Care Performance Measures Research Articles

Prioritizing and Implementing Primary Care Performance Measures for Ontario.

In the fall of 2014, Health Quality Ontario1 released A Primary Care Performance Measurement Framework for Ontario. Recognizing the large number of recommended measures and the limited availability of data related to those measures, the Steering Committee for the Primary Care Performance Measurement (PCPM) initiative established a prioritization process to select two subsets of high-value performance measures – one at the system level and one at the practice level. This article describes the prioritization process and its results and outlines the initiatives that have been undertaken to date to implement the PCPM framework and to advance primary care performance measurement and reporting in Ontario. Establishing a framework for primary care measurement and prioritizing system- and practice-level measures are essential steps toward system improvement. Our experience suggests that the process of implementing a performance measurement system is inevitably non-linear and incremental.

Social Risk Adjustment in Health Care Performance Measures

Social Risk Adjustment in Health Care Performance Measures

Selecting Patient-Reported Outcome Measures to Contribute to Primary Care Performance Measurement: a Mixed Methods Approach.

New models of primary care include patient-reported outcome measures (PROMs) to promote patient-centered care. PROMs provide information on patient functional status and well-being, can be used to enhance care quality, and are proposed for use in assessing performance. Our objective was to identify a short list of candidate PROMs for use in primary care practice and to serve as a basis for performance measures (PMs). We used qualitative and quantitative methods to identify relevant patient-reported outcome (PRO) domains for use in performance measurement (PRO-PM) and their associated PROMs. We collected data from key informant groups: patients (n = 13; one-on-one and group interviews; concept saturation analysis), clinical thought leaders (n = 9; group discussions; thematic analysis), primary care practices representatives (n = 37; six focus groups; thematic analysis), and primary care payer representatives (n = 10; 12-question survey; frequencies of responses). We merged the key informant group information with findings from environmental literature scans. We conducted a targeted evidence review of measurement properties for candidate PROMs. We used a scoping review and key informant groups to identify PROM evaluation criteria, which were linked to the National Quality Forum measure evaluation criteria. We developed a de novo schema to score candidate PROMs against our criteria. We identified four PRO domains and 10 candidate PROMs: 3 for depressive symptoms, 2 for physical function, 3 for self-efficacy, 2 for ability to participate. Five PROMs met ≥ 70% of the evidence criteria for three PRO domains: PHQ-9 or PROMIS Depression (depression), PF-10 or PROMIS-PF (physical functioning), and PROMIS Self-Efficacy for Managing Treatments and Medications (self-efficacy). The PROMIS Ability to Participate in Social Roles and Activities met 68% of our criteria and might be considered for inclusion. Existing evidence and key informant data identified 5 candidate PROMs to use in primary care. These instruments can be used to develop PRO-PMs.

Does Provider Gender Affect the Quality of Primary Care?

Women providers have a more patient-centered communication style than men, and some studies have found women primary care providers are more likely to meet quality performance measures. To explore gender differences in the quality of primary care process and outcome measures. Retrospective analysis of primary care performance data from 1year (2018-2019). A total of 586 primary care providers (311 women and 275 men) who cared for 241,428 primary care patients at 96 primary care clinics at 8 Veterans Affairs (VA) medical centers. Our primary outcome was a composite quality measure that averaged all thirty-four primary care performance measures that assessed performance in cancer screening, diabetes care, cardiovascular care, tobacco counseling, risky alcohol screening, immunizations, HIV testing, opiate care, and continuity. Our secondary outcomes were performance on each of the 34 measures. There was no difference in the average performance on our composite measure between men and women (75.8% vs. 76.6%, p = 0.17). Among the 34 primary care quality measures collected, there was no difference between male and female providers' performance. Using a more conservative cut-point, women were more likely to screen at-risk diabetic patients for hypoglycemia and document follow-up on risky alcohol behavior noted during patient check-in. These differences were clinically small and likely due to chance, given the multiple measures evaluated in this study. We found little evidence of difference in the performance on primary care quality measures between male and female providers.

The NQF Scientific Methods Panel

In the summer of 2017, the National Quality Forum (NQF) announced the formation of a Scientific Methods Panel (hereafter referred to as "the Panel") as part of a redesign of its endorsement process. NQF created the Panel in response to stakeholder request during a Kaizen improvement event held in May 2017. Given the Panel's role in the endorsement of performance measures used in national payment programs, the objective of this article is to describe the work of the Panel, and to describe its function in the larger context of the NQF measure endorsement process and in the measurement enterprise writ large. This article also serves as an introduction to a series of planned white papers being authored by the panel on specific technical issues in the area of health care performance measurement.

Association Between HEDIS Performance and Primary Care Physician Age, Group Affiliation, Training, and Participation in ACA Exchanges.

There are a limited number of studies investigating the relationship between primary care physician (PCP) characteristics and the quality of care they deliver. To examine the association between PCP performance and physician age, solo versus group affiliation, training, and participation in California's Affordable Care Act (ACA) exchange. Observational study of 2013-2014 data from Healthcare Effectiveness Data and Information Set (HEDIS) measures and select physician characteristics. PCPs in California HMO and PPO practices (n = 5053) with part of their patient panel covered by a large commercial health insurance company. Hemoglobin A1c testing; medical attention nephropathy; appropriate treatment hypertension (ACE/ARB); breast cancer screening; proportion days covered by statins; monitoring ACE/ARBs; monitoring diuretics. A composite performance measure also was constructed. For the average 35- versus 75-year-old PCP, regression-adjusted mean composite relative performance scores were at the 60th versus 47th percentile (89% vs. 86% composite absolute HEDIS scores; p < .001). For group versus solo PCPs, scores were at the 55th versus 50th percentiles (88% vs. 87% composite absolute HEDIS scores; p < .001). The effect of age on performance was greater for group versus solo PCPs. There was no association between scores and participation in ACA exchanges. The associations between population-based care performance measures and PCP age, solo versus group affiliation, training, and participation in ACA exchanges, while statistically significant in some cases, were small. Understanding how to help older PCPs excel equally well in group practice compared with younger PCPs may be a fruitful avenue of future research.

Clinical Performance Measures for Neurocritical Care: A Statement for Healthcare Professionals from the Neurocritical Care Society.

Performance measures are tools to measure the quality of clinical care. To date, there is no organized set of performance measures for neurocritical care. The Neurocritical Care Society convened a multidisciplinary writing committee to develop performance measures relevant to neurocritical care delivery in the inpatient setting. A formal methodology was used that included systematic review of the medical literature for 13 major neurocritical care conditions, extraction of high-level recommendations from clinical practice guidelines, and development of a measurement specification form. A total of 50,257 citations were reviewed of which 150 contained strong recommendations deemed suitable for consideration as neurocritical care performance measures. Twenty-one measures were developed across nine different conditions and two neurocritical care processes of care. This is the first organized Neurocritical Care Performance Measure Set. Next steps should focus on field testing to refine measure criteria and assess implementation.

Primary care performance of alternatively licenced physicians in Ontario, Canada: a cross-sectional study using administrative data

ObjectivesMedical Regulatory Authorities (MRAs) provide licences to physicians and monitor those physicians once in practice to support their continued competence. In response to physician shortages, many Canadian MRAs developed alternative...

Identification and ranking of specific balanced scorecard performance measures for hospitals: A case study of private hospitals in the Klang Valley area, Malaysia.

Performance measurement is a necessity for private hospitals as they need to be efficient, attract customers, increase profitability, and survive in the competitive environment of the health care industry. Hospitals typically struggle to identify appropriate performance measures because of lack of reliable source of performance measures for private hospitals. Despite numerous studies on performance measurement, few studies have focused on performance measures in private hospitals. This paper aims to fill that gap by identifying and ranking a specific set of performance measures that are feasible and relevant for private hospitals. Forty-four health care performance measures in four balanced scorecard (BSC) performance perspectives (financial, customer, internal business processes, and learning and growth) were compiled and filtered based on "feasibility" and "relevance" criteria using a questionnaire survey in private hospitals in the Klang Valley area, Malaysia. Since all collected data were in numeric format, data analysis was performed quantitatively. Consequently, 31 BSC performance measures were identified for private hospitals. Next, the 31 performance measures went through a ranking survey in Klang Valley private hospitals. Therefore, a weight between 0 and 1 with a range of 0.095 to 0.207 was obtained for each performance measure to help hospitals quantify their overall performance more accurately.

What's Driving High Disenrollment in Medicare Advantage?

Disenrollment rates are one way that policy makers assess the performance of Medicare Advantage (MA) health plans. We use 3 years of data published by the Centers for Medicare & Medicaid Services (CMS) to examine the characteristics of MA contracts with high disenrollment rates from 2015 to 2017 and the relationship between disenrollment rates in MA contracts and 6 patient experiences of care performance measures. We find that MA contracts with high disenrollment rates were significantly more likely to be for-profit, small, and enroll a greater proportion of low-income and disabled individuals. After adjusting for plan characteristics, contracts with the highest levels of disenrollment were statistically significantly more likely to perform poorly on all 6 patient experience measures. CMS should consider additional oversight of MA contracts with high levels of disenrollment and consider publishing disenrollment rates at the plan level instead of at the contract level.

An on-site health home for homeless men in addiction recovery.

Patients with comorbid substance abuse, mental health disorders, and chronic health conditions face difficult challenges when attempting to access health care. A large gospel rescue mission developed an onsite wellness center, based on an integrated, embedded practice health home model, to promote health care access among homeless men in addiction recovery. The center model integrated primary care with behavioral health, specialty care referrals, and wellness services to address the multifaceted needs of the population. Standardized health care performance measures and resident and staff feedback support the effectiveness of the model in promoting improved health care access and treatment adherence. Future directions for program expansion include infrastructure development, expanded community outreach, and evaluation of effectiveness of the onsite health home through systematic program evaluation and research.

Governance and performance measurement in integrated care. An Evidence Based Integrated Care Approach

Introduction: Healthcare institutions in The Netherlands are faced with the facts of increasing extent of internal and external accountability. This is related to the fact that healthcare institutions and their professionals are obliged to register a full set of indicators which are required input to effect this accountability. This is also known as governance. One of the definitions is: to control and to account for Minderman 2008 or controlling accountability Hoek 2007. On the one side in integrated care, care pathways are characterized by the delivery of care interventions proof of concept and on the other side pathways are characterized by the organization of the delivery of care interventions proof in context. Both concept and context of care are related to governance and performance measurement in healthcare. In general governance in healthcare in The Netherlands focuses on control, accountability and controlling the boards, mostly within one care organisation. However in integrated care governance and performance measurement should ideally be on cooperation and trust between the organizations. Governance therefore includes various forms of accountability, concerning several areas: from government national and local, to organizations and commissioners, to organizations and their supervisory boards, to organizations and their financiers and the patient. Healthcare organisations must be accountable to e.g.: The Dutch Healthcare Inspectorate, The care insurance companies and The National Healthcare Institute. Furthermore, healthcare institutions have to account for their efforts to deliver quality of healthcare. The way this is done is through a system administrating their internal performance indicators. In this respect, one can ask how indicators are administrated within healthcare organisations and how external accountability is designed. Different gaps of governance and accountability can thus be found e.g.: A gap between what accountancy data in care institutions is collected, their network and what is externally justified to the involved parties. The gap between governance and is the ones accountable to people and municipals are involved in decentralization. Gap of citizens and governance. Theory/Methods: A systematic review of literature on what is the current knowledge on governance in integrated care, and an extensive case study which will be conducted in Dutch healthcare organisations and healthcare network organisations. One of the characteristics of case study method is: a narrow domain with several research units, in depth rather than a broad view, the supposed concerns in many cases the entire research area instead of a few variables like in a survey study. Discussion: What should governance as an accountability tool look like within the context of evidence-based integrated care and what knowledge is gained and how can this knowledge be used to meet accountability issues?

Quality assessment of linked Canadian clinical administrative hospital and vital statistics death data

IntroductionThree Canadian clinical-administrative hospital databases were linked to the Canadian Vital Statistics Death Database (CVSD) to provide information about patients who died following discharge from hospital as well as supplementary information about patients that died in-hospital. Quality was assessed using a guided approach and through feedback from initial users.&#x0D; Objectives and ApproachThe linked datasets were created to develop and validate health care indicators and performance measures and perform outcome analyses. It is therefore imperative to evaluate the data’s fitness for use. Quality was assessed by calculating coverage of deaths for all linked contributors, creating a profile of the linked dataset and analyzing issues that were identified by users. These analyses were guided by an existing Data Source Assessment Tool, which provides a set of criteria that allow for assessment across five dimensions of quality, thus allowing for appropriate determination of a given set of data’s fitness for use.&#x0D; ResultsDeterministic linkage of the datasets resulted in linkage rates that ranged from 66.9% to 90.9% depending on the dataset or data year. Linkage rates also varied by Canadian jurisdictions and patient cohort. Variables had good data availability with rates of 95% or higher. Initial users identified a significant number of duplicate records that were flagged to and corrected by the data supplier. 1.4\% of acute hospital deaths had discrepancies in the death date captured in the two linked sources; the vast majority had a difference of only one day. A user group and issue tracking process were created to share information about the linked data and guarantee that issues are triaged to the appropriate party and allow for timely follow up with the data supplier.&#x0D; Conclusion/ImplicationsDocumentation provided by the data supplier was vital to understanding the linkage methodology and its impact on linkage rates. A guided data assessment ensured that strengths and limitations were identified and shared to support appropriate use. Feedback to the data supplier is supporting ongoing improvements to the linkage methodology.

Vaccination Trends in Patients With Heart Failure: Insights From Get With The Guidelines–Heart Failure

ObjectivesThis study sought to evaluate and contribute to the limited data on U.S. hospital practice patterns with respect to respiratory vaccination in patients hospitalized with heart failure (HF). BackgroundRespiratory infection is a major driver of morbidity in patients with HF, and many influenza and pneumococcal infections may be prevented by vaccination. MethodsThis study evaluated patients hospitalized at centers participating in the Get With The Guidelines–HF (GWTG-HF) registry from October 2012 to March 2017. The proportion of patients receiving vaccination was described for influenza and pneumococcal vaccination, respectively. The association of hospital-level vaccination rates with individual GWTG-HF performance measures and defect-free care was evaluated using multivariable modeling. ResultsThis study evaluated 313,761 patients discharged from 392 hospitals during the study period. The proportion of patients receiving influenza vaccination was 68% overall and declined from 70% in 2012 to 2013 to 66% in 2016 to 2017 (p < 0.001), although this was not statistically significant after adjustment (odds ratio: 1.05 per flu season; 95% confidence interval [CI]: 0.94 to 1.18). The proportion of patients receiving pneumococcal vaccination was 66% overall and decreased over the study period from 71% in 2013 to 60% in 2016 (p < 0.001), remaining significant after adjustment (odds ratio: 0.75 per calendar year; 95% CI: 0.67 to 0.84). Hospitals with higher vaccination rates were more likely to discharge patients with higher performance on defect-free care and individual GWTG-HF performance measures (p < 0.001). In a subset of patients with linked Medicare claims, vaccinated patients had similar rates of 1-year all-cause mortality (adjusted hazard ratio: 0.96 [95% CI: 0.89 to 1.03] for influenza vaccination; adjusted hazard ratio: 0.95 [95% CI: 0.89 to 1.01] for pneumococcal vaccination) compared with those not vaccinated. ConclusionsNearly 1 in 3 patients hospitalized with HF at participating hospitals were not vaccinated for influenza or pneumococcal pneumonia, and vaccination rates did not improve from 2012 to 2017. Hospitals that exhibited higher vaccination rates performed well with respect to other HF quality of care measures. Vaccination status was not associated with differences in clinical outcomes. Further randomized controlled data are needed to assess the relationship between vaccination and outcomes.

Quality Indicators for Evaluating Prehospital Emergency Care: A Scoping Review.

A scoping review was conducted through a search of PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA); EMBase (Elsevier; Amsterdam, Netherlands); CINAHL (EBSCO Information Services; Ipswich, Massachusetts USA); Web of Science (Thomson Reuters; New York, New York USA); and the Cochrane Library (The Cochrane Collaboration; Oxford, United Kingdom). To increase the sensitivity of the literature, a search of the grey literature and review of select websites was additionally conducted. Articles were selected that proposed at least one PEC QI and whose aim was to discuss, analyze, or promote quality measurement in the PEC environment. The majority of research (n=25 articles) was published within the last decade (68.0%) and largely originated within the USA (68.0%). Delphi and observational methodologies were the most commonly employed for QI development (28.0%). A total of 331 QIs were identified via the article review, with an additional 15 QIs identified via the website review. Of all, 42.8% were categorized as primarily Clinical, with Out-of-Hospital Cardiac Arrest contributing the highest number within this domain (30.4%). Of the QIs categorized as Non-Clinical (57.2%), Time-Based Intervals contributed the greatest number (28.8%). Population on Whom the Data Collection was Constructed made up the most commonly reported QI component (79.8%), followed by a Descriptive Statement (63.6%). Least reported were Timing of Data Collection (12.1%) and Timing of Reporting (12.1%). Pilot testing of the QIs was reported on 34.7% of QIs identified in the review. Overall, there is considerable interest in the understanding and development of PEC quality measurement. However, closer attention to the details and reporting of QIs is required for research of this type to be more easily extrapolated and generalized. Howard I , Cameron P , Wallis L , Castren M , Lindstrom V . Quality indicators for evaluating prehospital emergency care: a scoping review. Prehosp Disaster Med. 2018;33(1):43-52.

Performance Measures for Contraceptive Care: A New Tool to Enhance Access to Contraception.

Contraception is an essential health service for reducing unintended pregnancy rates, improving health outcomes, and reducing health care costs. However, contraceptive services may not consistently provide access to the full method mix and to patient-centered care. Improving the quality of contraceptive care is a critical strategy to improve contraceptive use, health outcomes, and the patient experience of care. We here describe the three National Quality Forum-endorsed performance measures for contraceptive care, which are intended to monitor 1) provision of most and moderately effective methods, 2) access to long-acting reversible contraception, and 3) provision of most and moderately effective methods and access to long-acting reversible contraception after childbirth. These contraceptive care measures are designed to ensure that contraceptive care is accessible and offers the full spectrum of methods. Payers, health care systems, public agencies, and researchers could all monitor these performance measures for different populations. We describe the crucial role of clinicians in disseminating and using the contraceptive care performance measures for quality improvement. We describe ongoing efforts to improve contraceptive care quality, including the development of measures to monitor other dimensions of quality such as the safety and patient-centeredness of care. Thirty-eight million women at risk of unintended pregnancy are counting on us to improve the quality of family planning care in the United States and ensure that all women have the resources and tools to make free, informed choices about whether and when to become pregnant.

NFPRHA commentary on the contraceptive care performance measures

NFPRHA commentary on the contraceptive care performance measures

From theory to application: using performance measures for contraceptive care in the Title X family planning program

ObjectiveThe objective was to describe a Performance Measure Learning Collaborative (PMLC) designed to help Title X family planning grantees use new clinical performance measures for contraceptive care. Study designTwelve Title X grantee‐service site teams participated in an 8-month PMLC from November 2015 to June 2016; baseline was assessed in October 2015. Each team documented their selected best practices and strategies to improve performance, and calculated the contraceptive care performance measures at baseline and for each of the subsequent 8 months. ResultsPMLC sites implemented a mix of best practices: (a) ensuring access to a broad range of methods (n=7 sites), (b) supporting women through client-centered counseling and reproductive life planning (n=8 sites), (c) developing systems for same-day provision of all methods (n=10 sites) and (d) utilizing diverse payment options to reduce cost as a barrier (n=4 sites). Ten sites (83%) observed an increase in the clinical performance measures focused on most and moderately effective methods (MME), with a median percent change of 6% for MME (from a median of 73% at baseline to 77% post-PMLC). ConclusionEvidence suggests that the PMLC model is an approach that can be used to improve the quality of contraceptive care offered to clients in some settings. Further replication of the PMLC among other groups and beyond the Title X network will help strengthen the current model through lessons learned. ImplicationsUsing the performance measures in the context of a learning collaborative may be a useful strategy for other programs (e.g., Federally Qualified Health Centers, Medicaid, private health plans) that provide contraceptive care. Expanded use of the measures may help increase access to contraceptive care to achieve national goals for family planning.

Feasibility of and Rationale for the Collection of Orthopaedic Trauma Surgery Quality of Care Metrics.

Reproducible metrics are needed to evaluate the delivery of orthopaedic trauma care, national care, norms, and outliers. The American College of Surgeons (ACS) is uniquely positioned to collect and evaluate the data needed to evaluate orthopaedic trauma care via the Committee on Trauma and the Trauma Quality Improvement Project. We evaluated the first quality metrics the ACS has collected for orthopaedic trauma surgery to determine whether these metrics can be appropriately collected with accuracy and completeness. The metrics include the time to administration of the first dose of antibiotics for open fractures, the time to surgical irrigation and débridement of open tibial fractures, and the percentage of patients who undergo stabilization of femoral fractures at trauma centers nationwide. These metrics were analyzed to evaluate for variances in the delivery of orthopaedic care across the country. The data showed wide variances for all metrics, and many centers had incomplete ability to collect the orthopaedic trauma care metrics. There was a large variability in the results of the metrics collected among different trauma center levels, as well as among centers of a particular level. The ACS has successfully begun tracking orthopaedic trauma care performance measures, which will help inform reevaluation of the goals and continued work on data collection and improvement of patient care. Future areas of research may link these performance measures with patient outcomes, such as long-term tracking, to assess nonunion and function. This information can provide insight into center performance and its effect on patient outcomes. The ACS was able to successfully collect and evaluate the data for three metrics used to assess the quality of orthopaedic trauma care. However, additional research is needed to determine whether these metrics are suitable for evaluating orthopaedic trauma care and cutoff values for each metric.

Establishing a Primary Care Performance Measurement Framework for Ontario

A systematic approach to Primary Care Performance Measurement is needed to provide useful information on a regular basis to inform planning, management and quality improvement at both the practice and system levels. Based on an environmental scan, a summit of primary care stakeholders and a stakeholder survey and supported by Measures and Technical Working Groups, the Ontario Primary Care Performance Measurement Steering Committee, representing 20 stakeholder organizations, identified system- and practice-level measurement priorities and related specific performance measures across nine domains of primary care performance. This initiative addressed measures' selection and technical specification. It did not include data collection. Lessons learned in Ontario can assist other jurisdictions developing frameworks for monitoring and reporting on primary care performance. Cross-country alignment could lead to a coordinated approach to measure and target areas for primary care performance improvement in Canada.