IMPROVING PATIENT CARE
A Cohort Study
Fasiha Kanwal, MD, MSHS; Mark S. Schnitzler, PhD; Bruce R. Bacon, MD; Tuyen Hoang, PhD; Paula M. Buchanan, PhD; and Steven M. Asch, MD, MPH
+ Author Affiliations
Abstract
Background: Medicare has proposed quality-of-care indicators for chronic hepatitis C virus (HCV) infection. The extent to which these standards are met in practice is largely unknown.
Objective: To evaluate the quality of health care that patients with HCV receive and the factors associated with receipt of quality care.
Design: Retrospective cohort study.
Setting: Nationwide U.S. health insurance company research database.
Participants: 10 385 patients with HCV enrolled in the database between 2003 and 2006. Patients were included if they were eligible for at least 1 quality indicator.
Measurements: Quality of HCV care received by patients, as measured by 7 explicit quality indicators included in Medicare's 2009 Physician Quality Reporting Initiative.
Results: Proportions of patients meeting quality indicators varied, ranging from 21.5% for vaccination to 79% for the HCV genotype testing indicator. Overall, 18.5% of patients (95% CI, 18% to 19%) received all recommended care. Older age and presence of comorbid conditions were associated with lower quality, whereas elevated liver enzyme levels, cirrhosis, and HIV infection were associated with higher quality. Patients who saw both generalists and specialists received the best care (odds ratio of receiving care for which a patient is eligible: specialists alone, 0.79 [CI, 0.66 to 0.95]; primary care physician alone, 0.44 [CI, 0.40 to 0.48]).
Limitations: The study had an observational retrospective design, used a convenience sample, and had no information on patient ethnicity. It may be that the indicators or the reporting of the indicators of HCV care—and not the care itself—is suboptimum.
Conclusion: Health care quality, based on Medicare criteria, is suboptimum for HCV. Care that included both specialists and generalists is associated with the best quality. Our results support the development of specialist and primary care collaboration to improve the quality of HCV care.
Primary Funding Source: Saint Louis University Liver Center.
Article and Author Information
Disclaimer: The opinions and assertions contained herein are the sole views of the authors and are not to be construed as official or as reflecting the views of the Department of Veterans Affairs.
Grant Support: Dr. Kanwal is supported by Veterans Affairs Health Services Research and Development Service Investigator Initiated Research Award IIR-07-111. This study was supported by an intramural grant from the Saint Louis University Liver Center.
Potential Conflicts of Interest: Dr. Kanwal: Grants received: Saint Louis University Liver Center. Dr. Bacon: Consultancies: Merck/Schering-Plough, Valeant. Honoraria: Merck/Schering-Plough, Gilead Sciences, Three Rivers Pharma, Vertex, Human Genome Sciences. Royalties: UpToDate. Dr. Bacon has also received payment for development of educational presentations, including service on speakers' bureaus, and has had his travel/accommodations expenses covered or reimbursed. Dr. Buchanan: Grants received (money to institution): Veterans Affairs Health Services Research and Development Service, Saint Louis University Liver Center. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M09-2380.
Reproducible Research Statement: Study protocol: Available from Dr. Kanwal (e-mail, fasiha.kanwal@va.gov). Statistical code: Available from Dr. Kanwal (e-mail, fasiha.kanwal@va.gov), Dr. Schnitzler (e-mail, schnitm@slu.edu), or Dr. Buchanan (e-mail, pbuchan1@slu.edu). Data set: Not available. These or similar data are available from commercial health insurance companies in the United States.
Requests for Single Reprints: Fasiha Kanwal, MD, MSHS, John Cochran Veterans Affairs Medical Center, 915 North Grand Boulevard, 111 JC/GI, St. Louis, MO 63106; e-mail, fasiha.kanwal@va.gov.
Current Author Addresses: Dr. Kanwal: John Cochran Veterans Affairs Medical Center, 915 North Grand Boulevard, 111 JC/GI, St. Louis, MO 63106.
Drs. Schnitzler and Buchanan: Center for Outcomes Research, Saint Louis University School of Medicine, 3545 Lafayette Avenue, St. Louis, MO 63104.
Dr. Bacon: Saint Louis University School of Medicine, Department of Internal Medicine, Division of Gastroenterology & Hepatology, 3635 Vista Avenue at Grand Boulevard, St. Louis, MO 63110-0250.
Drs. Hoang and Asch: Department of Internal Medicine and Health Services Research, Veterans Affairs Greater Los Angeles Medical Center, 11301 Wilshire Boulevard, Building 500 (111-G), Los Angeles, CA 90073.
Author Contributions: Conception and design: F. Kanwal, M.S. Schnitzler, S.M. Asch.
Analysis and interpretation of the data: F. Kanwal, M.S. Schnitzler, T. Hoang, P.M. Buchanan, S.M. Asch.
Drafting of the article: F. Kanwal, M.S. Schnitzler, P.M. Buchanan, S.M. Asch.
Critical revision of the article for important intellectual content: F. Kanwal, M.S. Schnitzler, B.R. Bacon, S.M. Asch.
Final approval of the article: M.S. Schnitzler, B.R. Bacon, P.M. Buchanan, S.M. Asch.
Provision of study materials or patients: M.S. Schnitzler.
Statistical expertise: M.S. Schnitzler, T. Hoang, P.M. Buchanan.
Obtaining of funding: F. Kanwal, M.S. Schnitzler.
Administrative, technical, or logistic support: F. Kanwal, B.R. Bacon.
Collection and assembly of data: M.S. Schnitzler, P.M. Buchanan.
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