The peer review organizations (PROs) are Medicare's private, community-based quality improvement contractors. Historically, PROs focused on utilization review and Medicare beneficiary complaints. Beginning in 1996, however, the PROs became increasingly focused on quality improvement activities aimed at measuring providers' success in applying various methods designed to improve the care provided to Medicare patients.

In 1999, in order to systematically track quality and evaluate PRO improvement efforts, HCFA contracted with the PROs for $236 million over a three-year period to improve care for six conditions: breast cancer, diabetes, heart failure, heart attack, stroke and pneumonia. Among the 24 quality indicators used to assess improvement in these areas are, for example, preventative steps like quickly getting an aspirin to a heart attack patient, and providing eye exams every two years for patients with diabetes. For the first time, the results will appear in the October 4 edition of the Journal of the American Medical Association (JAMA).

In 2002, HCFA will re-measure performance on these 24 indicators to determine if there has been improvement, and decide whether a different approach to quality improvement should be considered.

The PROs are also involved in local quality improvement projects on a variety of topics, and are employed under HCFA's Payment Error Prevention Project (PEPP), which is aimed at reducing erroneous Medicare payments to hospitals.

Study methodology

Baseline inpatient data was gathered using a random sample from Medicare claims. Based on this sample, hospital medical records were reviewed by Clinical Data Abstraction Centers (CDACs), which are employed by HCFA under a separate contract. Immunization data was gathered both by a random telephone survey and provider notes in the medical record. Mammography rates and diabetes data were determined through review of Medicare claims.

The project focuses primarily on inpatient care, except for diabetes and mammography screening, which are outpatient measures. It is our understanding that HCFA will continue to explore opportunities to better capture the quality of care delivered in non-hospital settings.

How will the information be displayed?

The JAMA article will attach to each state a cumulative performance score for the 24 quality indicators. In addition, a national map will show, by quartile, where each state's compliance with the quality indicators falls (75-100 percent compliance, 50-75 percent compliance, etc.).

What does the data show?

The data is a national snapshot that reveals that there are opportunities for improvement in these six areas of care. The article underscores two key points: improvement will require beneficiaries, hospitals, physicians and others to work together; and improvement is a never-ending goal because advances in science and technology are occurring rapidly, with today's preferred course of treatment possibly outdated tomorrow.

Is this information confidential?

Current law prohibits the PROs from releasing to the public data that is specific to any particular provider, patient or practitioner.

Next steps at the national level
  • HCFA is expected to portray this baseline data as a "call to action" that invites PROs, practitioners, providers, health plans and purchasers to work as partners to achieve national improvement.
  • Later this fall, HCFA plans to organize, with the help of the National Quality Forum, a session to foster communication and collaboration on quality improvement projects.
  • HCFA is also likely to include in its Patient Safety Hospital Medicare Conditions of Participation (slated for release before the end of the year) new requirements that hospitals demonstrate a commitment to quality improvement, including performance measurement activities.

Additional resources
  • Information on the PRO program, including national quality improvement projects, is available at
  • Additional information about PROs and a new report on local PRO quality improvement activities is available from the American Healthcare Quality Association at:
  • Clinical guidelines and best-practice research information can be found at
  • The Journal of the American Medical Association (JAMA) can be found at

The following talking points and sample questions can help you respond to inquiries from the media and the public about the quality of health care provided in your organization.

Talking Points

JAMA article/HCFA study on Quality of Care for Seniors

  • This is the first national snapshot that highlights improvements that can be made to improve care that already is of the highest quality.

As the study points out, quality is best achieved when local physicians, nurses and hospitals come together voluntarily to focus on improving care.
  • The data reveal opportunities to improve the way care is delivered. This means making sure the right care is provided at the right time in the right setting.
  • We are committed to improving patient care, and constantly work to do so.

In my hospital:
  • Need to remember that doctors and nurses work 24 hours a day/seven days a week in a complex, high-paced environment to treat and cure critically ill patients.

Nearly 100 million ER visits a year.
Nurses and doctors care for about 31 million seniors each year.
Nearly half a billion hospital visits (inpatient and outpatient) each year.
  • Advances in technology and the science of medical treatment occur at a mind-boggling pace. That's why physicians and nurses need reliable resources to help make sense of what is proven practice and what is not.
  • This field is scrutinized more than any other. Out of that comes constant self-examination and improvement.
  • This information will help create partnerships of hospital leaders, physicians and nurses to target areas of improvement.
      When we work together at the community level, we can make great strides in improving quality. [PROVIDE LOCAL EXAMPLE.]
      Improving quality involves everyone-physicians, nurses, hospitals and patients. It's essential that seniors are educated about important factors affecting their health, such as mammograms and flu shots.

Tough Questions

Be prepared to respond to these kinds of questions that could be generated as a result of the JAMA article/HCFA study

  • Why is there so much variation?

That is the critical question, but we don't know. For the first time, we have the data needed to begin determining the answer. Although hospitals are constantly performing internal reviews of how they deliver care, this information is important to help us delve deeper into the causes of regional variation.

  • Are our seniors getting sub-standard care?

Is it because they are seniors? Nurses and physicians work around the clock to care for all patients. Our seniors receive quality care. But this information shows that there are some areas to improve upon. We are committed to doing so.

  • Is it fair to say that this applies to the general public as well?

The JAMA study specifically looks at care for Medicare beneficiaries. But, it also helps hospitals examine how to improve care for all patients.

  • If caregivers aren't following these basic standards of care, can we assume that care is all over the map for trickier procedures as well?

While there is agreement on some care approaches, legitimate differences may exist among physicians on many treatment decisions. And the same cure is not appropriate for every patient. For example, while a standard of care for a heart attack patient is to provide aspirin, many older patients cannot tolerate aspirin. In addition, treatment is often affected by patient preference.

Also, it takes a great deal of study for physicians to reach a general consensus about approaches to care. Recent studies have challenged the recommendation that women in their 50s receive an annual mammogram, finding that a thorough physical exam is just as effective. As science evolves, so does the practice of medicine.

  • What's the solution?

The key is a commitment to continually improve the care that patients receive. That is achieved by continuous education, for providers as well as patients, about standards of care and treatments.

  • These care standards seem like no-brainers. Why aren't these things being done now?

In the vast majority of cases, these standards are being met. But more work is needed to better understand why variations exist, so we can improve care across the country.

  • Why aren't all these standards being met 100 percent?

The study raises more questions than answers; further research is needed. We do know that variation exists in some cases because of physician and patient preferences. In areas where there is agreement among the medical community on specific treatments, we must work to make sure our physicians and nurses are aware of this information.

  • What do you expect the results to be when these indicators are measured again?

Quality patient care is our first priority. Hospitals are committed to working with physicians, nurses and other caregivers to constantly improve care. As technology and medicine advances, we'll continue to advance patient care.

  • Does inadequate staffing play into this?

HCFA's report does not identify the reasons for the variation in care.

  • Isn't this something hospitals should have known about? Why hasn't anything been done about this before?

This is the first national snapshot about these specific conditions. Now that we have this information, we can make a good system even better. We are committed to doing so.

  • Whose fault is it that standards are not always being met?

Fault is a moot point when it comes to quality of care. To improve care, everyone needs to work together. And, because the report does not identify the causes of variation, it is impossible to determine precisely where that variation originates.

  • Are systems in place to protect the consumer?

This field is scrutinized more than any other. National and state organizations oversee quality of care in hospitals. In addition, hospitals have internal checks and balances to ensure that care is safe and effective. The result is constant self-examination and improvement within our hospitals.

  • If you are so scrutinized, why do hospitals, on average, earn only a grade of "C" for the care they provide?

America's hospitals deliver the best care in the world. Every day, millions of patients witness first-hand the miracle of modern medicine. What we should focus on is how to continuously improve on this success. This study identifies areas the health care community needs to continue to work on.

  • Doesn't this report mean you've hastened the death of thousands of patients?

That assessment is unsubstantiated, and we disagree with it. What is clear is that we, as a field, can do better. By identifying, for the first time, specific areas for improvement, we are better equipped to do so.

  • Doesn't this just confirm that the Institute of Medicine's report on medical errors was accurate?

Any death caused by error is one too many. We are putting great energy into looking at ways to improve health care for the communities we serve. This JAMA study is just one of many opportunities all caregivers should take advantage of to analyze how they deliver care and where there may be room for improvement.


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