Managing Your Health

Quality Recognition

Research & Reports

Presentations & Speeches

Experience From Other Cities

Health Quality Organizations

Evidence in health care is vital to making informed decisions.  We encourage you to review the findings and insights from research and reports produced by health care experts and other professionals in the Puget Sound area and throughout the country.

Clinical Improvement Report: Heart Disease

Clinical Improvement Report: Diabetes

Clinical Improvement Report: Prescription Drugs

Clinical Improvement Report: Depression

Clinical Improvement Report: Low Back Pain

Clinical Improvement Report: Prevention

Clinical Improvement Report: Asthma

Other Research and Reports

Clinical Improvement Teams (CITs)

The Alliance has convened a number of clinical improvement teams focused on specific conditions or categories of care.  These teams are made up of groups of physicians and other experts in the Puget Sound region and are brought together to:

1. Identify and recommend evidence-based guidelines for use by physicians and other health professionals to help ensure that they provide the most effective care to every patient with the specific condition;

2. Choose measures that will be used to rate the performance of medical practices and hospitals regarding care they provide; and

3. Identify specific strategies that will help improve the quality of care and the health and long-term wellbeing for people in the Puget Sound region. 

Each team submits a final report that is reviewed by the Alliance Quality Improvement Committee (QIC) and Board of Directors.  The reports provide detailed information about clinical care guidelines, quality measures and several high priority strategies to bring about positive changes for patients, physicians, and others.  Once approved by the QIC and the Board of Directors, the reports are shared with doctors and other health care professionals in clinics, medical practices, hospitals, and professional societies and associations throughout the Puget Sound region.  These clinical improvement reports – approved by the Board – are now available from the Puget Sound Health Alliance. 

All Alliance participants have direct access to the CIT reports and other Alliance materials by going to the log-in section of the website. Click here to find out how to become an Alliance participant.  Non-members can request copies of the report by completing the “contact us” form.  

Clinical Improvement Report: Heart Disease

Heart disease was selected by the Alliance because of its significant social and economic impact.  Cardiovascular disease, diseases of the heart and blood vessels, is the number one cause of death in the United States. In 2003, cardiovascular disease accounted for 37% of all deaths nationwide. In 2005, direct and indirect costs associated with cardiovascular disease topped $393 billion, or 20% of all health care expenditures nationally.  The Heart Disease CIT – composed of physicians and other providers, consumers, employers, and public health and policy experts – focused its efforts on cardiovascular disease in adults, specifically targeting coronary artery disease (angina and heart attacks) and heart failure.

The CIT recommended 23 performance measures, three of which were developed by the team.  The team next focused its attention on the best ways to change the behaviors of providers, patients, employers and health plans to achieve optimal performance on the selected measures, and to improve the quality of care received by adults with cardiovascular disease. 

In order of priority for implementation, the strategies recommended by the Heart Disease CIT were:

• Promote an accepted standardized tool for heart disease risk assessment for use by doctors and consumers;
• Promote and support the adoption and use of electronic health records or patient registries to clinics throughout the region;
• Promote positive behavior change that reduces health risks for people with heart disease;
• Collaborate with and endorse the work of others in the region as the literature on improving quality develops; and
• Encourage doctors, clincians, hospitals and other facilities to improve the coordination when a patient is discharged from a hospital and transitions to the next phase of care, especially for high-risk patients with heart failure.

For each of the above strategies, the Heart Disease CIT developed specific recommendations and guidance on implementation, which are presented in detail in the body of the final report.  An underlying theme of the recommendations is the development of collaborative relationships and partnerships with other local organizations working towards similar goals.

This report, along with the Diabetes CIT final report, was reviewed and endorsed  by health care professionals across the region, including physicians, medical groups, hospitals, natural medicine providers and many others in the Puget Sound community.

For a copy of this Clinical Improvement Team Report, please fill out the “contact us” form and include your email address and the name of the report you would like to receive.

Clinical Improvement Report: Diabetes

The Diabetes CIT – composed of physicians and other providers, consumers, employers, and public health and policy experts – focused its efforts on treatment of adults in physician office settings for Type 1 and Type 2 diabetes, with an emphasis on how to reduce risks and how to manage the condition over the long term.

The CIT recommended 14 performance measures, three of which were developed by the team, that cover (1) how to manage the care of people diagnosed with diabetes over the long term (eight measures) and (2) how to reduce risks in patients diagnosed with diabetes (six measures).  The team next focused its attention on the best ways to change the behavior of providers, patients, employers and health plans to achieve best performance on the selected measures and to improve the quality of care received by adults with diabetes. 

The six high-priority strategies recommended by the Diabetes CIT were:

1. Registries - Promote and support the adoption and use of registries in physician office settings in the five-county region;

2. Financial Incentives - Encourage health plans and employers to create incentives and eliminate access barriers so that patients and doctors can most effectively manage diabetes; 

3. Patient Self Management - Promote and support self management discussions between doctors and patients in the physician office setting; 

4. Patient Education - Promote diabetes education between doctors and patients in clinical care and community settings; 

5. Clinical Reminders and Feedback to Providers - Promote the use of clinical reminders to providers regarding the service needs of individual patients (see #1 Registries above); and

6. Patient Reminder Systems - Promote the use of patient appointment reminders sent directly to patients with diabetes. 

This report, along with the Heart Disease CIT final report, was reviewed and endorsed  by health care professionals across the region, including physicians, medical groups, hospitals, natural medicine providers and many others in the Puget Sound community.

For a copy of this Clinical Improvement Team Report, please fill out the “contact us” form and include your email address and the name of the report you would like to receive.

Clinical Improvement Report: Prescription Drugs

The use of prescription drugs is an important part of health care for many patients. For employers and consumers alike, the percentage of the health care dollar spent on prescription drugs is sizeable (and growing). The Puget Sound Health Alliance CIT - made up of local medical, pharmacy and other health care professionals - has completed its Phase I & II recommendations, which explore ways to improve the quality and affordability of care by:

1. Identifying drugs or prescribing patterns where there is strong evidence of widespread overuse, under-use, or misuse, and recommending opportunities for change that achieve significant improvements in quality or reductions in costs;

2. Providing advice on ways to align prescription-drug-related quality improvement and financial incentives for physicians and other providers, patients, employers, and health plans; and

3. Identifying barriers to change and developing recommendations for how each can be overcome in a timely manner.

The first report on clinical improvement for pharmaceuticals includes recommendations regarding the need to increase the percentage of prescriptions filled for generics rather than brand-name drugs, particularly in categories where a large number of patients have been prescribed drugs for which equally-effective and lower-cost generics are readily available. The Alliance promotes to physicians and consumers the value of choosing generics in the following drug categories:

• Cholesterol lowering agents (statins)
• Antidepressants (SSRIs or selective serotonin reuptake inhibitors)
• Gastric acid secretion reducers (PPIs or proton pump inhibitors)
• Non-steroidal anti-inflammatory drugs (NSAIDs)

The report includes other recommendations, such as encouraging medical clinics and hospitals to adopt policies to reduce the sales and marketing influence of pharmaceutical companies on the treatment decisions made by physicians. Such policies would restrict or eliminate drug company sales visits in facilities where patient care is provided, and reduce or eliminate the distribution of free brand-name drug samples.  In addition, the Alliance will encourage physicians and patients to eliminate the inappropriate prescribing and use of antibiotics.

For a copy of this Clinical Improvement Team Report, please fill out the “contact us” form and include your email address and the name of the report you would like to receive.

Clinical Improvement Report: Depression

Depression is common in the United States and around the world.  Almost 19 million Americans suffer from major depression in any given year, and an estimated 35 million people, or 15% of the population, will suffer from depression in their lifetime.  The Puget Sound Health Alliance CIT – made up of mental health and primary care provider communities, health plans, employers, and academic institutions – has completed and summarized its recommendations in a final report.  This report includes strategies for patients and providers around improving care, for example:

1. Patients should be active participants in their care and should follow the treatment advice from their doctor or other health care team member;

2. Doctors and other providers should use evidence-based clinical guidelines in the management of major depression (NOTE: The CIT did not endorse a specific set of clinical guidelines, but did site two sets: the Colorado Clinical Guidelines Collaborative, and the Institute of Clinical Systems Improvement);

3. Doctors and other health care professionals should aim to coordinate care across settings, including both the primary care physician and mental health specialists; and,

4. Doctors and other health professionals should screen patients for major depression, focusing on those who are at high risk because of chronic disease, alcohol or drug abuse, or a history of depression.

The report includes recommendations for health plans, pharmacy benefit managers, and employers about creating a positive community environment for change and recommended clinical performance measures in the areas of adherence to treatment, diagnosis and monitoring, and treatment effectiveness.

For a copy of this Clinical Improvement Team Report, please fill out the “contact us” form and include your email address and the name of the report you would like to receive.

Clinical Improvement Report: Low Back Pain

Low back pain is a leading cause of work-related disability and workers’ compensation for people under age 45, affecting about two-thirds of all adults at some point in time.  Medical costs associated with back pain are in excess of $25 billion per year and employers face huge costs in lost productivity and disability payments.  The Puget Sound Health Alliance CIT – made up of community members, representing clinical specialists, complementary and alternative medicine practitioners, patients, employers, health plans, and clinical researchers – has completed and summarized its recommendations in a final report. 

The report includes recommendations for the treatment of low back pain during the first six weeks, including:

1. All patients with low back pain should have a complete exam to determine whether there are any red flag conditions (e.g. pain lasting more than six weeks, bowel incontinence, history of cancer);

2. In the absence of red flag conditions, patients should be thoroughly assessed for history of back pain and whether previous therapy was effective;

3. In the absence of red flag conditions, imaging (e.g., x-ray, MRI) should not be done during the first six weeks following the onset of localized low back pain (back pain that occurs in a single location);

4. Surgery in the first six weeks in the absence of red flags or symptoms that get worse is not recommended; and

5. Generally, doctors and other health care providers should follow a conservative approach to treatment of low back pain during the first six weeks (when red flag conditions are not present), with the goal of preventing re-injury. 

The report also includes recommendations for preventing acute back pain from becoming chronic, including:

1. Doctors and other providers should assess all patients with low back pain for emotional status and work-life issues, provide reassurance to reduce fear and anxiety, and promote things that the patient can do to manage the condition (active self-management);

2. In the absence of red flag conditions, bed rest is not recommended and patients should be advised to remain active, returning to normal activity as soon as possible;

3. Patients with back pain who smoke should be assisted with smoking cessation; and

4. Patients with low back pain should be assessed for functional status, using commonly available tests (such as the SF-36 or SF-12 Health Survey). 

The report also includes recommendations for clinical performance measures to determine rates of unnecessary surgery and unnecessary imaging within the first six weeks after an initial provider visit.

For a copy of this Clinical Improvement Team Report, please fill out the “contact us” form and include your email address and the name of the report you would like to receive.

Clinical Improvement Report: Prevention

According to statistics compiled by the Commonwealth Fund, only 42% of adults over the age of 50 in Washington State have received recommended preventive care - such as screening for colorectal cancer, mammograms, Pap smears, and flu shots - at appropriate ages.  In the 2006 edition of America’s Health Rankings, from the United Health Foundation, Washington state’s childhood immunization rates were 42nd in the nation.  With the aim to improve the rate at which preventive care is delivered, the Puget Sound Health Alliance Prevention CIT - made up of physicians and other providers, consumers, employers, and public health and policy experts - has completed and summarized its recommendations in a final report.

Given the broad nature of the topic of prevention, the CIT members selected a subset of topic areas for discussion for which there was the greatest need for improvement and/or that had the greatest potential impact on the health of the community.   The six topics chosen were:

• Physical activity and nutrition
• Tobacco use
• Aspirin chemoprophylaxis
• Colorectal cancer screening
• Influenza immunizations
• Childhood immunizations

Though this list does not include all preventive strategies or services, it does target areas of high priority that could be useful in developing models and strategies for preventive care in general.  In addition to making specific recommendations for Alliance stakeholders within each topic area, the CIT also made two general recommendations for prevention:

1. Providers should schedule a planned, regularly recurring preventive care visit for all patients, on an annual basis or on a schedule that best meets individual patient needs.  This visit should not replace preventive care services that are offered at each visit.  Health plans and employers should ensure coverage for preventive care visits.
2. Employers and health plans should use Health Risk Assessments (HRAs) to help consumers understand their personal health risks and develop a plan to improve their health.  HRAs should always include mechanisms to calculate Body Mass Index (BMI); assess cardiovascular, diabetes, and depression risk; and to record key measurements such as blood pressure and cholesterol levels.

For a copy of this Clinical Improvement Team Report, please fill out the “contact us” form and include your email address and the name of the report you would like to receive.

Clinical Improvement Report: Asthma

More than 22 million American adults and children suffer from asthma and the prevalence is increasing.  It is one of the most common chronic diseases of childhood, affecting more than 6 million children in the United States. The quality of asthma management often falls short of best practices, both locally and nationally and there is an ongoing need for improvement and consistency in the multifaceted management of asthma. With the aim to improve the quality of asthma care in the region, the Puget Sound Health Alliance Asthma CIT— made up of physicians and other providers, consumers, employers, and public health and policy experts—has completed and summarized its recommendations in a final report.

The CIT divided its work into the four critical components of asthma care as described in the National Asthma Education and Prevention Program Expert Panel Report-3 2007 (NAEPP EPR-3 2007), whose evidence-based clinical guidelines the CIT recommended:

• Assessment and Monitoring
• Education for a Partnership in Asthma Care
• Environmental Triggers and Comorbid Conditions
• Medications

The CIT recommended two performance measures for inclusion in future rounds of Alliance public performance reporting:

1. Appropriate use of controller medications

The percentage of patients with persistent asthma and who were prescribed medications acceptable as primary therapy for long-term control of asthma during the measurement year

2. Spirometry use 

The percentage of patients with persistent asthma who have had spirometry within the past year.

In addition to making specific recommendations for Alliance stakeholders within each component of care, the CIT also made three general recommendations for asthma:

1. The Puget Sound Health Alliance and its members should support the Washington State Children and Adult Asthma Collaboratives.
2. The Alliance supports an incremental Pay-for-Performance model that rewards providers for (1) meeting qualification standards for a patient-centered medical home (PCMH) and (2) achieving target levels for designated process or outcome clinical performance measures.
3. Plans and purchasers to be innovative with approaches to encourage healthy behaviors among employees and members, and to evaluate and communicate the outcomes of any such approaches so that evidence on successful cost-effective benefit designs and incentives can accumulate and be disseminated.

For a copy of this Clinical Improvement Team Report, please fill out the “contact us” form and include your email address and the name of the report you would like to receive.

Other Research and Reports:

Hospital Transparency See the Washington State Hospital Association website for information comparing hospital pricing and quality, with answers to commonly asked questions about hospital bills.  Links of interest:

• Hospital Pricing: Information on charges at Washington hospitals
• Hospital Quality Measures: Washington hospitals' performance on selected quality measures such as heart attack and heart failure
• Understanding Your Hospital Bill: Answers to common questions about hospital bills

Better Care, Lower Costs brochure (PDF from U.S. Department of Health & Human Services about the importance of health care public reporting, aligned incentives, and health IT)

Survey of Puget Sound Consumers Regarding Health Care Quality and Affordability (PDF of survey results, 05/2006)

Puget Sound Health Alliance Case Study (PDF of report, Progressive Policy Institute 01/2006)

Quality of Health Care in America (PDF of report, RAND, 2004)

Doing Well by Doing Good: Improving the Business Case for Quality (PDF of report, A. Gosfield & Dr. J. Reinertsen, 2003)

If you would like to draw from this information for use in your own communication, please cite the source, both the author and the Alliance website. Thank you.

What do you think? If you have other research or reports that would be of value to share with patients, employees, employers, physicians, hospitals or others, please let us know.  Also, if you find any of these resources particularly helpful or if you have comments, we'd like to hear from you.