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Research from DMS underpins "leap" in health-care quality

John Birkmeyer, M.D., may have realized the ultimate researcher's dream—he doesn't have to wait years to see his work put into practice; it's in use now. A consortium of major businesses called the Leapfrog Group is using its purchasing clout—and Birkmeyer's analysis showing how implementing three safety standards would save more than 58,000 lives a year and prevent some 522,000 medication errors —to drive the health-care industry into immediate adoption of patient-safety and errorprevention strategies.

Vacuum: "Researchers often face prospects of doing their work in a vacuum," says Birkmeyer, an assistant professor of surgery who practices at the Veterans Affairs Medical Center in White River Junction, Vt. "I leapt at the chance to actually begin to apply some of these things. The thing that's exciting about the Leapfrog Group is the immediacy and the high probability that it's actually going to happen. Most attempts to regulate and improve health-care quality have occurred at the legislative and political level. Thus by its very nature, it's often held hostage to the interests of all parties involved, which don't necessarily represent the interests of individual patients.

"The Leapfrog Group, because they're private-sector payers and basically can just say 'We're going to do this,'. . . has side-stepped all of the delay and political intrusion."

The 60-member Leapfrog Group includes several Fortune 500 companies as well other large private and public health-care purchasers. Together, they spend $40 billion a year on health benefits for 20 million Americans. They have decided to base their purchase of health care on three patient-safety standards —chosen because they promise to yield significant health benefits, can be implemented fairly quickly, and can be monitored effectively:

  • Computerized physician order entry (CPOE): Physicians would use a computerized prescription system to eliminate or reduce errors due to illegible handwriting, decimal-point errors, and failure to check for drug interactions and allergies. Such a system could reduce serious prescribing errors in hospitals by more than 50%, according to Birkmeyer's analysis.

  • Evidence-based hospital referral: Physicians would be required to refer patients needing certain high-risk surgeries and pregnant women facing high-risk deliveries to hospitals offering the best survival odds based on scientifically valid criteria—such as the number of times a hospital performs these procedures each year. Birkmeyer's research indicates this could reduce a patient's risk of dying by over 30%.

    John Birkmeyer, left, has marshalled the data underlying the national Leapfrog Group with help from several Dartmouth colleagues, including economist Jonathan Skinner, seated; internist Joshua Lee; and statistician Chris Birkmeyer.
    Photo by Flying Squirrel Graphics

  • ICU staffing: ICUs would have to be staffed by physicians with credentials in critical-care medicine. It's expected that this would reduce the risk of patients dying in the ICU by 10%.

    Although the Leapfrog standards will apply only to hospitals in metropolitan areas, Birkmeyer notes that DHMC already meets most of the criteria. The Medical Center is currently developing a CPOE system, for instance, and physicians certified in critical-care medicine staff its ICU.

    Effect: "I personally think that Leapfrog will ultimately have its greatest effect just by its ability to exert a fair amount of peer pressure among hospitals," says Birkmeyer. "Just by going public, before any of the safety standards have ever really been implemented, they've already had a significant effect just by making . . . patients aware that there are these things that are heavily correlated with hospital quality that they can then ask about."

    Not everyone is thrilled with the Leapfrog approach, however. "Now that the Leapfrog Group has raised these worthy goals, maybe they'll help pay for them," Rick Wade, senior vice president of the American Hospital Association, was quoted as saying in one news article. Indeed, the up-front costs of developing and implementing a CPOE system can be substantial; hiring intensivists to staff ICUs can be expensive; and referring surgery elsewhere can mean lost revenue for the sending hospital.

    Change: "It's fair to say that hospitals and physicians are overwhelmed by regulatory attempts," Birkmeyer says. "And this is, to many people, just the latest and most intrusive one."

    In addition, there are fears that the changes could threaten the viability of small hospitals and thus limit access to health care for some patients. "The Leapfrog Group anticipated this as a common criticism, which is why at least in phase one . . . they're basically exempting rural areas," says Birkmeyer. "Some people within the quality-improvement camp would argue that rather than focusing on external measures, . . . essentially moving people around to the best hospitals, that instead we should be focusing on mechanisms for how to internally improve the care at all hospitals.

    "I think that there's room for both approaches," he adds.

    -Laura Stephenson Carter

    If you would like to offer any feedback about this article, we would welcome getting your comments at DartMed@Dartmouth.edu.

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