating evidence-based care processes into routine practice. That’s something that people have been working on for awhile, but there are still opportunities there. Another important area for hospitalists is in the development and evaluation of approaches to improve patient safety and reduce harm among hospitalized patients. This includes work on hospital-acquired infections, adverse drug events, falls, and other complications of hospitalization, including venous thromboembolism.

Another topic that has been gaining attention lately is the issue of cost and utilization. Readmission is a part of that, but there are also opportunities to reduce unnecessary utilization and improve value that go beyond simply improving care transitions and reducing readmission rates. Laboratory testing and diagnostic imaging are good examples here. Another research area is patient experience. This has become even more important to hospitals since it is now part of Medicare’s Hospital Value-Based Purchasing Program. Yet, it seems like the evidence base for how we improve patient experience is still relatively limited. Efforts to improve communication and collaboration between physicians, nurses, and other care team members are great examples of this.

HN: How ambitious should hospitalists be when developing a QI project?

Dr. Lindenauer: It is very dependent on the context. It’s not critical that every quality improvement process undergo an evaluation of the sort that could allow it to be published in the Journal of Hospital Medicine or other journals. But measurement is a fundamental aspect of quality improvement, and thus every quality improvement project involves some evaluation.

It makes sense to invest more effort in a research project if you’re evaluating a strategy that is especially innovative or hasn’t been described or analyzed before. More rigorous evaluation is probably also appropriate if you’re carrying out a project or program that is especially important to the hospital because it is tackling a problem that affects a large number of patients, is associated with high costs, or has large clinical impact. Even if it’s been done before, those factors would make the topic of greater relevance and interest to reviewers at a journal and ultimately to clinicians at other hospitals. On the other hand, if you’re the 100th team to implement a rapid response team, it may not be worth the time and effort to conduct a rigorous evaluation.

HN: There’s a lot of QI work going on right now. Is the word getting out about those results and are they actually changing the way hospitalists practice?

Dr. Lindenauer: I think so. There’s obviously a lot of quality improvement work that takes place that never sees the light of day. But I also see hospitalists leading local efforts to improve transitions of care for patients who are discharged, improve the process of interdisciplinary rounds, and employ a variety of strategies to reduce catheter-associated urinary tract infections and central line associated bloodstream infections. For the most part, these QI projects have come out of the recent QI literature; out of efforts made by QI researchers to evaluate those interventions in the same rigorous way that other biomedical innovations are being evaluated. Are there opportunities to do more? The answer is undoubtedly yes. However, compared to where we were a decade ago, it seems that there is a lot more good quality improvement research being published than in the past.

HN: How do pay-for-performance programs and public reporting impact quality improvement efforts in U.S. hospitals?

Dr. Lindenauer: They certainly grab the attention of hospital leaders. There’s little doubt about that.

There’s less evidence that either strategy has been associated with more than very modest improvements in care quality. There is perhaps a bit more evidence for public reporting, but even some of the largest and most ambitious trials of public reporting, such as the EFFECT study in Canada, were largely negative (JAMA 2009;302:2330-7). So there are still significant questions about the impact of public reporting on quality improvement, as well as on patient and provider choices.

We’re about to embark on a very grand experiment in pay-for-performance through the Hospital Value-Based Purchasing Program, which was part of the Affordable Care Act. To date, the evidence for the benefits of financial incentives on hospital care is very limited. However, there are a number of factors that may have attenuated the impact of financial incentives in the hospital and it remains to be seen what will happen when these new pay-for-performance programs are implemented.

Dr. Peter K. Lindenauer is used to making headlines with his research on hospital quality of care. Dr. Lindenauer, who directs the Center for Quality of Care Research at Baystate Medical Center in Springfield, Mass., led the research team that uncovered significant variations in how physicians care for patients with acute exacerbations of chronic obstructive pulmonary disease (Ann. Intern. Med. 2006;144:894-903). The following year, he and his colleagues at Baystate published research showing that patients cared for by hospitalists have slightly shorter lengths of stay without related increases in mortality or readmission (N. Engl. J. Med. 2007;357:2589-600). These days, Dr. Lindenauer, who is also an associate professor of medicine at Tufts University, Boston, is devoting much of his time to HOMERUN, the Hospital Medicine Re-engineering Outcomes Research Network, which was started by hospitalists and is being funded in part by the Association of American Medical Colleges.

Dr. Lindenauer, a member of the Hospitalist News editorial advisory board, shared his thoughts on the state of quality improvement in U.S. hospitals and offered some advice to hospitalists considering research projects.

Hospitalist News: What general areas are ripe for quality improvement research projects at the academic and community hospital levels?

Dr. Lindenauer: One natural place for hospitalists to focus on is developing and evaluating strategies for translating evidence-based care processes into routine practice. That’s something that people have been working on for awhile, but there are still opportunities there. Another important area for hospitalists is in the development and evaluation of approaches to improve patient safety and reduce harm among hospitalized patients. This includes work on hospital-acquired infections, adverse drug events, falls, and other complications of hospitalization, including venous thromboembolism.

Another topic that has been gaining attention lately is the issue of cost and utilization. Readmission is a part of that, but there are also opportunities to reduce unnecessary utilization and improve value that go beyond simply improving care transitions and reducing readmission rates. Laboratory testing and diagnostic imaging are good examples here. Another research area is patient experience. This has become even more important to hospitals since it is now part of Medicare’s Hospital Value-Based Purchasing Program. Yet, it seems like the evidence base for how we improve patient experience is still relatively limited. Efforts to improve communication and collaboration between physicians, nurses, and other care team members are great examples of this.

HN: How ambitious should hospitalists be when developing a QI project?

Dr. Lindenauer: It is very dependent on the context. It’s not critical that every quality improvement process undergo an evaluation of the sort that could allow it to be published in the Journal of Hospital Medicine or other journals. But measurement is a fundamental aspect of quality improvement, and thus every quality improvement project involves some evaluation.

It makes sense to invest more effort in a research project if you’re evaluating a strategy that is especially innovative or hasn’t been described or analyzed before. More rigorous evaluation is probably also appropriate if you’re carrying out a project or program that is especially important to the hospital because it is tackling a problem that affects a large number of patients, is associated with high costs, or has large clinical impact. Even if it’s been done before, those factors would make the topic of greater relevance and interest to reviewers at a journal and ultimately to clinicians at other hospitals. On the other hand, if you’re the 100th team to implement a rapid response team, it may not be worth the time and effort to conduct a rigorous evaluation.

HN: There’s a lot of QI work going on right now. Is the word getting out about those results and are they actually changing the way hospitalists practice?

Dr. Lindenauer: I think so. There’s obviously a lot of quality improvement work that takes place that never sees the light of day. But I also see hospitalists leading local efforts to improve transitions of care for patients who are discharged, improve the process of interdisciplinary rounds, and employ a variety of strategies to reduce catheter-associated urinary tract infections and central line associated bloodstream infections. For the most part, these QI projects have come out of the recent QI literature; out of efforts made by QI researchers to evaluate those interventions in the same rigorous way that other biomedical innovations are being evaluated. Are there opportunities to do more? The answer is undoubtedly yes. However, compared to where we were a decade ago, it seems that there is a lot more good quality improvement research being published than in the past.

HN: How do pay-for-performance programs and public reporting impact quality improvement efforts in U.S. hospitals?

Dr. Lindenauer: They certainly grab the attention of hospital leaders. There’s little doubt about that.

There’s less evidence that either strategy has been associated with more than very modest improvements in care quality. There is perhaps a bit more evidence for public reporting, but even some of the largest and most ambitious trials of public reporting, such as the EFFECT study in Canada, were largely negative (JAMA 2009;302:2330-7). So there are still significant questions about the impact of public reporting on quality improvement, as well as on patient and provider choices.

We’re about to embark on a very grand experiment in pay-for-performance through the Hospital Value-Based Purchasing Program, which was part of the Affordable Care Act. To date, the evidence for the benefits of financial incentives on hospital care is very limited. However, there are a number of factors that may have attenuated the impact of financial incentives in the hospital and it remains to be seen what will happen when these new pay-for-performance programs are implemented.

Dr. Peter K. Lindenauer is used to making headlines with his research on hospital quality of care. Dr. Lindenauer, who directs the Center for Quality of Care Research at Baystate Medical Center in Springfield, Mass., led the research team that uncovered significant variations in how physicians care for patients with acute exacerbations of chronic obstructive pulmonary disease (Ann. Intern. Med. 2006;144:894-903). The following year, he and his colleagues at Baystate published research showing that patients cared for by hospitalists have slightly shorter lengths of stay without related increases in mortality or readmission (N. Engl. J. Med. 2007;357:2589-600). These days, Dr. Lindenauer, who is also an associate professor of medicine at Tufts University, Boston, is devoting much of his time to HOMERUN, the Hospital Medicine Re-engineering Outcomes Research Network, which was started by hospitalists and is being funded in part by the Association of American Medical Colleges.

Dr. Lindenauer, a member of the Hospitalist News editorial advisory board, shared his thoughts on the state of quality improvement in U.S. hospitals and offered some advice to hospitalists considering research projects.

Hospitalist News: What general areas are ripe for quality improvement research projects at the academic and community hospital levels?

Dr. Lindenauer: One natural place for hospitalists to focus on is developing and evaluating strategies for translating evidence-based care processes into routine practice. That’s something that people have been working on for awhile, but there are still opportunities there. Another important area for hospitalists is in the development and evaluation of approaches to improve patient safety and reduce harm among hospitalized patients. This includes work on hospital-acquired infections, adverse drug events, falls, and other complications of hospitalization, including venous thromboembolism.

Another topic that has been gaining attention lately is the issue of cost and utilization. Readmission is a part of that, but there are also opportunities to reduce unnecessary utilization and improve value that go beyond simply improving care transitions and reducing readmission rates. Laboratory testing and diagnostic imaging are good examples here. Another research area is patient experience. This has become even more important to hospitals since it is now part of Medicare’s Hospital Value-Based Purchasing Program. Yet, it seems like the evidence base for how we improve patient experience is still relatively limited. Efforts to improve communication and collaboration between physicians, nurses, and other care team members are great examples of this.

HN: How ambitious should hospitalists be when developing a QI project?

Dr. Lindenauer: It is very dependent on the context. It’s not critical that every quality improvement process undergo an evaluation of the sort that could allow it to be published in the Journal of Hospital Medicine or other journals. But measurement is a fundamental aspect of quality improvement, and thus every quality improvement project involves some evaluation.

It makes sense to invest more effort in a research project if you’re evaluating a strategy that is especially innovative or hasn’t been described or analyzed before. More rigorous evaluation is probably also appropriate if you’re carrying out a project or program that is especially important to the hospital because it is tackling a problem that affects a large number of patients, is associated with high costs, or has large clinical impact. Even if it’s been done before, those factors would make the topic of greater relevance and interest to reviewers at a journal and ultimately to clinicians at other hospitals. On the other hand, if you’re the 100th team to implement a rapid response team, it may not be worth the time and effort to conduct a rigorous evaluation.

HN: There’s a lot of QI work going on right now. Is the word getting out about those results and are they actually changing the way hospitalists practice?

Dr. Lindenauer: I think so. There’s obviously a lot of quality improvement work that takes place that never sees the light of day. But I also see hospitalists leading local efforts to improve transitions of care for patients who are discharged, improve the process of interdisciplinary rounds, and employ a variety of strategies to reduce catheter-associated urinary tract infections and central line associated bloodstream infections. For the most part, these QI projects have come out of the recent QI literature; out of efforts made by QI researchers to evaluate those interventions in the same rigorous way that other biomedical innovations are being evaluated. Are there opportunities to do more? The answer is undoubtedly yes. However, compared to where we were a decade ago, it seems that there is a lot more good quality improvement research being published than in the past.

HN: How do pay-for-performance programs and public reporting impact quality improvement efforts in U.S. hospitals?

Dr. Lindenauer: They certainly grab the attention of hospital leaders. There’s little doubt about that.

There’s less evidence that either strategy has been associated with more than very modest improvements in care quality. There is perhaps a bit more evidence for public reporting, but even some of the largest and most ambitious trials of public reporting, such as the EFFECT study in Canada, were largely negative (JAMA 2009;302:2330-7). So there are still significant questions about the impact of public reporting on quality improvement, as well as on patient and provider choices.

We’re about to embark on a very grand experiment in pay-for-performance through the Hospital Value-Based Purchasing Program, which was part of the Affordable Care Act. To date, the evidence for the benefits of financial incentives on hospital care is very limited. However, there are a number of factors that may have attenuated the impact of financial incentives in the hospital and it remains to be seen what will happen when these new pay-for-performance programs are implemented.