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This Issue: Ensuring High-Quality Care | Table of Contents: Fall 2018 | Download this issue

Editorials from VA Research Scientists

Why aren't we using home blood pressure monitoring?

Dr. Laura Petersen Dr. Laura Petersen

In an editorial published in JAMA, Dr. Laura A. Petersen and colleagues advise that home blood pressure monitoring (HBPM) is superior to taking a single reading in the medical office. Home monitoring gives providers better control of patient treatment, say the researchers, and makes for more accurate reporting on physician quality measures. Petersen is director for the VA Center for Innovations in Quality Effectiveness and Safety (iQUEST) in Houston.

Primary care providers typically take a single blood pressure reading during a routine office visit. While that measurement is easily documented in the electronic medical record and is readily available for later comparison, it may not paint an accurate picture of blood pressure control. Petersen and colleagues point to evidence-based guidelines that recommend using HBPM to confirm a diagnosis of hypertension and guide treatment. They also note that 10 to 50 percent of patients who have a high blood pressure reading in the office will have normal blood pressure readings at home.

Most physicians are aware of the benefits of HBPM, the team writes, yet quality reporting guidelines, like the Healthcare Effectiveness Data and Information Set (HEDIS), do not currently accept readings from a HBPM. They suggest that health systems and physicians can help change that standard by adopting a hybrid approach that uses HBPM where available, and office blood pressure readings for other patients. Using HBPM can reduce misleading estimates of hypertension control, improve patient satisfaction, and allow physicians to more easily adjust treatment between widely spaced office visits.

Are lay rescuers adequately prepared for CPR?

Dr. Saket Girotra Dr. Saket Girotra

In an editorial published in Circulation: Cardiovascular Quality and Outcomes, Drs. Kimberly Dukes and Saket Girotra caution that an overly simplified approach to cardiopulmonary resuscitation (CPR) training for lay rescuers may not meet their emotional needs adequately and could discourage them from attempting CPR in a crisis.

Current thinking recommends simplifying the approach to CPR training for the lay rescuer. For example, in 2012, the British Heart Foundation teamed with actor Vinnie Jones to create a video that demonstrates hands-only CPR done to the rhythm of the Bee Gee's song "Staying Alive." The intent was to make CPR accessible to everyone. But this approach, say the researchers, may not provide lay rescuers with the necessary resources to accomplish effective CPR.

The researchers, both with the Iowa City VA Medical Center, point out that bystander CPR can double survival rates for heart attacks that occur out of the hospital—yet currently, fewer than 4 in 10 CPR rescues involve bystanders in the U.S. They suggest that better training could address needs like emotional distress after conducting CPR; uncertainty about when to start CPR; and fear of hurting the patient.

Dukes and Girotra suggest that CPR training that involves real-life simulations could address both the highly technical requirements of CPR and the emotionally stressful components. However, delivering simulation training for lay rescuers would not be logistically practical, say the researchers—instead, they recommend further studies to identify better ways to teach and deliver CPR training.

Bedrest in the hospital is toxic

Dr. Mitesh Patel Dr. Mitesh Patel

Studies have shown that too much bedrest can lead to functional decline in hospitalized patients, especially those over the age of 65. In an editorial published in the Annals of Internal Medicine, Drs. Mitesh Patel and S. Ryan Greysen propose the best way to maintain patient agility is for the hospitalist to conduct a mobility assessment for each patient who is hospitalized. Once a baseline is established, they say, the physician should then develop a mobility plan for the patient that covers both inpatient and discharge goals. 

Patel, who is on staff at the Corporal Michael J. Crescenz VA Medical Center in Philadelphia, and his coauthor propose that there may be a threshold number of steps that can prevent functional decline in hospitalized patients. Several studies have suggested that 1,000 steps per day—roughly half a mile—can stave off loss of functional independence after a hospitalization. Yet, most patients rarely leave their beds when in the hospital. In one study that made use of a motion monitor, hospitalized patients left their beds an average of only 45 minutes per day.

To combat that disconnect, say Patel and his coauthor, a hospital mobility plan can outline daily patient goals for both walking and time spent out of the bed. For example, the Hospital of the University of Pennsylvania uses a five-level mobility guide to help patients understand their activity goals—ranging from most time spent in bed to 90 percent of time awake spent walking or sitting in a chair. The authors recommend recruiting not only nurses but also patient care assistants and volunteers to help patients with walking.

Helping consumers make good health care choices

Dr. Jeffrey Kullgren Dr. Jeffrey Kullgren

Increasing financial pressures in health care have brought about a wealth of reports on the quality and cost of health care services. Ideally, providing quality reports can help patients choose high-value providers—those who offer high-quality care at a reasonable price. Yet, consumers are faced with the difficult task of sorting through vast amounts of quality data to find the best deal, according to Dr. Jeffrey Kullgren, a health services researcher at the VA Ann Arbor Healthcare System in Michigan.

In an editorial published in Health Services Research, Kullgren discusses the challenges inherent in presenting consumers with accurate yet straightforward information on choosing cost-effective health care. Studies show that many consumers rely on recommendations from family or friends, or refer to their insurance plan's list of providers when choosing a physician. Even if they do consult quality reports, often the reports are targeted to physicians, not consumers, and are incomplete.

Rather than restrict consumer choices to a small network of high-value providers, Kullgren proposes enhancing existing reports or tools so that they better meet consumer needs. One way to achieve that goal is to adopt market-research techniques used by online retail companies. Building a customizable interface that makes use of customer preferences and past choices could make the health care decision process easier for patients.

Another tactic is the use of financial incentives, similar to those used by health insurance companies. Kullgren says that tying lower co-pays to providers with higher levels of cost efficiency could incent patients to choose a high-value physician. Finally, he says there is an opportunity for the health care industry to teach consumers how to use quality and price information to help them make the best health care choices.

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