Quality Matters Winter 04

hese relatively new forces
pose unique challenges
for hospital administrators.
According to The National
Survey on Consumers'
Experiences with Patient
Safety and Quality
Information, conducted by
the Kaiser Family Foundation,
the Agency for Healthcare
Research and Quality (AHRQ),
and Harvard School of Public
Health, released in November
2004, Americans say the
nation's quality of care has
not improved. Five years after
the Institute of Medicine's
report, To Err is Human:
Building a Safer Health
System, on medical errors
in hospitals, this survey of
over 2,000 adults conducted
by telephone from July to
September 2004 found the
following:

· 40 percent say the quality
of healthcare is worse.
· 17 percent say the quality
of healthcare has improved.
· 38 percent say it has
stayed the same.
· 47 percent say they are
concerned about the
safety of medical care.
· 55 percent say they are
dissatisfied with the
quality of healthcare.

Quality versus
patient safety

Narrowly interpreted, patient
safety deals with issues such
as medication errors, unclear
abbreviations, and physical
safety (falls). Quality measures
are broader in scope yet
encompass patient safety.
For example, not receiving
aspirin on arrival for a patient
diagnosed with an acute
myocardial infarction places
that patient at risk for a
negative outcome. In other
words, it compromises the
safety of the patient.
Administrators need to link
these two concepts, as they
are one and the same.

Establishing a culture of
safety is an emerging concept
in healthcare management.

This means the environment
is conducive to the reporting
of errors or near misses
without fear of punishment.
Conversely, reporting
errors and near misses is
rewarded so problems can
be fixed. This philosophy is
based on the premise that
most errors are the result
of system failures.

To meet quality and safety
goals, some hospital admin-
istrators are conducting
WalkRoundsTM on various
hospital units. These activities
give the administrators an
opportunity to hear from
staff, physicians, patients,
and families regarding the
quality or safety of services
provided. "Where is the
next patient going to be
harmed?" is a common

question posed to staff.
A broader question might be,
"How can I, as administrator,
help you achieve and/or
maintain a quality or safety
improvement?" Administrators
learn a great deal from these
types of queries, and staff
feel empowered to participate
in solutions.

To meet quality
and safety goals,
some hospital
administrators
are conducting
WalkRoundsTM on
various hospital
units.

The "Hospital Survey on
Patient Safety Culture," was
developed by the AHRQ in
partnership with Premier,
Inc. (a leading healthcare
alliance collectively owned by
more than 200 independent
U.S. hospitals and healthcare
systems), the Department of
Defense, and the American
Hospital Association.
Announced in November
2004 and released in January
2005, this survey will help
hospitals determine a baseline
measurement of their
safety culture.

Suppor t from the top

Elizabeth Bradley, PhD,
Associate Professor at Yale
School of Medicine, reports
on a study undertaken to
identify what constitutes
"support from the top." In
this study, produced by the
Colorado Foundation for
Medical Care and funded by
the Centers for Medicare &
Medicaid Services (CMS),
45 participants from eight
diverse hospitals were
interviewed. Participants
included physicians, nurses,
quality improvement
personnel, and administrators.
Five key characteristics and
roles of Senior Managers
were identified and are
described below:

Personal engagement
· Engage key staff, physi-
cians, and the Board in
the business of quality
· Participate on quality
teams
· Disseminate quality data
to the Board and other
executives

Relationship with medical
staff
· Understand and respond
to clinical staff goals,
needs, and values
· Negotiate skillfully to find
common ground

Promotion of organiza-
tional culture of quality
improvement
· Set widely shared clinical
goals
· Reward interdepartmental
collaboration
· Encourage innovation
· Tolerate risk-taking and
failure in quality
improvement efforts

Establish organizational
structures that support
quality improvement
· Authorize and structure
quality improvement
teams and councils
· Empower teams by linking
them to central decision-
making bodies

Procure resources
· Ensure adequate staff for
quality improvement work
· Ensure adequate
information technology
staff to support quality
improvement

It is evident that hospital
administrators are in pivotal
roles related to patient safety
and quality. Having and using
relevant resources is but one
strategy in this endeavor.
Ohio KePRO's Acute Care
Services project leaders are
available for consultation to
support your efforts. For
further information on quality
improvement and patient
safety, please contact Ohio
KePRO's Acute Care
Services Team at
1-800-385-5080; e-mail:
hospital@ohqio.sdps.org.
Or visit Ohio KePRO's Web
site at www.ohiokepro.com.

--Barbara G. Stiebeling,
             RN, MSN
  Quality Improvement
        Project Leader

The survey was pilot tested
in 21 U.S. hospitals by more
than 1,400 employees for
comprehension and relevance.
A toll-free audio conference
will be sponsored in January
2005 by AHRQ and its
partners to introduce the
survey. Please visit the AHRQ
Web site for further details at
www.ahcpr.gov. The survey
can be found online at www.
ahrq.gov/qual/hospculture.

MEDQIC WEB SITE HELPS
PROVIDERS MAKE RAPID
QUALITY IMPROVEMENTS

In January 2005, the Centers for Medicare & Medicaid Services (CMS)

will unveil an advanced feature of the new MedQIC Web site at

www.medqic.org, a multifaceted database and search engine. This new

feature will enable Medicare providers to find, use and share quality

improvement resources. A partial list of features includes: find a colleague,

submit a resource, rate a resource, and all evidence-based information

on quality improvement projects initiated by CMS.

edQIC strategically fits into the
Medicare quality improvement
efforts of healthcare providers, serving
Quality Improvement Organizations
(QIOs) and providers in a number of
critically important ways. QIOs are
facing escalating demands to effectively
and rapidly foster transformational
improvements in healthcare. MedQIC
is, and will become, an increasingly
rich source of information, strategies,
tools, and supporting documents, which
can be used to supplement and reinforce
QIO interactions with providers. MedQIC
will also bring efficiencies associated
with centralization of materials.

Benefits to providers
For providers with growing staffing and
financial pressures, as well as increasing
demands to make fundamental change,
MedQIC offers them strategies, actions,
and practical vetted tools that can be
used to make improvements quickly and
effectively. The tools are organized to
correspond to the CMS quality improve-
ment priorities and can substantially
reduce the time, confusion and effort
providers must put forth to implement
change.

MedQIC is designed to provide needed
resources for direct care staff. Physicians
and nurses are caring, talented, and

dedicated professionals whose successful
delivery of healthcare, despite our flawed
infrastructure, is nothing short of
miraculous. QIOs encourage them to
take a proactive role in demanding and
fostering fundamental changes in the
way our system supports healthcare
delivery. It is our systems that need to
be fixed, not our people. MedQIC offers
them resources that can help fix the
systems. Interventions and tools are
sorted by settings and topics of interest.
Actions are organized so frontline
workers, senior leaders and external
groups can see what they can do to
bring about change.

MedQIC's new feature
allows providers to find,
use and share quality
improvement resources.

MedQIC was built using the Institute
for Healthcare Improvement's (IHI's)
Web site as a model, a partnership that
has proven to be successful. The IHI sets
the standard for quality improvement.
Since its inception, it has led us to
believe we can achieve the goal of
getting the right care to every person
every time. Much of the success of IHI

has been the result of its steadfast
application of Nolan's Model for
Improvement. The IHI's Web site at
www.ihi.org incorporates this model
in a way that is very logical and user-
friendly. Partnering with IHI and building
on its successes gives us the opportunity
to reach those populations with
improvements in a faster and more
substantial way.

Meeting place for ideas
The healthcare community will play
a significant role in the evolution of
MedQIC. MedQIC will reach its full
potential when it truly becomes a
meeting place for ideas and sharing.
Improvement cannot occur in isolation.
Healthcare providers are the ultimate
source of content for the Web site.
MedQIC can become a meeting place
for all those interested in improving
care. The resources are free, and the
hope is that those who use them will
also share their own tools, successes
and modifications, so that we can all
learn to improve healthcare together.

--Alina Wilkinson, MA
Senior Analyst

The above article was prepared with the
assistance of Margaret M. Toth, MD,
Chief Quality Officer, Delmarva Foundation.

Physician Acknowledgement Monitoring
Crucial to Hospital Payment Under Medicare

Hospitals are required under Medicare Conditions of

Par ticipation to obtain a physician acknowledgment

statement. This statement must be signed and dated

at the time the physician is granted admitting privi-

leges or admits his or her first patient to the hospital.

Since hospital reimbursement is based in part on

the diagnoses and procedures documented by the

physician, the physician attests in the statement that

he or she will document this information accurately.

The statement also outlines the penalties for

misrepresenting this information.

hen the hospital submits a claim, it must have on file
a signed and dated acknowledgment from the attending
physician that he or she has received the statement. Existing
acknowledgments signed by physicians already on staff remain
in effect as long as they have admitting privileges at the hospital.
Hospitals must meet these conditions in order to receive
payment under the Prospective Payment System (PPS). If
the signed acknowledgment statement is not in place, the
Centers for Medicare & Medicaid Services (CMS) may with-
hold payment or terminate the provider agreement.

CMS may withhold payment or
terminate the provider agreement
if the signed notice is not in place.

Ohio KePRO is able to assist hospitals
throughout the QI process.

or discuss an issue. Hospitals are also encouraged to contact
Ohio KePRO with any questions or concerns. When Ohio
KePRO's monitoring process is complete, we notify each
hospital by letter. If a deficiency is found in the first sample
of claims data, another random sample is validated to ensure
that a pattern does not exist. If a pattern is identified, Ohio
KePRO follows up with the hospital by requesting a Quality
Improvement Plan to correct the deficiencies. If the deficiency
affects payment under the PPS program, Ohio KePRO must
follow up with AdminaStar Federal (the fiscal intermediary)
and CMS as necessary.

The monitoring process
Ohio KePRO is required by CMS to monitor hospitals at
least annually to ensure that they are obtaining the
acknowledgment statements from physicians. To initiate
this process, Ohio KePRO requests a list of all physicians
from each hospital with new admitting privileges during the
time period. In addition to the physician's name, Ohio
KePRO requests the physician's unique physician identifica-
tion number (UPIN), date of admitting privileges, date of
signature on the acknowledgment statement, and a copy of
the signed acknowledgment statement. Ohio KePRO then
validates this information against hospital claims data.

It is always Ohio KePRO's goal to help hospitals attain and
maintain 100 percent compliance with this CMS requirement.
Ohio KePRO is able to assist hospitals throughout the quality
improvement process. We also offer help in designing,
implementing, and monitoring a process that works well
for each hospital.

For more information, please contact Ohio KePRO's Review
Team at 1-800-385-5080; e-mail: review@ohqio.sdps.org.

--Martha Truby, BSEd, RHIA
Review Supervisor

At any time during our monitoring process, Ohio KePRO may
contact a hospital directly to obtain additional information

National Surgical Care Improvement
Project Partnership Forming to
Reduce Surgical Complications

Ohio KePRO will continue to provide technical and professional guidance and support for the new Surgical Care

Improvement Project (SCIP) in Ohio when a national campaign launches this coming summer to reduce surgical

complications. SCIP's goal is to reduce surgical complications by 25 percent nationally by the year 2010 in four

target areas: surgical site infections, and cardiac, respirator y, and venous thromboembolic complications.

ince the 2000 Institute of Medicine's
report: To Err is Human, Building
a Safer Health System, drew attention
to the number of preventable errors in
healthcare, intense public scrutiny has
providers, insurers and purchasers
searching for reliable methods to improve
quality in surgical care. According to
studies, more than 40 million surgical
procedures are performed in the United
States each year and, depending on
the procedure, up to one-half of these
procedures could have postoperative
complications associated with them.
Complications can include respiratory
difficulty, blood clots, adverse cardiac
events and infection. These complica-
tions take a significant toll on the patients
involved and raise the overall cost of
healthcare, increasing length of stay and
hospital costs.

National quality partnership
SCIP is a national quality partnership of
public and private sector organizations
that is promising to be a transformational
effort to prevent postoperative compli-
cations in the United States. This project
will build upon the successes of the three-
year national Surgical Infection Prevention
(SIP) Project, which began in August
2002. A national SCIP steering com-
mittee and multiple technical expert
panels are working to develop a quality
improvement framework to improve
both patient safety and the quality of
care for surgical services nationwide.

Preliminary information about the SCIP
Partnership was presented to the
medical community for the first time
at the American College of Surgeons'
Congress, held October 10-14, 2004,

in New Orleans, Louisiana, by one of
the SCIP steering committee members,
David Hunt, MD, FACS, medical officer
with the Centers for Medicare & Medicaid
Services (CMS) Quality Improvement
Group.

"SCIP will take the measures we have
been using for SIP, which are entirely
for antimicrobial prophylaxis, and
expand them to address a number of
postoperative complications such as
acute myocardial infarction or postop
pneumonia," said Dr. Hunt. "Through
SCIP, we will continue to work on
surgical site infections, but the scope
of what we're going to address will
expand considerably."

The SCIP partnership was initiated in
2003 by CMS and the Centers for Disease
Control and Prevention (CDC) through
the formation of a steering committee.
Representatives of 10 organizations
comprise the committee, including the
Agency for Healthcare Research and
Quality, American College of Surgeons,
American Hospital Association, American
Society of Anesthesiologists, Association
of periOperative Nurses, CMS, CDC,
Department of Veterans Affairs,
Institute for Healthcare Improvement
and Joint Commission on Accreditation
of Healthcare Organizations.

In September 2003, CMS awarded
contracts to three state Medicare Quality
Improvement Organizations (QIOs) for
a SCIP pilot project. Ohio KePRO, the
Ohio QIO, and Health Care Excel, the
Kentucky QIO, are the Medicare con-
tractors for the three-state pilot. The
Oklahoma Foundation for Medical

Quality, the Oklahoma QIO, has also
contributed to the Ohio pilot. QIOs in
the pilot states provide appropriate
interventions to enhance quality
improvement and also test feasibility
of collecting, reporting, and analyzing
surgical processes and outcome meas-
ures in a community setting. Lessons
learned in the pilot will guide the
national approach to surgical care
improvement.

Developmental activities underway
In preparation for an official launch in
summer 2005, several developmental
activities are currently under way,
including completion of the three-state
demonstration pilot, the formation of
four technical expert panels to provide
specialized guidance for improving each
of the four target areas and development
of information, materials and evidence-
based strategies to help the hospitals
and their professional staffs participate--
and succeed--in this national effort.

"What is so exciting about SCIP is the
intense and intimate participation by all
the organizations, as well as the spread
of the work outside the Medicare
population," Dr. Hunt adds.

For more information about SCIP, visit
and bookmark the SCIP Partnership's
Web site at www.MedQIC.org/scip or
Ohio KePRO's at www.ohiokepro.com.
Or contact Ohio KePRO's Acute Care
Services Team at 1-800-385-5080;
e-mail: hospital@ohqio.sdps.org.

--Adapted from the Centers for
Medicare & Medicaid Services

INFLUENZA
ANTIVIRAL
MEDICATIONS:
CDC 2004-2005
INTERIM
CHEMOPROPHYLAXIS
AND TREATMENT
GUIDELINES

Influenza antiviral medications are an important

adjunct to influenza vaccine in the prevention and

Providers
Urged to Promote
Pneumococcal Vaccine

oncerns recently about the flu vaccine supply
make protection against pneumonia critical.
Ohio KePRO reminds healthcare providers to pro-
mote the pneumococcal vaccine to their Medicare
patients.

This heightened awareness
about the flu vaccine
provides an ideal opportu-
nity to assess patients and
ensure their pneumococcal
vaccination status.

                                    Pneumococcal pneumonia
                                    kills more people every year
                                    than all other vaccine-
                                    preventable diseases
                                    combined, according to
                                    the Centers for Disease
                                    Control and Prevention
(CDC). The CDC estimates that as many as 40,000
Americans die from pneumonia each year.

treatment of influenza. In the setting of the current

vaccine shortage, the Centers for Disease Control and

Prevention (CDC) has developed interim recommen-

dations on the use of antiviral medications for

The federal government's goal is to have 90 percent of
the elderly vaccinated against pneumococcal disease
by 2010. About 63 percent of the elderly are currently
vaccinated against pneumococcal disease. Medicare claims
data for 2002 suggest that in Ohio about 640,000 of
1.1 million Medicare beneficiaries over age 65 need a
pneumonia shot.

the 2004-05 influenza season. These interim

recommendations are provided, in conjunction with

previously issued recommendations on use of vaccine,

to reduce the impact of influenza on persons at high

risk for developing severe complications secondary

to infection. The recommendations are not intended

to guide the use of these medications in other

situations, such as outbreaks of avian influenza.

These interim recommendations may be updated as

more information on the supply of influenza vaccine

High-risk individuals requiring the
pneumococcal vaccination include:
· People who are age 65 or older.
· People who have chronic illnesses.
· People with heart or lung diseases.
· People with diabetes mellitus.
· People with sickle cell disease, alcoholism, chronic
   liver diseases or cerebrospinal fluid leaks.
· People with a weak immune system.
· People with human immunodeficiency virus
   (HIV) or AIDS.
· People with chronic renal failure, or organ
   transplantation.
· People with Hodgkin's disease, lymphoma, multiple
   myeloma and those who have had their spleen
   removed.
· Residents of nursing homes or other long-term
   care facilities.

and antiviral medications becomes available.

--Adapted from the Centers for Medicare &
Medicaid Services

(Continued on page 8)

Influenza Antiviral Medication
(Continued from page 7)

Background
Influenza antiviral medications have
long been used to limit the spread and
impact of institutional influenza out-
breaks. They also are used for treatment
and chemoprophylaxis of persons in
other settings. In the United States, four
antiviral medications (amantadine,
rimantadine, oseltamivir, and zanamivir)
are approved for treatment of influenza,
though limited supplies of zanamivir
are currently available. When used for
treatment within the first two days of
illness, all four antiviral medications
are similarly effective in reducing the
duration of illness by one or two days.
Only three antiviral medications
(amantadine, rimantadine, and
oseltamivir) are approved for
chemoprophylaxis of influenza. More
detailed information about each
medication, including dosage and
approved persons for use, may be found
at http://www.cdc.gov/flu/professionals/
treatment.

2004-2005 antiviral medications
usage guidelines
CDC is issuing interim recommendations
for the use of antiviral medications
during the 2004-2005 season. Local
availability of these medications may
vary from community to community,
which could impact how these
medications should be used. The
recommendations are as follows:

(1) CDC encourages the use of aman-
tadine or rimantadine for chemopro-
phylaxis and use of oseltamivir or
zanamivir for treatment as supplies allow,
in part to minimize the development
of amantadine resistance among
circulating influenza viruses.

(2) People who are at high risk of
serious complications from influenza
may benefit most from antiviral med-
ications. Therefore, in general, people
who fall into these high-risk groups
should be given priority for use of
influenza antiviral medications:

Treatment
· Any person experiencing a potentially
life-threatening influenza-related
illness should be treated with
antiviral medications.

· Any person at high risk for serious
complications of influenza and who is
within the first 2 days of illness onset
should be treated with antiviral med-
ications. (Pregnant women should consult
their primary provider regarding use
of influenza antiviral medications.)

Rimantadine is not approved for
treatment of children under 13 years old.
For treatment, these persons should
receive amantadine (children aged
1-12), oseltamivir (children aged 1-12),
or zanamivir (children aged 7-12).

Any person experiencing
a potentially life-
threatening influenza-
related illness should
be treated with
antiviral medications.

Chemoprophylaxis
· All persons who live or work in insti-
tutions caring for people at high risk
of serious complications of influenza
infection should be given antiviral
medications in the event of an insti-
tutional outbreak. This includes
nursing homes, hospitals and other
facilities caring for persons with
immunosuppressive conditions, such
as HIV/AIDS. When vaccine is available,
vaccinated staff require chemopro-
phylaxis only for the 2-week period
following vaccination. Vaccinated
and unvaccinated residents should
receive chemoprophylaxis for the
duration of institutional outbreak
activity. Rapid tests or other influenza
tests should be used to confirm
influenza as the cause of outbreaks as
soon as possible. However, treatment
and chemoprophylaxis should be
initiated if influenza is strongly
suspected and test results are not yet
available. Other outbreak control
efforts such as cohorting of infected
persons and the practice of respiratory
hygiene and other measures should
also be implemented. For further
information on detection and control
of influenza outbreaks in acute
care facilities, please visit
http://www.cdc.gov/ncidod/hip/INFE
CT/flu_acute.htm.

· All persons at high risk of serious
influenza complications should be
given antiviral medications if they
are likely to be exposed to others
infected with influenza. For example,
when a high-risk person is part of a
family or household in which someone
else has been diagnosed with influenza,
the exposed high-risk person should
be given chemoprophylaxis for 7 days.

(3) Antiviral medications can be con-
sidered in other situations when the
available supply of such medications
is locally adequate.
· Chemoprophylaxis of persons in
  communities where influenza viruses
  are circulating, which typically lasts
  for 6-8 weeks:
     · Persons at high risk of serious
       complications who are not
       able to get vaccinated.
     · Persons at high risk of serious
       complications who have been
       vaccinated but have not had
       time to mount an immune
       response to the vaccine. In
       adults, chemoprophylaxis should
       occur for a period of 2 weeks
       after vaccination. In children
       aged less than 9 years old,
       chemoprophylaxis should
       occur for 6 weeks after the
       first dose, or 2 weeks after the
       second dose, depending on
       whether the child is scheduled
       to receive one or two doses of
       vaccine.
     · Persons with immunosuppressive
       conditions who are not expected
       to mount an adequate antibody
       response to influenza vaccine.
     · Healthcare workers with direct
       patient care responsibilities
       who are not able to obtain
       vaccine.
· Treatment of infected adults and
  children aged older than 1 year who
  do not have conditions placing them
  at high risk for serious complications
  secondary to influenza infection.

(4) Where the supplies of both influenza
vaccine and influenza antiviral med-
ications may not be sufficient to meet
demand, CDC does not recommend the
use of influenza antiviral medications
for chemoprophylaxis of non-high-risk
persons in the community.

Private sector sources of
influenza antiviral medications
Pharmaceutical distributors should be
contacted directly for availability and
procurement of antiviral medications.

Strategic national stockpile
The United States has a limited supply
of influenza antiviral medications stored
in the Strategic National Stockpile (SNS)
for emergency situations. Efforts are
underway by Health and Human
Services to procure additional supplies
of antiviral medications. Some of the
supply will be held in reserve in the
event of an influenza pandemic.
However, some of the supply will be
made available to states and territories
for use in outbreak settings, as might
occur in a hospital or long-term
care facility.

Change in ACEI for LVSD
Measures (HF-3, AMI-3):
Incorporation of ARBs

Excessive activation of the renin-angiotensin hormone system is a

hallmark of heart failure and is an important mediator of adverse

clinical outcomes in patients with HF and left ventricular systolic

dysfunction (LVSD). Both angiotensin converting enzyme inhibitors

(ACEIs) and angiotensin receptor blockers (ARBs) act to decrease the

activity of the renin-angiotensin system and have been studied in

clinical heart failure trials. Randomized trials, studying a wide range

Requesting influenza antiviral
medications from the SNS
Influenza antiviral medications in the
SNS can be requested only by state or
territory Health Departments.
Institutions (hospitals or long-term
care facilities) experiencing an urgent
need for such medications should
convey their request to the state or
territory health department.
1. The state or territory health
   department should call 770-488-
   7100, the CDC's 24/7 emergency
   number, to make a request for
   antiviral medications. A logistics
   plan is being drafted and will be
   available to all state and territorial
   health departments in the
   near future.
2. The state or territory health
   department should indicate there
   is an urgent priority use situation
   (as defined previously) that can
   be addressed by use of antiviral
   medications, and should indicate
   that all reasonable efforts have
   been made to procure influenza
   antiviral medications from private
   distributors.

of patients with heart failure and LVSD, have demonstrated the efficacy

of ACEIs compared to placebo in reducing mortality and morbidity

from heart failure.^1,2 Thus, ACEIs have long been considered the

cornerstone of therapy for all patients with heart failure and LVSD

unless contraindicated or not tolerated.

ubsequent heart failure trials assessed ARBs
as alternatives to ACEIs or have compared
ARBs with placebo in patients who are intolerant
of ACEIs. Early studies failed to demonstrate the
equivalence of ARBs to ACEIs.^3,4However, more
recent trials demonstrate that ARBs have an
important role in heart failure treatment. The
CHARM Alternative trial compared ARBs with
placebo in patients with heart failure and a history
of prior intolerance of ACEIs.⁵In this trial, the
ARB candesartan was well tolerated and reduced
mortality and hospitalization.

The VALIANT trial directly compared an ACEI with an ARB (as well as the
combination of the two) in patients with signs and symptoms of heart failure or
LVSD after acute myocardial infarction.⁶In this trial, the ARB was statistically
"non-inferior" to ACEIs in this patient population. This study was the first to
demonstrate the equivalence of ARBs, albeit in a circumscribed patient
population (i.e., those after myocardial infarction).

For more information, visit
www.cdc.gov/flu or call the National
Immunization Hotline at 800-232-2522
(English), 800-232-0233 (Español),
or 800-243-7889 (TTY).

--From the Centers for Disease
Control and Prevention

Recent trials demonstrate that ARBs have an
important role in heart failure treatment.

For both heart failure and AMI, the ACEI quality measures have evolved to
acknowledge the changing evidence. Although many questions remain unanswered,
and although many experts believe that ACEIs should remain the first-line method
of renin-angiotensin blockade in patients with heart failure, the accumulating

(Continued on page 10)

Changes in ACEI for LVSD measures
(Continued from page 9)

References
1. Garg R, Yusuf S. Overview of randomized trials of angiotensin-converting

evidence has provided the impetus to include ARBs as
acceptable alternatives to ACEIs. Guideline committees have
also supported the inclusion of ARBs in performance measures

enzyme inhibitors on mortality and morbidity in patients with heart

failure. Collaborative Group on ACE Inhibitor Trials. JAMA.
1995;273:1450-1456.

2. Flather MD, Yusuf S, Kober L et al. Long-term ACE-inhibitor therapy in

for AMI and for heart failure. This measure is based on the
premise that all patients with heart failure and LVSD,
including those post-MI, should be treated with either an

ACEI or an ARB unless there is documentation of a specific
absolute contraindication or drug intolerance to both ACEIs
and ARBs. Because it is known that many patients with

heart failure still do not receive either an ACEI or ARB,⁹ improvement of care as assessed by this measure is expected
to have an important impact on patient outcomes.

patients with heart failure or left-ventricular dysfunction: a systematic
overview of data from individual patients. ACE-Inhibitor Myocardial

Infarction Collaborative Group. Lancet. 2000;355:1575-1581.

3. Pitt B, Poole-Wilson PA, Segal R et al. Effect of losartan compared with
captopril on mortality in patients with symptomatic heart failure:

randomised trial--the Losartan Heart Failure Survival Study ELITE II.

Lancet. 2000;355:1582-1587.
4. Dickstein K, Kjekshus J. Effects of losartan and captopril on mortality

and morbidity in high-risk patients after acute myocardial infarction:

the OPTIMAAL randomised trial. Optimal Trial in Myocardial Infarction
with Angiotensin II Antagonist Losartan. Lancet. 2002;360:752-760.

5. Granger CB, McMurray JJ, Yusuf S et al. Effects of candesartan in

Implementation
CMS/JCAHO Technical Measures Workgroup has approved
a two-step plan of implementation:

patients with chronic heart failure and reduced left-ventricular systolic
function intolerant to angiotensin-converting-enzyme inhibitors: the

CHARM-Alternative trial. Lancet. 2003;362:772-776.

1. Short Term Effective January 1, 2005+ discharges
The short-term steps will address the inclusion of ARBs
through relabeling of data element and measure names, and
rewording of ACEI data element definitions. Programming
changes are not warranted, ensuring expeditious inclusion
of ARBs.
· Change current data element names from "ACEI
Prescribed at Discharge" to "ACEI or ARB Prescribed at
Discharge" and "Contraindication to ACEI at Discharge"
to "Contraindication to Both ACEI and ARB at
Discharge." Notes for abstraction, inclusion/exclusion
lists, etc. within the definitions will be revised and
reworded accordingly.
· Revise AMI/HF measure names: "ACEI or ARB for LVSD."
· Reflect data element and measure name changes in all
CMS-JCAHO manual documentation (e.g., Data Element
Lists, Data Dictionary, Measure Information Forms,
Algorithms, Verification section, CART related sections).
· Add new medication table in Appendix C containing
the list of ARBs.

6. Pfeffer MA, McMurray JJ, Velazquez EJ et al. Valsartan, captopril, or both
in myocardial infarction complicated by heart failure, left ventricular

dysfunction, or both. N Engl J Med. 2003;349:1893-1906.

7. Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M,
Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ,

Ornato JP, Pearle DL, Sloan MA, Smith SC Jr; American College of

Cardiology; American Heart Association; Canadian Cardiovascular
Society. ACC/AHA guidelines for the management of patients with
ST-elevation myocardial infarction--executive summary. A report of

the American College of Cardiology/American Heart Association Task
Force on Practice Guidelines (Writing Committee to revise the 1999
guidelines for the management of patients with acute myocardial
infarction). J Am Coll Cardiol. 2004 Aug 4;44(3):671-719.

8. Executive Council of the Heart Failure Society of America. Implications
of recent clinical trials for heart failure performance measures. HFSA
Position Statement. J Card Fail. 2004;10:4-5.

9. Masoudi FA, Rathore SS, Wang Y et al. National patterns of use and
effectiveness of angiotensin converting enzyme inhibitors in older
patients with heart failure and left ventricular systolic dysfunction.

Circulation. 2004;110:724-731.

Accumulating evidence has provided
the impetus to include ARBs as
acceptable alternatives to ACEIs.

--From the Joint Commission on Accreditation

of Healthcare Organizations and the
Colorado Foundation for Medical Care,
the Medicare Quality Improvement Organization for Colorado

2. Long TermEffective October 1, 2005+ discharges
The long-term plan will allow differentiating between ACEI
and ARBs through the addition of new ARB data elements.
These changes will require programming changes.
· Two new data elements will be added, "ARB Prescribed at
Discharge" and "Contraindication to ARB at Discharge."
· The two original ACEI data elements, "ACEI Prescribed at
Discharge" and "Contraindication to ACEI at Discharge,"
will be restored to enable separation of patients who
received ACEI from those who received ARBs.
· CART tool will be reprogrammed accordingly.

FLU VACCINE
SHORTAGE UPDATE

Providers throughout Ohio have voiced questions and concerns

about the vaccination performance measurement in light of the

influenza vaccine shortage.

he following is an excerpt from a
joint memorandum issued
December 2, 2004 by the Centers for
Medicare & Medicaid Services (CMS)
and the Joint Commission on the
Accreditation of Healthcare
Organizations (JCAHO).

"The Centers for Medicare & Medicaid
Services (CMS) and The Joint
Commission on Accreditation of
Healthcare Organizations (JCAHO)
have worked together to coordinate
specific abstraction instructions
regarding the Influenza Vaccination
Status question as follows:

· If there is no vaccine available, the
response, "None of the above/Not
documented/UTD" should be selected.
This selection will result in the case
not being captured in the measure
numerator.
· Data resulting from PN 7 will not be
used for public reporting on either
JCAHO's Quality Check or CMS'
Hospital Compare Web sites for the
2004-2005 flu season data collection
period including 4th Quarter '04
and 1st Quarter '05 discharges."

Vaccine supply
As this issue of Quality Matters was
going to press in early January, the
federal government was attempting to
secure supplies of influenza vaccine from
foreign sources. Even if it successfully
obtains more vaccine, the supply will
still be insufficient to vaccinate the U.S.
population. Therefore, the influenza
vaccine guidelines issued by the Centers
for Disease Control and Prevention (CDC)
for vaccination with inactivated vaccine
are still recommended. The interim
influenza guidelines define the priority
groups for vaccination with inactivated
influenza vaccine as follows:

· All children aged 6-23 months
· Adults aged 65 years and older
· Persons aged 2-64 years with under-
lying chronic medical conditions
· All women who will be pregnant
during influenza season
· Residents of nursing homes and
long-term care facilities
· Children 6 months-18 years of age
on chronic aspirin therapy
· Healthcare workers with direct
patient care
· Out-of-home caregivers and house-
hold contacts of children aged less
than 6 months

Live Attenuated Influenza Vaccine
(FluMist®)
The CDC also reported that all healthy
people 5 to 49 years of age who are not
pregnant are eligible to receive the live
attenuated influenza vaccine (LAIV).
This includes most out-of-home care-
givers and household contacts of chil-
dren less than 6 months of age and most
healthcare workers. The exception is
healthcare workers caring for severely
immunocompromised patients in special
care units. The flu shot is preferred for
these healthcare workers because there
is a risk of passing the weakened live
virus in LAIV to the severely immuno-
compromised patient. Such healthcare
workers who get LAIV must avoid contact
with severely immunocompromised
patients for seven days. For further
information about LAIV visit the CDC's
Web site at http://www.cdc.gov/flu/
about/qa/nasalspray.htm.

Influenza antiviral medications
The CDC also issued interim guidelines
regarding influenza antiviral medica-
tions. The article on page 7 details
these guidelines.

For more information
CDC has a 24/7 central telephone hot-
line available in English and Spanish.
1-800-CDC-INFO (1-800-232-4636).
The number for the hearing impaired
is 1-800-243-7889 (TTY/TDD). The
following also contain useful information
about the flu and flu vaccine supply:

Sources of Further Information
"Interim Influenza vaccination
Recommendations 2004-2005
Influenza Season," October 5, 2004,
Department of Health & Human
Services, Centers for Disease Control
and Prevention. http://www.
cdc.gov/flu/protect/whoshouldget.htm.

"Antiviral Drugs and the Flu," October
22, 2004, Department of Health &
Human Services, Centers for Disease
Control and Prevention. http://www.
cdc.gov/fluprotect/antiviral/index.htm

"Questions and Answers: The Nasal-Spray
Flu Vaccine (Live Attenuated Influenza
Vaccine) [LAIV]," updated October 19,
2004, Department of Health & Human
Services, Centers for Disease Control
and Prevention. http://www.
cdc.gov/flu/about/qa/nasalspray.htm

" Flu Activity," October 31-November 6,
2004, Department of Health & Human
Services, Centers for Disease Control
and Prevention. http://www.cdc.gov/
flu/weekly/fluactivity.htm

"Good Health Habits" Department of
Health & Human Services, Centers for
Disease Control and Prevention. http://
www.cdc.gov/flu/protect/preventing.htm

--Patricia Nelson, RN
Quality Improvement
Project Coordinator

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QUALITY IMPROVEMENT CALENDAR

January
   National Glaucoma Awareness Month
   National Thyroid Awareness Month
   National Cataract Awareness Month

February
    American Heart Month
    National Hypertension Awareness Month
    Women's Heart Health Day--1st
    National Wear Red Day for Women--4th
    National Cardiac Rehabilitation Week--13th19th
    National Cardiovascular Professionals Week--
   13th19th
    National Women's Heart Day--18th

March
    National Colorectal Cancer Awareness Month
    National Save Your Vision Month
    Brain Awareness Week--14th20th
    American Diabetes Alert Day--22nd
    National Doctors Day--28th
    Patient Safety Awareness Week--6th12th

Interested in finding ways to help patients stop smoking?
Then join the Smoking Cessation e-mail exchange list.
Please send your full name and e-mail address to
dsvec@ohqio.sdps.org. Instructions will then be sent
to you by e-mail on how to register for the Smoking
Cessation e-mail exchange list.

Acute Care Services Team
David A. Bitonte, DO, MBA, FAOCA
Rita Bowling, RN, MSN, MBA, CPHQ
Jennifer Bitterman, RHIA, MBA
Meghan Harris, MS
Lynn Mistovich RN
Donna Moore, RN, MBA, CPHQ
Patricia Nelson, RN
Diane Oye, RN, BA
Karl E. Peters
Rosann Pasko, MS
Amanda Stroupe Renner, MPH
Liz Simpson
Barbara G. Stiebeling, RN, MSN
Mona D. Wendell, RN, BA, MBA
Alina S. Wilkinson, MA

Medical Editor:
David A. Bitonte, DO, MBA, FAOCA

Executive Editor:
Suzana C. Iveljic, MBA

Editor :
Rober t A. Feigenbaum, MS

Associate Editor:
Barbara G. Stiebeling, RN, MSN

Please note: Ohio KePRO's office will be closed on
Februar y 21, 2005, in observance of Presidents' Day.

Publication No. 4020-OH-004-1/2005. This material was prepared by Ohio
KePRO, the Medicare Quality Improvement Organization for Ohio, under
contract with the Centers for Medicare & Medicaid Services (CMS), an
agency of the U.S. Department of Health and Human Services. The contents
presented do not necessarily reflect CMS policy.