Patients are more likely to receive high-quality care in nonprofit hospitals and in hospitals with more registered nurses and advanced technology, reports a comprehensive Harvard Medical School (HMS) analysis published in the December 11 Archives of Internal Medicine.

Bruce Landon, MD, MBA, an associate professor of health care policy in the Department of Health Care Policy at HMS, and colleagues found that overall, nonprofit hospitals consistently performed better than for-profit hospitals in delivery of high-quality care for three common medical conditions: congestive heart failure (CHF); heart attack (acute myocardial infarction, AMI); and pneumonia. Hospitals with higher registered nurse staffing levels, more advanced technology, and federal or military designation all had high performance.

"Our study is the first to comprehensively examine the characteristics of hospitals that are associated with higher quality of care for these three important medical conditions," says Landon, who is also an associate professor of medicine in the Department of Health Care Policy and at Beth Israel Deaconess Medical Center, where he is a practicing internist.

Importance of nurses
This study assessed the quality of care for CHF, AMI, and pneumonia in more than 4,000 hospitals in the United States that reported data to the Joint Commission on Accreditation of Healthcare Organizations or the Center for Medicare and Medicaid Services. Since the Medicare Modernization Act of 2003, hospitals have been required to report their performance on 10 measures in the areas of CHF, AMI, and pneumonia in order to receive their full Medicare payment update. The study also examined which hospital characteristics (such as ownership, size, location, teaching status, and proportion of Medicare or Medicaid admissions) were associated with high-quality performance.

In addition, the authors created an index to assess how the number of registered nurse staffing levels affected quality of care. Hospitals with more registered nurses performed better on all quality measures, but licensed practical nurse staffing was associated with lower performance. Nurse staffing levels were calculated as the average number of hours of care by a registered nurse or a licensed practical nurse per inpatient day. This measure was derived by adjusting reports of nurse staffing levels by the average inpatient census at each hospital.

"Nurses, as the primary caregivers for hospitalized patients, provide a crucial link between doctors and patients," says Landon. "Our study supports the importance of adequate nursing care to the quality of treatment patients receive."

Quality assessment
Landon and colleagues evaluated the number of patients who received appropriate care across all of the measures for the three medical conditions. Overall, 76 percent of patients hospitalized with CHF, AMI, or pneumonia received recommended care.

Nonprofit hospitals consistently performed better than for-profit hospitals for each condition, and federal and military hospitals had the highest performance. "Because a large portion of federal and military hospitals are part of the Veterans Health Administration, this suggests that lessons learned from their decade-long experience in quality improvement deserve further study," said Landon. "It seems likely that the information technology and computerized reporting systems at the VA contributed to their high performance.” Hospitals that served greater proportions of Medicaid patients had low quality of care across all conditions studied.

Hospitals in the Midwest and Northeast, not in rural areas, had better performance, as did hospitals with more advanced technology available.

Landon and colleagues also performed analyses that examined the relationships between the various quality measures. This analysis suggests that rather than examining quality by disease (e.g., AMI, CHF, or pneumonia), it might be more useful from a quality-improvement perspective to examine quality measures according to functional roles in the hospital. The researchers created composite measures in the areas of treatment and diagnosis and counseling and prevention as well for each of the three diseases, but found that quality varied more by functional roles in the hospital than by the particular disease being treated.

"Efforts to improve quality in hospitals should therefore focus on core competencies that can improve care across multiple diagnoses," said Landon.

FOR MORE INFORMATION, PLEASE CONTACT: Leah Gourley, Harvard Medical School, 617-432-0442, public_affairs@hms.harvard.edu