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Health Care Purchasers Should Reward Hospitals for Patient Safety Practices, Says Business Group

Nancy Tarleton Landis

Harnessing the power of the marketplace to promote patient safety is the goal of a new initiative by the Leapfrog Group, a consortium of more than 60 private and public sector large purchasers of health care. The members—including General Motors, IBM, Verizon Communications, Delta Air Lines, several large pharmaceutical manufacturers, and the Office of Personnel Management, which buys health insurance coverage for federal government employees—provide health benefits to more than 20 million Americans. Each year, the members and their employees spend more than $40 billion on health care.

The initiative aims to "mobilize large purchasers to alert America's health industry that big leaps in patient safety will be recognized and rewarded." Leapfrog member companies have agreed, by following a set of purchasing principles, to reward providers for major advances in protecting patients from preventable medical errors. Members have agreed to educate their employees about the importance of comparing health care provider performance. Leapfrog's message to employees: Your choice of providers can affect the safety of your care.

In November, the consortium launched its promotion of three "standards" that offer patient safety "leaps":

  1. Computerized physician order entry (CPOE) through error-prevention software,
  2. For seven specific complex treatments, referral of patients to higher-volume hospitals, and
  3. Increased monitoring of patients in intensive care units (ICUs) by physicians trained in critical care.

Leapfrog chose to start with hospital-focused safety measures because patient safety has been studied most extensively in that setting. The three standards were selected because they are evidence based, implementation is feasible in the near term, consumers can easily understand their value, and health plans purchasers and consumers can readily ascertain their presence or absence in selecting among providers.

Potential benefits. At a November 15 press conference launching the initiative, results of an independent analysis of the potential benefits of the Leapfrog strategy were presented. In relation to each of the three standards, the researchers estimated the number of patients in urban and suburban hospitals receiving care in suboptimal conditions, the baseline risk, and the potential risk reduction if the three standards were fully implemented in metropolitan hospitals.

Leapfrog exempted rural hospitals because of access issues and other potential problems.

According to the estimate, 522,000 serious medication errors per year would be avoided through CPOE. The number of deaths potentially avoided by CPOE was not calculated, but the researchers noted that 500 deaths would occur if 0.1% of these errors were fatal and 5000 deaths if 1% were fatal. Use of the other two standards would save more than 58,000 lives. Thus, Leapfrog "conservatively estimates" that nearly 60,000 deaths could be prevented, Leapfrog executive director Suzanne F. Delbanco said at the press conference.

According to the study report, the analyses relied on a limited number of studies conducted in specific institutions or parts of the country. Therefore, the researchers used very conservative estimates of effectiveness of the safety measures.

Hospitals that meet the Leapfrog standard for CPOE must use test cases and a testing protocol to demonstrate that their CPOE system intercepts at least 50% of common serious prescribing errors. They must document acknowledgment by the prescriber of the interception prior to any override, and they must post the test case interception rate on a Web site. The baseline analysis assumed that 98% of inpatients are currently treated at hospitals not meeting the Leapfrog CPOE standard.

The Leapfrog standard for referral to higher-volume hospitals includes five surgical procedures (coronary artery bypass grafting, elective repair of abdominal aortic aneurysm, coronary angioplasty, esophagectomy, and carotid endarterectomy) as well as deliveries of low-birth-weight neonates and those with major congenital anomalies. Leapfrog has "left open the possibility of replacing volume standards with more direct quality measures" but relied on the numbers of patients with these complex conditions because volume was the best available criterion for quality of hospital care. According to Leapfrog, a majority of patients currently receive care at hospitals that would not meet most of the referral standards.

To meet the Leapfrog standard for ICU physician staffing, hospitals must have ICUs managed by physicians who are board-certified in critical care medicine; are present in the ICU during daytime hours and provide clinical care exclusively in the ICU; and, at other times, can return pages within five minutes and rely on qualified in-hospital physicians or physician extenders to reach their ICU patients within five minutes. The analysis of potential benefit of this measure used the assumption that 15% of all ICU patients are currently treated in units that meet the standard.

Implications of the Leapfrog effort. The Business Roundtable (BRT), an association of corporate chief executive officers (CEOs), sponsors the Leapfrog Group and provided core funding for staff and expenses. Speaking at the press conference and responding to questions were Lewis B. Campbell, CEO of Textron Inc. and chair of the BRT health and retirement task force; Bruce E. Bradley, Director of Managed Care Plans, General Motors Corporation (GM); Leapfrog executive Delbanco; and David W. Bates, M.D., of Harvard Medical School and Brigham and Women's Hospital, Boston, who has conducted extensive research on adverse drug events and systems for preventing them.

The costs of implementing the Leapfrog standards and the consequences to hospitals that do not meet them were on the minds of questioners. Hospitals will need to make investments, said the panelists; some costs will be passed along to employers and health plans, but in the long term identifying and reducing errors will result in lower health care costs. Bates said the CPOE system at Brigham and Womens cost $1.9 million to implement but saves between $5 million and $10 million annually.

Concerning the imperfect state of available CPOE technology, Bates acknowledged that there is currently no off-the-shelf system that does not require customization. But, he said, vendors are getting more interested in building these systems. Only 7% of hospitals have CPOE systems and even fewer require physicians to use them, he said. However, "If hospitals have incentives, they'll adopt them."

Leapfrog says it will focus on recognizing and rewarding hospitals that have gone the extra mile to protect their patients from avoidable medical errors. It will not require hospitals to meet the safety standards but hopes to encourage them to do so. Leapfrog will not seek sanctions against hospitals, other than using the purchasing power of its members. "We've seen in the past that sanctions don't work to raise people to a higher standard," said Delbanco.

As for mandatory versus voluntary reporting of medical errors, Bradley said Leapfrog does not take a position. Members of the consortium are not proposing new solutions or standards but communicating those already identified by experts, he said. Leapfrog is about "creating a market for safety."

Bradley spoke of GM's experience using the Leapfrog standards in the past year. The company "gives financial incentives to employees to enroll in the higher quality health plans," he reported. GM's work developed into a much broader, communitywide effort with other major auto makers joining in. One important strategy for success is "physician engagement," he noted; communities that implement the Leapfrog standards need to "identify physician leaders as champions to help work with their colleagues."

Leapfrog says it envisions "regional rollouts" of the program in nonrural areas with a high concentration of Leapfrog enrollees. Regional rollouts allow individual communities to decide how to implement the standards, Delbanco said."

The consortium will work with the MEDSTAT Group to collect hospital-specific information. Members will use this information to let enrollees know which hospitals meet the three safety standards.

Leapfrog hopes to provide the health care system with a business case for improving patient safety practices. Underlying the effort is the belief that the health industry would improve more rapidly if purchasers better recognized and rewarded superior safety and overall value.