Achievable Benchmarks Of Care Research Articles

Developing realistic benchmarks for glaucoma care delivery

ABSTRACT Clinical Relevance Realistic benchmarks can serve as comparators for optometrists wishing to engage in clinical practice audits of their glaucoma care. Background The iCareTrack study established the appropriateness of glaucoma care delivery through clinical record audits of Australian optometry practices. Benchmarks required for monitoring and improving glaucoma care delivery do not exist. This study developed realistic benchmarks for glaucoma care and then benchmarked the performance of practices from the iCareTrack study to establish aspects of care that warrant attention from quality improvement initiatives. Methods Benchmarks were developed from the pre-existing iCareTrack dataset using the Achievable Benchmarks of Care (ABC) method. The iCareTrack study had audited the appropriateness of glaucoma care delivery against 37 clinical indicators for 420 randomly sampled glaucoma patient records from 42 Australian optometry practices. The four-step ABC method calculates benchmarks based on the top 10% of best-performing practices adjusted for low patient encounter numbers. iCareTrack results were compared to the benchmarks to explore the distribution of practices that were at, above or below benchmark. Results Benchmarks were developed for 34 of 37 iCareTrack indicators. For 26 (of 34) indicators, the benchmarks were at or above 90% appropriateness. The benchmarks for 14 (of 34) iCareTrack indicators were met by more than 80% of eligible practices, indicating excellent performance. Some aspects of glaucoma care such as peripheral anterior angle assessment, applanation tonometry, and visual field assessment appeared to be delivered sub-optimally by optometrists when compared to the benchmarks. Conclusion This study established benchmarks for glaucoma care delivery in optometry practices that reflect realistic and top achievable performance. The large number of indicators with benchmarks above 90% confirmed that glaucoma care can and should be delivered by optometrists at very high levels of appropriateness. Benchmarking identified pockets of sub-optimal performance that can now be targeted by quality improvement initiatives.

Pediatric Respiratory Illnesses: An Update on Achievable Benchmarks of Care.

Pediatric respiratory illnesses (PRI): asthma, bronchiolitis, pneumonia, croup, and influenza are leading causes of pediatric hospitalizations, and emergency department (ED) visits in the United States. There is a lack of standardized measures to assess the quality of hospital care delivered for these conditions. We aimed to develop a measure set for automated data extraction from administrative data sets and evaluate its performance including updated achievable benchmarks of care (ABC). A multidisciplinary subject-matter experts team selected quality measures from multiple sources. The measure set was applied to the Public Health Information System database (Children's Hospital Association, Lenexa, KS) to cohorts of ED visits and hospitalizations from 2017 to 2019. ABC for pertinent measures and performance gaps of mean values from the ABC were estimated. ABC were compared with previous reports. The measure set: PRI report includes a total of 94 quality measures. The study cohort included 984 337 episodes of care, and 82.3% were discharged from the ED. Measures with low performance included bronchodilators (19.7%) and chest x-rays (14.4%) for bronchiolitis in the ED. These indicators were (34.6%) and (29.5%) in the hospitalized cohort. In pneumonia, there was a 57.3% use of narrow spectrum antibiotics. In general, compared with previous reports, there was improvement toward optimal performance for the ABCs. The PRI report provides performance data including ABC and identifies performance gaps in the quality of care for common respiratory illnesses. Future directions include examining health inequities, and understanding and addressing the effects of the coronavirus disease 2019 pandemic on care quality.

Short-term pediatric thyroidectomy outcome: Analysis of the Pediatric Health Information System (PHIS) database.

Thyroidectomy is the most commonly performed pediatric endocrine surgery. Our objective is to measure the short-term outcome of pediatric thyroidectomies, and report on factors associated with postoperative complications. This is a retrospective cohort study, performed using the Pediatric Health Information System (PHIS) database on patients ≤18 years of age, from 47 children's hospitals across the United States, who underwent partial or total thyroidectomy from January 1, 2009 to December 31, 2019. A total of 6405 patients were included, mostly female (76.8%), and 46.9% were 15-18 years-old. Age <1 year, Hispanic and Black race, comorbidity with complex chronic conditions were associated with more complications. The overall short-term complication rate was 27.7%, with hypocalcemia accounting for the majority (15.6%). Complication rates were lower in benign or non-specific thyroid nodules as compared with malignancy and Graves' disease. Complication rates were significantly lower for partial thyroidectomy versus total thyroidectomy and both neck dissections and parathyroid re-implantations were associated with increased risk of complications. The mean length of stay was 1.4 days. Complications were associated with prolonged hospital stay (2.4 vs. 1.2 days) and increased cost ($19441 vs. $11232) (p<0.001), but not associated with hospital volume (p=0.36). Endocrine-related complications accounts for the majority of surgical morbidity following pediatric thyroidectomies performed at pediatric hospitals, and complications does not appear to be correlate with surgical volume. The calculated Achievable Benchmarks of Care (ABC) pooled complication rates from the top performing hospitals may serve as a goal for improvement.

Establishment of achievable benchmarks of care in the neurodiagnostic evaluation of simple febrile seizures.

Current guidelines recommend against neurodiagnostic testing for the evaluation of simple febrile seizures. (1) Assess overall and institutional rates of neurodiagnostic testing and (2) establish achievable benchmarks of care (ABCs) for children evaluated for simple febrile seizures at children's hospitals. Cross-sectional study of children 6 months to 5 years evaluated in the emergency department (ED) 2016-2019 with simple febrile seizures at 38 children's hospitals in Pediatric Health Information System database. We excluded children with epilepsy, complex febrile seizures, complex chronic conditions, and intensive care. Proportions of children who received neuroimaging, electroencephalogram (EEG), or lumbar puncture (LP) and rates of hospitalization for study cohort and individual hospitals. Hospital-specific outcomes were adjusted for patient demographics and severity of illness. We utilized hospital-specific values for each measure to calculate ABCs. We identified 51,015 encounters. Among the study cohort 821 (1.6%) children had neuroimaging, 554 (1.1%) EEG, 314 (0.6%) LP, and 2023 (4.0%) were hospitalized. Neurodiagnostic testing rates varied across hospitals: neuroimaging 0.4%-6.7%, EEG 0%-8.2%, LP 0%-12.7% in patients <1-year old and 0%-3.1% in patients ≥1 year. Hospitalization rate ranged from 0%-14.5%. Measured outcomes were higher among hospitalized versus ED-only patients: neuroimaging 15.3% versus 1.0%, EEG% 24.7 versus 0.1% (p < .001). Calculated ABCs were 0.6% for neuroimaging, 0.1% EEG, 0% LP, and 1.0% hospitalization. Rates of neurodiagnostic testing and hospitalization for simple febrile seizures were low but varied across hospitals. Calculated ABCs were 0%-1% for all measures, demonstrating that adherence to current guidelines is attainable.

Level of appropriate primary diabetic eyecare delivered and achievable in optometry practices in Australia

ABSTRACTClinical relevanceCurrent levels of appropriateness for primary diabetic eyecare delivered by Australian optometrists are presented along with realistic targets (benchmarks) for quality improvement. The demonstrated methods can be used in practice evaluation and benchmarking of other clinical practice areas and settings.BackgroundTo examine the appropriateness of diabetic eye-care delivery and establish achievable benchmarks of care (ABCs) for optometry practices in Australia.MethodIn a retrospective audit, clinical records of patients with type-II diabetes obtained from a randomly selected nationally representative sample of optometry practices were assessed against evidence-based clinical indicators. Appropriate care is defined as care delivered in compliance with the indicators. The ABC for each indicator was calculated as the average performance for the top 10% of optometry practices after Bayesian adjustment to account for a low number of eligible records.ResultsThe audit of 420 randomly selected patient records from 42 practices against 12 clinical indicators showed an overall appropriateness of 69% (95% confidence interval (CI) 66%, 73%) for overall diabetic eye care. While a high level of appropriateness was identified for recall period (93%, 95% CI 85%, 100%) and referral (100%, 95% CI 38%, 100%), larger gaps existed in history taking (46%, 95% CI 44%, 52%), dilated fundus examination (80%, 95% CI 76%, 84%) and iris examination (0%, 95% CI 0%, 56%). The ABCs for 8 of 12 indicators were 100%, and the remaining three indicators had ABCs above 80%. An ABC for the iris examination indicator could not be calculated owing to the low number of eligible patient record cards.ConclusionsThis study demonstrated a systematic process of practice evaluation and benchmarking in optometry practices. The diabetic eye care delivered by Australian optometrists was largely appropriate; however, improvement opportunities exist for history taking and physical examination. The ABCs demonstrate that excellence in primary diabetic eye care is attainable and will serve as an important tool in future initiatives to reduce the identified evidence-to-practice gaps.

Deimplementation in Bronchiolitis: How Low Can We Go?

Achievable benchmarks of care (ABCs) provide a goal for deimplementation initiatives by defining attainable performance. ABCs have previously been defined for bronchiolitis.1 It is unclear, however, whether these previously defined ABCs have an expiration date. Are ABCs a static benchmark, or do they require modification over time?Bronchiolitis is an ideal target for deimplementation initiatives to reduce the use of low-value tests and treatments because no interventions improve its course.2,3 In this issue of Pediatrics, Ralston et al4 examine the evolution of ABCs for bronchiolitis over time using data from the Pediatric Health Information System (PHIS). Ralston et al4 calculated both ABCs and performance gaps for 6 nonrecommended tests and treatments for 2 cohorts of patients diagnosed with bronchiolitis: those evaluated in and discharged from the emergency department (ED) and those admitted as either inpatient or observation status. Children evaluated between 2006 and 2019 were included and divided into 2 time periods separated by the updated 2014 American Academy of Pediatrics bronchiolitis guideline. In the ED cohort, they found improvements in ABCs for chest radiography and bronchodilator use, whereas, in the admitted cohort, they found improvements in ABCs for chest radiography, viral testing, and antibiotic use. The authors also found performance gaps, defined as the difference between the benchmark and median performance, to be largest for viral testing and bronchodilator use in both cohorts. The large performance gaps demonstrate that much of the cohort lags far behind optimal performers for these two measures.The results of Ralston et al,4 although important, suffer from limitations in their approach and those inherent in their use of administrative data. The PHIS database represents only 20% of pediatric hospitalizations in the United States and is limited to hospitals with the resources to participate. It is not clear whether community hospitals warrant different ABCs. Additionally, given the lack of clinical details available through the PHIS, the authors could not distinguish whether testing at a referring institution affected disposition or, for patients requiring hospitalization, whether a particular test or treatment performed early in the visit was performed by the ED or inpatient team. With the amount of evidence showing no benefit of additional testing and treatments for bronchiolitis,2 assessing the rationale behind a particular intervention and not just improvement efforts should be considered but cannot be with administrative data alone. For example, an imaging study performed at presentation versus with an unexpected clinical deterioration requires a different improvement target. The PHIS database includes the timing of tests and treatments by day. The study would have been strengthened if the authors had differentiated between tests obtained and treatments provided early versus late in the hospitalization.When it comes to bronchiolitis, the initiatives to address its management, most of which fall under the category of medical overuse, are too numerous to count.5 From the American Academy of Pediatrics bronchiolitis guideline2 to the American Board of Internal Medicine’s Choosing Wisely campaign6 to the multitude of local and national quality improvement initiatives,3,5 it is disappointing that ongoing performance gaps exist. Part of the challenge comes from the difficulty inherent to deimplementation work7 and the variability in the clinical course of bronchiolitis. As clinicians, it can be difficult to minimize interventions because providing supportive care is often perceived as “doing nothing,” which runs contrary to our desire to help.8,9 Additionally, simplification of quality improvement initiatives for bronchiolitis neglects the consideration of many other conditions presenting with respiratory distress in an infant (eg, myocarditis or sepsis) that often require diagnostic testing to differentiate them from bronchiolitis. One consideration to address such diagnostic challenges is to systematically approach the communication of contingency planning around diagnostic uncertainty so that providers can decide the ideal time, if any, to rule out a nonbronchiolitis etiology via testing.Sharp declines in hospitalizations for bronchiolitis and other childhood respiratory illnesses have occurred during the coronavirus disease 2019 pandemic.10 Clinicians, including trainees, have seen scant cases of respiratory illness during their core rotations, and although the decline in hospitalizations for viral respiratory infections is certainly good for children and their families, the return of bronchiolitis is likely to result in a steep learning curve. This curve includes what tests and treatments are considered low value (all of them) because their unfamiliarity with the clinical findings and management of bronchiolitis and its differentiation from other similarly presenting conditions may lead to increased use of nonrecommended tests and treatments.Regardless of what the postpandemic future of bronchiolitis holds, Ralston et al4 found improvements in ABCs for not ordering several nonrecommended tests over the last decade. Despite this encouraging improvement, performance gaps remain, and the study by Ralston et al4 offers suggestions for further closing that gap. Perhaps more importantly, in their work, Ralston et al4 highlight the need to revisit ABCs over time as baseline performance improves.

The Evolution of Quality Benchmarks for Bronchiolitis.

Evidence suggests that average performance on quality measures for bronchiolitis has been improving over time, but it is unknown whether optimal performance, as defined by Achievable Benchmarks of Care (ABCs), has also changed. Thus, we aimed to compare ABCs for established bronchiolitis quality measures between 2 consecutive time periods. As a secondary aim, we evaluated performance gaps, defined as the difference between median performance and ABCs, to identify measures that may benefit most from targeted quality initiatives. We used hospital administrative data from the Pediatric Health Information System database to calculate ABCs and performance gaps for nonrecommended bronchiolitis tests and treatments in 2 groups (patients discharged from the emergency department [ED] and those hospitalized) over 2 time periods (2006-2014 and 2014-2019) corresponding to publication of national bronchiolitis guidelines. Substantial improvements were identified in ABCs for chest radiography (ED -8.8% [confidence interval (CI) -8.3% to -9.4%]; hospitalized -17.5% [CI -16.3% to -18.7%]), viral testing (hospitalized -14.6% [CI -13.5% to -15.7%]), antibiotic use (hospitalized -10.4% [CI -8.9% to -11.1%]), and bronchodilator use (ED -9.0% [CI -8.4% to -9.6%]). Viral testing (ED 11.5% [CI 10.9% to 12.1%]; hospitalized 21.5% [CI 19.6% to 23.4%]) and bronchodilator use (ED 13.8% [CI 12.8% to 14.8%]; hospitalized 22.8% [CI 20.6% to 25.1%]) demonstrated the largest performance gaps. Marked changes in ABCs over time for some bronchiolitis quality measures highlight the need to reevaluate improvement targets as practice patterns evolve. Measures with large performance gaps, such as bronchodilator use and viral testing, are recommended as targets for ongoing quality improvement initiatives.

Achievable Benchmarks of Care for Pediatric Readmissions.

Most inpatient care for children occurs outside tertiary children's hospitals, yet these facilities often dictate quality metrics. Our objective was to calculate the mean readmission rates and the Achievable Benchmarks of Care (ABCs) for pediatric diagnoses by different hospital types: metropolitan teaching, metropolitan nonteaching, and nonmetropolitan hospitals. We used a cross-sectional retrospective study of 30-day, all-cause, same-hospital readmission of patients less than 18 years old using the 2014 Healthcare Utilization Project National Readmission Database. For each hospital type, we calculated the mean readmission rates and corresponding ABCs for the 17 most common readmission diagnoses. We define outlier as any hospital whose readmission rate fell outside the 95% CI for an ABC within their hospital type. We analyzed 690,949 discharges at 525 metropolitan teaching hospitals (550,039 discharges), 552 metropolitan nonteaching hospitals (97,207 discharges), and 587 nonmetropolitan hospitals (43,703 discharges). Variation in readmission rates existed among hospital types; however, sickle cell disease (SCD) had the highest readmission rate and ABC across all hospital types: metropolitan teaching hospitals 15.7% (ABC 7.0%), metropolitan nonteaching 14.7% (ABC 2.6%), and nonmetropolitan 12.8% (ABC not calculated). For diagnoses in which ABCs were available, outliers were prominent in bipolar disorders, major depressive disorders, and SCD. ABCs based on hospital type may serve as a better metric to explain case-mix variation among different hospital types in pediatric inpatient care. The mean rates and ABCs for SCD and mental health disorders were much higher and with more outlier hospitals, which indicate high-value targets for quality improvement.

Bronchiolitis in children ‒ do we choose wisely?

AimThe aim of our study was to evaluate the adherence to the 2014 American Academy of Pediatrics guidelines for bronchiolitis.Material and methodsThe study measured the utility of diagnostic and therapeutic procedures in children with the first episode of bronchiolitis in their lives hospitalized at the University Children’s Hospital in Krakow, Poland, between September 2014 and March 2015. The results were compared with the achievable benchmarks of care (ABCs) for hospitalized children with bronchiolitis. Hospital performance was measured by five clinical indicators: chest X-ray utilization, viral testing implementation, steroids, antibiotics and bronchodilator prescriptions. Odds ratios (OR) with 95% confidence intervals (95%CI) were calculated for comparisons between hospital performance and ABCs.Results There were 214 children in the study group (56% were boys). Chest X-ray was performed in 95% of the children, while ABCs indicate 32.4% (OR=42; 95%CI [30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58]); viral testing in 67.9% children, whereas ABCs indicate 0.6% (OR=350; 95%CI [155-790]). Steroids were prescribed in 62% of the patients (ABCs=6.4%; OR=24; 95 %CI [18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31]), similarly antibiotics in 62% (ABCs=18.5%; OR=20; 95 %CI [1525]), bronchodilators were administered in 86% patients (ABCs=18.9%; OR=27; 95%CI [21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34]). All the analyzed procedures were used dozens of times more often than suggested by ABCs (the difference is highly statistically significant) ConclusionsOveruse of ineffective procedures and therapies in bronchiolitis remains common, with overuse of chest X-rays, viral testing, prescriptions of bronchodilators, corticosteroids and antibiotics. We should focus our efforts on strategies aimed at decreasing the procedures that have no benefit for children with bronchiolitis.

Evaluation of the quality of care of oncologic patients with pain in palliative and pain units based on the Achievable Benchmarks of Care (ABC): project 25Q

BackgroundCurrent guidelines on the management of cancer pain include information referred to integral patient management, in order to get an improvement in their quality of care. The assessment of compliance with the recommendations in daily practice constitutes a necessary feedback mechanism for consolidating theoretical recommendations. The objective of the study was to evaluate the fulfilment of quality of care recommendations for patients with cancer pain in real clinical practice.MethodsA retrospective observational study was designed. A total of 107 centres (81 pain units and 26 palliative care units) collected pooled information on 1605 patients.The study coordinating committee selected 12 structure and 13 process quality indicators based on the recommendations of different clinical practice guidelines. The process indicators were evaluated through the information obtained from 15 consecutively and retrospectively selected case histories. For each indicator, the participating physicians specified compliance or non-compliance, or whether the indicator measurement was not applicable to the reviewed patient. The degree of compliance with the recommendations on the management of patients with cancer pain was evaluated using the Achievable Benchmarks of Care (ABC)© (University of Alabama, Birmingham, AL, USA).ResultsMean compliance with all the indicators was 82.4% (95% CI 70.4–94.4). The ABC of the 13 process indicators selected for the study was 100%. No relevant differences were observed in the degree of compliance with the quality indicators between pain and palliative care units, or between geographical areas.ConclusionsThe selected recommendations are applicable to clinical practice and could be used to continuous evaluation of quality of care in patients with cancer. Compliance with the quality indicators in the participating units was very satisfactory.

Choosing Wisely Campaign: Report Card and Achievable Benchmarks of Care for Children’s Hospitals

Purpose In 2013 the Society of Hospital Medicine (SHM) responded to the 2012 Choosing Wisely Campaign (CWC) by releasing five recommendations to decrease overuse in common inpatient pediatric conditions. Our goals were to develop a Report Card (RC) based on those recommendations, calculate Achievable Benchmarks of Care (ABCs), and analyze performance among hospitals in the Pediatric Health Information System (PHIS) database of the Children’s Hospital …

Multisite Emergency Department Inpatient Collaborative to Reduce Unnecessary Bronchiolitis Care.

There is high variation in the care of acute viral bronchiolitis. We sought to promote collaboration between emergency department (ED) and inpatient (IP) units with the goal of reducing unnecessary testing and treatment. Multisite collaborative with improvement teams co-led by ED and IP physicians and a 1-year period of active participation. The intervention consisted of a multicomponent change package, regular webinars, and optional coaching. Data were collected by chart review for December 2014 through March 2015 (baseline) and December 2015 to March 2016 (improvement period). Patients <24 months of age with a primary diagnosis of bronchiolitis and without ICU admission, prematurity, or chronic lung or heart disease were eligible for inclusion. Control charts were used to detect improvement. Achievable benchmarks of care were calculated for each measure. Thirty-five hospitals with 5078 ED patients and 4389 IPs participated. Use of bronchodilators demonstrated special cause for the ED (mean centerline shift: 37.1%-24.5%, benchmark 5.8%) and IP (28.4%-17.7%, benchmark 9.1%). Project mean ED viral testing decreased from 42.6% to 25.4% after revealing special cause with a 3.9% benchmark, whereas chest radiography (30.9%), antibiotic use (6.2%), and steroid use (7.6%) in the ED units did not change. IP steroid use decreased from 7.2% to 4.0% after special cause with 0.0% as the benchmark. Within-site ED and IP performance was modestly correlated. Collaboration between ED and IP units was associated with a decreased use of unnecessary tests and therapies in bronchiolitis; top performers used few unnecessary tests or treatments.

Choosing Wisely Campaign: Report Card and Achievable Benchmarks of Care for Children's Hospitals.

In 2013, the Society of Hospital Medicine (SHM) released 5 pediatric recommendations for the Choosing Wisely Campaign (CWC). Our goals were to develop a report card on the basis of those recommendations, calculate achievable benchmarks of care (ABCs), and analyze performance among hospitals participating in the Pediatric Health Information System. Children hospitalized between January 2013 and September 2015 from 32 Pediatric Health Information System hospitals were studied. The quality metrics in the report card included the use of chest radiograph (CXR) in asthma and bronchiolitis, bronchodilators in bronchiolitis, systemic corticosteroids in lower respiratory tract infections (LRTI), and acid suppression therapy in gastroesophageal reflux (GER). ABCs were calculated for each metric. Calculated ABCs were 22.3% of patients with asthma and 19.8% of patients with bronchiolitis having a CXR, 17.9% of patients with bronchiolitis receiving bronchodilators, 5.5% of patients with LRTIs treated with systemic corticosteroids, and 32.2% of patients with GER treated with acid suppressors. We found variation among hospitals in the use of CXR in asthma (median: 34.7%, interquartile range [IQR]: 28.5%-45.9%), CXR in bronchiolitis (median: 34.4%, IQR: 27.9%-49%), bronchodilators in bronchiolitis (median: 55.4%, IQR: 32.3%-64.9%), and acid suppressors in GER (median: 59.4%, IQR: 49.9%-71.2%). Less variation was noted in the use of systemic corticosteroids in LRTIs (median: 13.5%, IQR: 11.1%-17.9%). A novel report card was developed on the basis of the SHM-CWC pediatric recommendations, including ABCs. We found variance in practices among institutions and gaps between hospital performances and ABCs. These findings represent a roadmap for improvement.

Abstract TMP62: Achievable Benchmarks for Quality of Care in the Coverdell Acute Stroke Program

Introduction: The value of setting performance benchmarks for quality improvement projects remains unclear. The Achievable Benchmarks of Care (ABC™) methodology has been proposed as an objective, reproducible, and data-driven approach, but it has not been widely utilized in stroke registries. We applied the ABC™ methodology to set benchmarks using data from the Coverdell stroke registry. Methods: Data were from Paul Coverdell National Acute Stroke Program from 2012-2014. Adherence data were calculated on 14 quality measures including tPA related treatment, hospital care, and discharge care. We applied the ABCTM methodology by first ranking hospitals in descending order of performance for each quality measure. We then calculated the pared mean performance associated with patients selected from these hospitals representing the top 10% and 50% of patients. Results: A total of 170 402 acute ischemic strokes from 465 hospitals in 11 states were included. The Figure shows overall 10% and 50% benchmarks (BM) for the 14 quality measures. BMs were high (&gt;90%) for 12 of the 14 measures. Two measures with lower performance were tPA administered among all ischemic stroke patients, and door to needle (DTN) &lt; 60 minutes. However, both measures improved significantly over time. The 10% BM for tPA administration improved from 28% in 2012 to 30% in 2014, while the 10% BM for DTN within 60 minutes improved from 82% in 2012 to 90% in 2014. Conclusions: The ABC™ methodology provides an objective method of calculation BMs for care. These data illustrate that BMs are already high for the majority of the quality measures tracked in the registry. Further analyses are ongoing to determine the acceptability of using these BMs to promote further improvements in care across the Coverdell Program.

Establishing benchmarks for the hospitalized care of children with asthma, bronchiolitis, and pneumonia.

Asthma, pneumonia, and bronchiolitis are the leading causes of admission for pediatric patients; however, the lack of accepted benchmarks is a barrier to quality improvement efforts. Using data from children hospitalized with asthma, bronchiolitis, or pneumonia, the goals of this study were to: (1) measure the 2012 performance of freestanding children's hospitals using clinical quality indicators; and (2) construct achievable benchmarks of care (ABCs) for the clinical quality indicators. This study was a cross-sectional trial using the Pediatric Health Information System database. Patient inclusions varied according to diagnosis: asthma (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 493.0-493.92) from 2 to 18 years of age; bronchiolitis (ICD-9-CM codes 466.11 and 466.19) from 2 months to 2 years of age; and pneumonia (ICD-9-CM codes 480-486, 487.0) from 2 months to 18 years of age. ABC methods use the best-performing hospitals that comprise at least 10% of the total population to compute the benchmark. Encounters from 42 hospitals included: asthma, 22186; bronchiolitis, 14882; and pneumonia, 12983. Asthma ABCs include: chest radiograph utilization, 24.5%; antibiotic administration, 6.6%; and ipratropium bromide use >2 days, 0%. Bronchiolitis ABCs include: chest radiograph utilization, 32.4%; viral testing, 0.6%; antibiotic administration, 18.5%; bronchodilator use >2 days, 11.4%; and steroid use, 6.4%. Pneumonia ABCs include: complete blood cell count utilization, 28.8%; viral testing, 1.5%; initial narrow-spectrum antibiotic use, 60.7%; erythrocyte sedimentation rate, 3.5%; and C-reactive protein, 0.1%. We report achievable benchmarks for inpatient care for asthma, bronchiolitis, and pneumonia. The establishment of national benchmarks will drive improvement at individual hospitals.

Paying physician group practices for quality: A statewide quasi-experiment

This article presents the results of a unique quasi-experiment of the effects of a large-scale pay-for-performance (P4P) program implemented by a leading health insurer in Washington state during 2001–2007. The authors received external funding to provide an objective impact evaluation of the program. The program was unique in several respects: (1) It was designed dynamically, with two discrete intervention periods—one in which payment incentives were based on relative performance (the “contest” period) and a second in which payment incentives were based on absolute performance compared to achievable benchmarks. (2) The program was designed in collaboration with large multispecialty group practices, with an explicit run-in period to test the quality metrics. Public reporting of the quality scorecard for all participating medical groups was introduced 1 year before the quality incentive payment program's inception, and continued throughout 2002–2007. (3) The program was implemented in stages with distinct medical groups. A control group of comparable group practices also was assembled, and difference-in-differences methodology was applied to estimate program effects. Case mix measures were included in all multivariate analyses.The regression design permitted a contrast of intervention effects between the “contest” approach in the sub-period of 2003–2004 and the absolute standard, “achievable benchmarks of care” approach in sub-period 2005–2007. Most of the statistically significant quality incentive program coefficients were small and negative (opposite to program intent). A consistent pattern of differential intervention impact in the sub-periods did not emerge.Cumulatively, the probit regression estimates indicate that neither the quality scorecard nor the quality incentive payment program had a significant positive effect on general clinical quality. Based on key informant interviews with medical leaders, practicing physicians, and administrators of the participating groups, the authors conclude that several factors likely combined to dampen program effects: (1) modest size of the incentive; (2) use of rewards only, rather than a balance of rewards and penalties; (3) targeting incentive payments to the group, thus potentially weakening incentive effects at the individual level.

Evaluation of Compliance with the EGS Guidelines in Spain, Using Achievable Benchmarks of Care (ABC®) methodology: The IMCA Study

To evaluate compliance with diagnostic and therapeutic recommendations of the European Glaucoma Society (EGS) for the management of glaucoma in Spain, as determined using the Achievable Benchmarks of Care approach. A panel of 3 experts extracted quality and process-of-care indicators from the EGS guidelines. Investigators from all over the country, representative of Spanish ophthalmologists, were invited to participate in the study, completing a questionnaire on quality indicators (pertaining to the center) and process-of-care indicators (pertaining to all patients) for the first, diagnostic visit (retrospective) and the study visit. A total of 495 Spanish ophthalmologists included 5,060 patients with glaucoma or intraocular hypertension. The treatment was initiated with monotherapy in 88.5% of the patients. Overall, the percentage compliance with diagnostic examinations was 84.6% for intraocular pressure measurement, 96.3% for optic nerve head evaluation, 76.6% for visual field evaluation, 29.5% for central corneal thickness evaluation, and 49.3% at the study visit. The benchmark performance was close to 100% for most examinations. Only 32.8% of the centres had a written protocol for the management of the patients with glaucoma, and in these centers the recommendations of the EGS were followed in a higher proportion (p<0.0001) than in the rest. The use of local protocols for the management of glaucoma seems to enhance compliance. Benchmark performance was close to 100% in most indicators, suggesting that EGS recommendations are attainable in Spain. The overall performance suggests that certain diagnostic procedures are, in practice, not as widely used as recommended.

Impact of Case Volume on Hospital Performance Assessment

Process performance measures are increasingly used to assess and reward hospital quality. The impact of small hospital case volumes on such measures is not clear. Using data from the Hospital Quality Alliance, we examined hospital performance for 8 publicly reported process measures for acute myocardial infarction (AMI) from 3761 US hospitals during the reporting period of January to December 2005. For each performance measure, we examined the association between hospital case volume, process performance, and designation as a "top hospital" (performance at or above the 90% percentile score). Sample sizes available for process performance assessment varied considerably, ranging from a median of 3 patients per hospital for timely administration of thrombolytics therapy to 62 patients for aspirin given on arrival at the hospital. In aggregate, hospitals with larger AMI case volumes had better process performance; for example, use of beta-blockers at arrival rose from 72% of patients at hospitals with less than 10 AMI cases to 80% of patients at hospitals with more than 100 cases (P < .001 for volume trend). In contrast, owing to an artifact of wide sampling variation in sites with small denominators, classification of a center as a top hospital actually declined rapidly with increasing case volume using current analytic methods (P < .001). This unexpected association persisted after excluding very low volume centers (<25 cases) and when using Achievable Benchmarks of Care. Using hierarchical models removed the paradoxical association but may have introduced a bias in the opposite direction. Large-volume hospitals had better aggregate performance but were less likely to be identified as top hospitals. Methods that account for small and unequal denominators are needed when assessing hospital process measure performance.

Introduction of complementary foods to the infant diet within the first year of life: evaluation of general recommendations using Achievable Benchmarks of Care®

The primary objective of the present study was to assess the effect of DHA and arachidonic acid (ARA) supplementation of infant formulas on the incidence of respiratory illnesses during the first year of life. Enrolment for this multicentre prospective open-label 12-month observational study was conducted from 2002 to 2003 and included 1392 children from 357 Spanish paediatricians (the GENERACION Study Group). Infants were assigned in the proportion 4.4 :1 to receive a formula supplemented with 3.2 g DHA and 6.4 g ARA/kg or a low or non-supplemented control formula. Eligible infants were healthy, born at a gestational age that exceeded 36 weeks and non-breast-fed. Infants were to visit the paediatrician at baseline and months 1, 3, 5, 7, 9, and 12. At each subsequent visit records were taken of: anthropometric measurements; month of introduction for gluten-free cereal, gluten, fruits, vegetables, meat, fish, egg yolk, whole egg, cow's milk and legumes; the occurrence of clinical symptoms associated with common ailments in infancy. Results of the main objective have been published elsewhere (1,2) , and showed a significantly lower incidence of bronchitis or bronchiolitis in DHA + ARA-fed children. The secondary objective was to determine the adherence to paediatricians' recommendations to guidelines (3,4) on the introduction of complementary foods to the infant's diet. Achievable Benchmarks of Care (ABC) 1 ratios were also calculated to determine the standards of excellence attained by the 10 % of top performers (5) and identify areas for improving adherence to guidelines on the introduction of complementary foods (6) . The Table summarizes the findings from the study. Overall, the adherence was appropriate for most recommendations, but some recommendations need to be reinforced, such as the introduction of fruits, fish, cow's milk and legumes.

Achievable Benchmarks of Care for Primary Care Quality Indicators in a Practice-Based Research Network

A number of sources publish health care quality reports in the United States, but there is limited information about achievable performance in primary care settings. The objective of this article is to report Achievable Benchmarks of Care (ABCs) for 54 quality indicators. Eighty-seven practices participating in a demonstration project in the Practice Partner Research Network (PPRNet), representing 35 US states and 711 969 patients, were included in the analyses. PPRNet practices use a common electronic medical record (Practice Partner, Seattle, Washington). ABCs ranged from 25% to 99%. High ABCs (> or =90%) were achieved for blood pressure screening, lipid screening, and avoiding antibiotics in upper respiratory infection. Some calculated ABCs may be lower than the actual ABCs due to incomplete data recording or abstracting. Primary care practices can achieve high performance across a number of quality indicators, and PPRNet ABCs can serve as benchmarks for primary care practitioners and payers.