This issue of CHP/PCOR's quarterly newsletter covers news and developments from the summer 2004 quarter. It features articles about:

Information technology can support the implementation of clinical research findings in practice settings. Technology can address the quality gap in health care by providing automated decision support to clinicians that integrates guideline knowledge with electronic patient data to present real-time, patient-specific recommendations. However, technical success in implementing decision support systems may not translate directly into system use by clinicians. Successful technology integration into clinical work settings requires explicit attention to the organizational context. We describe the application of a "sociotechnical" approach to integration of ATHENA DSS, a decision support system for the treatment of hypertension, into geographically dispersed primary care clinics. We applied an iterative technical design in response to organizational input and obtained ongoing endorsements of the project by the organization's administrative and clinical leadership. Conscious attention to organizational context at the time of development, deployment, and maintenance of the system was associated with extensive clinician use of the system.

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This material was originally published in the Journal of the American Medical Informatics Association (Volume 11; 368-376). This material may be read on-line or downloaded for personal use only. The material may be referenced by appropriate hyperlinks. However, the text of the material may not be altered without the express permission of the author and AMIA. Care should be taken when excerpting or referencing text to ensure that the views, opinions, and arguments of the author presented in the excerpt accurately reflect those contained in the original work.

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In early 2003, the Institute of Medicine (IOM) released its report, Priority Areas for National Action: Transforming Health Care Quality. The report listed 20 clinical topics for which "best practices" were strongly supported by clinical evidence. The rates at which these practices have been implemented in the United States has been disappointing low, at a cost of many thousands of lives each year.

To bring data to bear on the quality improvement opportunities articulated in the IOM's 2003 report, the Agency for Healthcare Research and Quality (AHRQ) engaged the Stanford-UCSF Evidence-based Practice Center (EPC) to perform a critical analysis of the existing literature on quality improvement strategies for a selection of the 20 disease and practice priorities noted in the IOM Report. The focus of the commissioned investigations is translating research into practice -- identifying those activities that increase the rate with which practices known to be effective are applied to patient care in real world settings. In other words, the EPC research effort aims to facilitate narrowing the "quality gap" that is in large part responsible for suboptimal health care practices and outcomes. In addition to furthering the IOM's quality agenda, this analysis also has been prepared in support of the National Healthcare Quality Report (NHQR) (also see National Healthcare Disparities Report).

In this, the first volume of Closing the Quality Gap, the authors introduce the series and its goal, while providing methodological and theoretical overviews for the quality improvement (QI) field of study. Subsequent volumes will address the relation of QI strategies to treatment practices for a number of the 20 priority areas identified in the IOM report.

Social trends and medical progress have fueled major changes in the epidemiology of child health in the United States. Injuries remain a major contributor to childhood illness and death. However, among noninjury causes, chronic illness now accounts for the majority of children's hospital days and deaths. Although mortality rates for all children have fallen dramatically, social disparities persist. Approximately half of all excess deaths among African-American children occur during infancy, primarily from extremely premature births, and the remaining portion, primarily from homicide and serious chronic conditions. These challenges may require changes in today's child health practices and policies.

OBJECTIVES: We examined consumers' search for information about health insurance choices and their use of the Internet for that search and to manage health benefits.

STUDY DESIGN: We surveyed a random sample of more than 4500 individuals aged 21 years and older who were members of a survey research panel during December 2001 and January 2002.

METHODS: The survey included questions about searching for health insurance information in 3 health insurance markets: Medicare, individual or nongroup, and employer-sponsored group. We also asked questions about use of the Internet to manage health benefits. We tabulated means of responses to each question by market and tested for independence across demographic groups using the Pearson chi-square test.

RESULTS: We identified important differences across and within markets in the extent to which people look for information about health insurance alternatives and the role of the Internet in their search. Although many individuals were unaware of whether their employer or health plan provided a website to manage health benefits, those who used the sites generally evaluated them favorably.

CONCLUSIONS: Our results suggest that the Internet is an important source of health insurance information, particularly for individuals purchasing coverage individually in the nongroup and Medicare markets relative to those obtaining coverage from an employer. In the case of Medicare coverage, studies focusing on beneficiaries' use of Internet resources may underestimate the Internet's importance by neglecting caregivers who use the Internet. Many individuals may be unaware of the valuable resources available through employers or health plans.

Cardiovascular specialists have been leaders in medicine because of our willingness to study major clinical issues by means of randomized clinical trials. Consequently, the evidence supporting many cardiovascular treatments is substantial, especially when the results of multiple large clinical trials are consistent in showing strong benefits. Cardiovascular professional societies also have been at the forefront in forging consensus among clinical experts and codifying best practice into practice guidelines. It is reasonable to expect that a treatment demonstrated to be effective in clinical trials and strongly endorsed by professional guidelines will be adopted by practicing physicians and consistently used in day-to-day patient care.

Angiotensin-converting enzyme (ACE) inhibitors have followed this pathway of building evidence and professional consensus. Many randomized clinical trials have clearly shown that ACE inhibitors reduce mortality and morbidity rates among patients with heart failure and left ventricular systolic dysfunction. Pooled data from 5 large trials showed the odds of death of patients randomized to ACE inhibitors were reduced by 26% compared with placebo, translating into roughly 6 fewer deaths per 100 patients treated. The economic outcomes also are favorable because much of the cost of prescribing ACE inhibitors for heart failure is recouped by the reduced need for hospital admissions. Consequently, the use of ACE inhibitors for heart failure is quite cost-effective. The American College of Cardiology/American Heart Association Guidelines Committee has weighed the evidence and given ACE inhibitors for treatment of heart failure a Class I recommendation. Indeed, use of ACE inhibitors is so well accepted that it is part of the quality-of-care clinical performance measure for heart failure. There is little, if any, controversy that ACE inhibitors should be generally prescribed for patients with heart failure due to systolic dysfunction.

Use of ACE inhibitors increased progressively for heart failure through the early 1990s, but growth in use has stalled more recently, and a substantial number of patients with heart failure still do not receive ACE inhibitors. The data reported by Masoudi and associates in this issue of Circulation show a stubborn, persistent gap between ideal practice and actual use of ACE inhibitors for heart failure. These investigators found that between 1998 and 2001, only 68% of patients 65 years of age and older with heart failure, systolic dysfunction, and no contraindications to treatment received an ACE inhibitor. This percentage rose only to 76% of patients when either ACE inhibitor or angiotensin receptor blocker (ARB) use was counted. The percentage of patients receiving ACE inhibitors or ARBs was below 80% in all but 3 of the 55 subgroups examined by Masoudi and associates. The investigators found little explanation for this persistent and vexing gap between actual and ideal performance, inasmuch as the only strong predictor of ACE inhibitor use versus nonuse was the presence of preexisting renal dysfunction. The latest national report card on this important aspect of heart failure treatment shows a "D+" for ACE inhibitor use (68%), rising only to a "C" (76%) if extra credit is given for ARB use. Should we accept these grades?

Closing the Gap

Perhaps the most optimistic interpretation of the data reported by Masoudi and associates is that evidence from clinical trials, by itself, will only go so far in changing clinical practice. Evidence may be necessary to alter the knowledge and attitudes of physicians about treatment, but this may not be sufficient to change their management consistently. To close the gap between actual and ideal performance, additional, specific measures are probably needed. A variety of active interventions have been shown to improve use of evidence-based therapies. Masoudi and associates did not report any data on use of measures within the hospitals or physician practices that might improve quality of care, so there may be an opportunity to adopt such measures more widely. Reminder systems for physicians, either simple chart-based measures or more sophisticated computerized approaches, can be quite effective in improving use of medications when physicians agree that the medication is effective. Critical pathways, care maps, and other structured approaches to quality improvement also may work well within hospitals to increase adherence to evidence-based practice guidelines. Reorganization of care by use of heart failure care teams or nurse facilitators may be even more effective, but these approaches require a much greater commitment of resources. Nevertheless, multidisciplinary approaches are particularly attractive in the care of patients with chronic diseases such as heart failure, because management of multiple factors, including adherence to diet and medication recommendations, is needed for successful outcomes. The structure of our medical care system also may contribute to the gap between actual and ideal clinical management; paying for innovative practice improvement programs has been difficult because they are not readily reimbursed in the fee-for-service model (although they may be well suited to prepaid integrated healthcare systems).

We have paid a lot of attention to translation of novel therapies from the basic laboratory to proof of efficacy in clinical trials, yet we've not paid enough attention to the final steps of learning how to best deliver consistent, high-quality care. With more attention to the nitty-gritty details of practice improvement, the grade for ACE inhibitor use in patients with heart failure could (and should) be raised to an "A" on the next report card.

In 1999, the American College of Physicians (ACP), then the American College of Physicians-American Society of Internal Medicine, and the American College of Cardiology/American Heart Association (ACC/AHA) developed joint guidelines on the management of patients with chronic stable angina. The ACC/AHA then published an updated guideline in 2002, which the ACP recognized as a scientifically valid review of the evidence and background paper. This ACP guideline summarizes the recommendations of the 2002 ACC/AHA updated guideline and underscores the recommendations most likely to be important to physicians seeing patients in the primary care setting. This guideline is the first of 2 that will provide guidance on the management of patients with chronic stable angina. This document will cover diagnosis and risk stratification for symptomatic patients who have not had an acute myocardial infarction or revascularization procedure in the previous 6 months. Sections addressing asymptomatic patients are also included. Asymptomatic refers to patients with known or suspected coronary disease based on history or on electrocardiographic evidence of previous myocardial infarction, coronary angiography, or abnormal results on noninvasive tests. A future guideline will cover pharmacologic therapy and follow-up.

PURPOSE

Smoking is the leading controllable risk factor for heart disease. Only about 69% of U.S. indoor workers are currently covered by a smoke-free workplace policy. This analysis projects the cardiovascular health and economic effects of making all U.S. workplaces smoke free after 1 year and at steady state.

METHODS

We estimated the number of U.S. indoor workers not covered by smoke-free workplace policies, and the effects of making all workplaces smoke free on smoking behavior and on the relative risks of acute myocardial infarctions and strokes. One-year and steady-state results were calculated using an exponential decline model. A Monte Carlo simulation was performed for a sensitivity analysis.

RESULTS

The first-year effect of making all workplaces smoke free would produce about 1.3 million new quitters and prevent over 950 million cigarette packs from being smoked annually, worth about $2.3 billion in pretax sales to the tobacco industry. In 1 year, making all workplaces smoke free would prevent about 1500 myocardial infarctions and 350 strokes, and result in nearly $49 million in savings in direct medical costs. At steady state, 6250 myocardial infarctions and 1270 strokes would be prevented, and $224 million would be saved in direct medical costs annually. Reductions in passive smoking would account for 60% of effects among acute myocardial infarctions.

CONCLUSION

Making all U.S. workplaces smoke free would result in considerable health and economic benefits within 1 year. Reductions in passive smoking would account for a majority of these savings. Similar effects would occur with enactment of state or local smoke-free policies.

Alleviating health disparities in the United States is a goal with broad support. Medical research undertaken to achieve this goal typically adopts the well-established perspective that racial discrimination and poverty are the major contributors to unequal health status. However, the suggestion is increasingly made that genetic research also has a significant role to play in alleviating this problem, which likely overstates the importance of genetics as a factor in health disparities. Overemphasis on genetics as a major explanatory factor in health disparities could lead researchers to miss factors that contribute to disparities more substantially and may also reinforce racial stereotyping, which may contribute to disparities in the first place. Arguments that promote genetics research as a way to help alleviate health disparities are augmented by several factors, including research funding initiatives and the distinct demographic patterns of health disparities in the United States.

PURPOSE:

Clopidogrel is more effective than aspirin in preventing recurrent vascular events, but concerns about its cost-effectiveness have limited its use. We evaluated the cost-effectiveness of clopidogrel and aspirin as secondary prevention in patients with a prior myocardial infarction, a prior stroke, or peripheral arterial disease.

METHODS:

We constructed Markov models assuming a societal perspective, and based analyses on the lifetime treatment of a 63-year-old patient facing event probabilities derived from the Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events (CAPRIE) trial as the base case. Outcome measures included costs, life expectancy in quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios, and events averted.

RESULTS:

In patients with peripheral arterial disease, clopidogrel increased life expectancy by 0.55 QALYs at an incremental cost-effectiveness ratio of $25,100 per QALY, as compared with aspirin. In poststroke patients, clopidogrel increased life expectancy by 0.17 QALYs at a cost of $31,200 per QALY. Aspirin was both less expensive and more effective than clopidogrel in post-myocardial infarction patients. In probabilistic sensitivity analyses, our evaluation for patients with peripheral vascular disease was robust. Evaluations of stroke and myocardial infarction patients were sensitive predominantly to the cost and efficacy of clopidogrel, with aspirin therapy more effective and less expensive in 153 of 1000 simulations (15.3%) in poststroke patients and clopidogrel more effective in 119 of 1000 simulations (11.9%) in the myocardial infarction sample.

CONCLUSION:

Clopidogrel provides a substantial increase in quality-adjusted life expectancy at a cost that is within traditional societal limits for patients with either peripheral arterial disease or a recent stroke. Current evidence does not support increased efficacy with clopidogrel relative to aspirin in patients following myocardial infarction.