Questions and Answers Center for Quality of Care Research Is a Study in Determination

Dr. Peter Lindenauer says the Center for Quality of Care Research at Baystate Medical Center was started with some very ambitious goals.

“We’ve embarked on something very ambitious — developing a research center that will compete with the very best health services and outcomes-research centers in Boston and around the country,’ said Lindenauer, director of the center, adding that, less than two years after its formation, the CQCR is certainly well on its way to meeting or exceeding those goals.

As evidence, he pointed to the June 16 issue of JAMA (the Journal of the American Medical Assoc.). Its lead story, titled “Association of Corticosteroid Dose and Route of Administration with Risk of Treatment Failure in Acute Exacerbation of Chronic Obstructive Pulmonary Disease,” was written by six members of the center’s team. What’s more, an editorial in that same edition praises not only the study’s results, but also its methods for reaching them — comparative-effectiveness research.

“The idea that our study would prompt an editorial called ‘An Act upon Comparative Effectiveness Research’ that basically said that the research conducted by this team was of such high quality that it provides sufficient evidence to change practice and to act was very exciting,” said Lindenauer. “That’s because this was an observational study and not a randomized trial, and what the editorial was saying is that, as with other problems in health care, it’s not feasible to conduct randomized control trials — it costs too much money, and there are too many questions to try to answer in that way.”

This was the second article written by center members to appear in JAMA since the spring, said Lindenauer, adding that both pieces — as well as another in the Journal of General Interest Medicine detailing another CQCR-led study on physician-review Web sites and their impact on physicians’ reputations — have garnered considerable press for Baystate (print, TV, and radio) locally, nationally, and even internationally.

But the center’s success cannot be measured by press clippings and sound bites alone, he told The Healthcare News, adding that it can also be qualified by the amount of grant money received for studies ($900,000) as well as the amount in the pipeline and likely to be received — another $4 million.

Meanwhile, it can be qualified in terms of the attention being focused on quality and safety as well as the prestige Baystate is garnering when it comes to important research in those areas — which are the real goals behind the formation of the center.

“We’re focused on the advancement of knowledge, which is one of Baystate Health’s core objectives,” he explained. “And we’re helping to solidify Baystate’s reputation nationally as a thought leader in quality through our research.”

For this issue, The Healthcare News spoke at length with Lindenauer about the center, its expectations for the future, and its early success in putting a spotlight on the issues of quality and safety.

Data with Destiny

As he talked about the CQCR, its mission and MO, Lindenauer, who has been with Baystate Health for 12 years and previously held the titles of associate medical director of Quality and medical director of Clinical Informatics, talked first about what it was not created to do — specifically the testing of new wonder drugs or treatment regimens.

“We’re not focused on carrying out clinical trials for the pharmaceutical industry, which is another model of research, but not one that is part of our vision,” he explained. “We’re not a research center trying to identify the next gene to identify patients at risk of early Alzheimer’s.”

From there, he moved on to detail what the Baystate board of directors had in mind when it decided to fund the center in early 2008.

“The goal of our center is to catalyze and support research activities across Baystate that are focused on quality and safety issues,” he said. “In particular, we are committed to the notion that quality improvement and patient safety deserve to be studied, and subjected to the same kind of rigorous scientific evaluation as any other kinds of medical interventions would be subjected to, in the belief that this is the only way to know that the work that we’re doing in quality and safety is likely to have positive benefits on patients.

“Quality and safety interventions are just like other medical interventions — sometimes they work, and sometimes they don’t,” he continued. “And so, unless we really subject them to scrutiny, we won’t know whether we ought to be committing our time, money, and effort to implement them.”

To gain a sense of the kind of work the CQRC is involved with, a visit to the ‘selected projects’ button on the center’s Web site is a prudent exercise. There, several past and current initiatives are detailed as follows:

• Variation in Treatment and Outcomes in Sepsis. Working with faculty from the Critical Care Division at Baystate Medical Center, the CQRC is studying the care and outcomes of more than 200,000 patients hospitalized for the treatment of sepsis. The work is focused on describing variations in treatment patterns and outcomes across hospitals, examining the effectiveness of common therapies, and exploring the relationship between cost and outcomes of care. Future studies will strive to identify hospital characteristics and processes associated with high-value sepsis care.
• VTE Prophylaxis in Hospitalized Medical Patients. The center is performing a comprehensive analysis of patient risk, physician prescribing, and outcomes for medical patients at high risk for venous thromboembolism at 400 U.S. hospitals. Specific projects include developing a risk-prediction model for developing VTE; describing patient, physician, and system factors associated with VTE prophylaxis; and examining the comparative effectiveness and cost-effectiveness of low molecular weight and unfractionated heparins. The project is funded by a grant from the Doris Duke Foundation.
• Readmission and Hospital Quality. Readmission of patients following hospital discharge is a clinically important, expensive, and often preventable adverse outcome. Working with colleagues at the Oklahoma Foundation for Medical Quality, the center is using Medicare claims files and patient-level data from Medicare’s Hospital Compare database to study the relationship between existing quality measures and risk-adjusted hospital readmission rates for pneumonia, heart failure, and myocardial infarction. This project is supported by a grant from the Baystate Medical Center Incubator Fund, and is part of a larger effort to examine the effects of public reporting on readmission rates.
• Potentially Inappropriate Medication Use among Hospitalized Elders. The Beers’ List identifies medications that should be avoided in persons age 65 or older because they are either ineffective or they pose an unnecessarily high risk and a safer alternative is available. Using administrative and billing data from more than 300 hospitals nationwide, the CQCR is evaluating variation in prescribing of these medications; association of their use with patient, physician, and hospital characteristics; and impact of their use on length of stay, falls, and hospital-acquired delirium.
• The Association of Specific Antibiotics with Subsequent Clostridium Difficile Infection in a Large Multi-hospital Database. The receipt of broad-spectrum antibiotics has been shown to be a necessary precursor to subsequent infection with Clostridium difficile. However, no previous studies have identified the antibiotics most likely to be associated with this hospital-acquired infection. Using a large database of over 1 million hospital admissions for common medical diagnoses, the center is examining associations between specific antibiotics and the diagnosis of Clostridium difficile diarrhea.
• Use of Inpatient Cardiac Telemetry Monitoring: Impact on Patient Safety and Costs. Telemetry is expensive and labor-intensive for hospitals. In collaboration with UMass Memorial Hospital, Beth Israel Deaconess Hospital, Mt. Auburn Hospital, and Tufts Medical Center, the center is conducting a retrospective examination of telemetry utilization among inpatients. This study will help it identify rates of appropriate and inappropriate uses of telemetry, find methods for limiting telemetry-associated expense, and improve efficiency of care for patients requiring telemetry.
• Relationship Between Health Information Technology (HIT) and Quality of Care. As the U.S. is facing the need to find strategies to improve quality of care while reducing costs, the CQCR is examining the relationship between use of health-information technologies and in-hospital quality of care. Using a large, retrospective database, quality scores from Medicare’s Hospital Compare Web site, and the Health Information Management Systems Society Foundation survey, the center is evaluating the performance of over 450 hospitals with various levels of implementation of health-information technology. This rich dataset will allow the center to examine the relationship between HIT and many different performance measures, from Hospital Compare composite scores to measures of the daily care provided at patients’ bedsides.

Getting Results

Looking at the sum of these initiatives and others, Lindenauer said the various projects all come back to what he considers the center’s overarching — and, in his view, unique — reason for being.

“Our focus is squarely on improving the treatment and the outcomes of patients, and that means improving, in many ways, the science of health care delivery,” he said. “Our primary focus is trying to discover effective methods for disseminating and implementing knowledge about what works into repeat clinical practice, bridging the gap between what we know to be best care and the care that’s actually delivered.

“We have a problem in the United States and around the world, where the promise of biomedical innovations and discoveries are never fully realized,” he continued. “Half the patients who ought to be benefiting and getting the therapies don’t get them because we don’t have reliable and effective methods of ensuring that care is delivered appropriately.”

Elaborating on what the center does, how, and why, Lindenauer said the CQCR is committed to the task of making sure that care is administered more appropriately, and to do that, its research is focused around several key questions, including:

• How often is there a problem in translating research into routine clinical practice?
• What are the effective methods for speeding the translation of scientific innovation into routine clinical practice?
• What are the barriers to doing it?
• Who are the patients who are benefiting?
• Who are the patients not benefiting?
• What strategies of the hospitals are the most successful ones?
• Can these strategies be replicated at other sites?

These and other queries were at the heart of the steroid-dose story, which concluded that patients are routinely given excessive doses of steroids after being hospitalized for severe attacks of COPD, and that such practices pose unnecessary risks for patients and increased costs for hospitals. The study determined that low-dose steroids administered orally are not associated with worse outcomes than high-dose intravenous therapy.

When asked how the center’s subjects for research are chosen, Lindenauer said many are identified by the CQCR’s core group of faculty members, who have specialized areas of clinical and methodological expertise.

“There are adult internists, ambulatory-based physicians, hospitalists, pediatricians, people who are more versed in clinical trials, others who have greater expertise in observational research methods, and faculty who have expertise in qualitative research methods and survey-based research,” he explained. “So we bring a broad set of both clinical disciplines and research methods to the center, and those investigators are the primary engines behind the development of new ideas.”

There are also broader collaborations, both across Baystate and well outside the system, that also generate ideas for research initiatives and also funding for such work, he continued. He cited, as just one example, a grant application being submitted to the National Institute of Allergies and Infectious Diseases to carry out a study among patients with community-acquired pneumonia to try to identify antibiotic regimens that are not effective, but also reduce the risk of developing antibiotic resistance.

That project is being led by an investigator at the University of Pennyslania, he said, but Baystate will be one of six sites taking part in the study.

There are many other examples of collaboration, he said, noting that most of the studies the CQCR becomes involved with have multiple partners.

Reaching a Conclusion

Summing up what the CQCR has been able to accomplish in less than two years, Lindenauer said the JAMA articles and all the other press accounts have certainly put Baystate on the map as a productive research center focused on quality and safety issues.

Now that it’s there, he and others at the center want to keep it there and make it an increasingly prominent point of reference for those involved in health care across the country and around the world.

More importantly, though, they want to sharpen their already-keen focus on bridging that gap between what is known to be best care and what’s currently being delivered.

And if they can do that, there will be considerably more press in the months and years to come.