Clinical Performance Measures Research Articles

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.

Health Information Technology Adoption and Clinical Performance in Federally Qualified Health Centers.

A national sample (N = 982) of federally qualified health centers (FQHCs) for the period 2011-2016 was examined regarding the relationship between the age and extent of health information technology (HIT) use and clinical performance. We found that each additional year of HIT use was associated with an approximate 4 percent increase in both process and outcome measures of clinical performance. Furthermore, FQHCs that fully adopted HIT had 7 percent higher clinical performance on hypertension control than those that did not adopt HIT. This study's findings can assist stakeholders to make informed decisions for improving care and sustaining a competitive advantage.

2019 AHA/ACC Clinical Performance and Quality Measures for Adults With High Blood Pressure: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures.

HomeCirculation: Cardiovascular Quality and OutcomesVol. 12, No. 112019 AHA/ACC Clinical Performance and Quality Measures for Adults With High Blood Pressure: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures

An Atrial Fibrillation Transitions of Care Clinic Improves Atrial Fibrillation QualityMetrics.

This study sought to assess whether an atrial fibrillation (AF)-specific clinic is associated with improved adherence to American College of Cardiology (ACC)/American Heart Association (AHA) clinical performance and quality measures for adults with AF or atrial flutter. There are significant gaps in care of patients with AF, including underprescription of anticoagulation and treatment of AF risk factors. An AF specialized clinic was developed to reduce admissions for AF but may also be associated with improved quality of care. This retrospective study compared adherence to ACC/AHA measures for patients who presented to the emergency department for AF between those discharged to a typical outpatient appointment and those discharged to a specialized AF transitions clinic run by an advanced practice provider and supervised by a cardiologist. Screening and treatment for common AF risk factors was also assessed. The study enrolled 78 patients into the control group and 160 patients into the intervention group. Patients referred to the specialized clinic were more likely to have stroke risk assessed and documented (99% vs. 26%; p<0.01); be prescribed appropriate anticoagulation (97% vs. 88%; p=0.03); and be screened for comorbidities such as tobacco use (100% vs. 14%; p<0.01), alcohol use (92% vs. 60%; p<0.01), and obstructive sleep apnea (90% vs. 13%; p<0.01) and less likely to be prescribed an inappropriate combination of anticoagulant and antiplatelet medications (1%vs. 9%; p<0.01). An AF specialized clinic was associated with improved adherence to ACC/AHA clinical performance and quality measures for adult patients with AF.

More than a cultural experience: Assessing the impact of a medical-surgical international clinical on nursing students' academic performance

A review of the extant literature suggests that there remains a dearth of evidence regarding the evaluation of well-defined outcomes related to international nursing clinical experiences. The purpose of this study was to explore the relationship between students' clinical experience (traditional versus international) and a number of academic outcomes including final medical-surgical course grades, performance on relevant Assessment Technologies Institute (ATI) proctored exams, and National Council Licensure Examination (NCLEX) pass rates. A non-experimental design was implemented using retrospective data obtained from a small university in the Midwest. Students complete a medical-surgical clinical in India during the interim of their third semester in the nursing program. Results of the t-tests show a statistically significant difference in final grades for Adult Health II theory when comparing students who completed a traditional clinical (M = 83.1, SD = 3.8) with those who completed an international clinical (M = 81.6, SD = 5.2); t(100) = 2.0, p = .043. The difference in mean scores for traditional clinical students (M = 70.3, SD = 6.6) versus international clinical students (M = 66.2, SD = 7.2) for the Adult Medical-Surgical proctored exam reached statistical significance, t(119) = 4.5, p ≤ .001. In contrast, there was no significant difference in means scores between the two groups with regard to scores on the Comprehensive Predictor proctored exam (traditional clinical, M = 76.1, SD = 5.9; international clinical, M = 75.2, SD = 6.4); t(121) = 1.0, p = .316. Finally, a chi square test of independence found that the relationship between clinical status and performance on NCLEX was not statistically significant, χ2 (1, N = 197) = 0.132, p = .716. Further research is needed to examine the impact of international clinicals on a broader range of outcomes including academic, cultural competency, and clinical performance measures.

Heart Rate and Heart Rate Variability Correlate with Clinical Reasoning Performance and Self-Reported Measures of Cognitive Load

Cognitive load is a key mediator of cognitive processing that may impact clinical reasoning performance. The purpose of this study was to gather biologic validity evidence for correlates of different types of self-reported cognitive load, and to explore the association of self-reported cognitive load and physiologic measures with clinical reasoning performance. We hypothesized that increased cognitive load would manifest evidence of elevated sympathetic tone and would be associated with lower clinical reasoning performance scores. Fifteen medical students wore Holter monitors and watched three videos depicting medical encounters before completing a post-encounter form and standard measures of cognitive load. Correlation analysis was used to investigate the relationship between cardiac measures (mean heart rate, heart rate variability and QT interval variability) and self-reported measures of cognitive load, and their association with clinical reasoning performance scores. Despite the low number of participants, strong positive correlations were found between measures of intrinsic cognitive load and heart rate variability. Performance was negatively correlated with mean heart rate, as well as single-item cognitive load measures. Our data signify a possible role for using physiologic monitoring for identifying individuals experiencing high cognitive load and those at risk for performing poorly during clinical reasoning tasks.

When a health policy cuts both ways: Impact of the National Emergency Access Target policy on staff and emergency department performance.

To explore the impact of the Four-Hour Rule/National Emergency Access Target (4HR/NEAT) on staff and ED performance. A mixed-methods study design was used to link performance data from 16 participating hospitals with the experiences reported by 119 ED staff during policy implementation. Quantitative and qualitative measures were triangulated to identify the staff and organisational effects on hospital performance. An overall score was developed to categorise hospitals into: high, moderate and low performers, then compared with four qualitative themes: social factors, ED management, ED outcomes and 4HR/NEAT compliance. Key factors identified were stress and morale; intergroup dynamics; interaction with patients; resource management; education and training; financial incentives; impact on quality and safety; perceived improvements on access block and overcrowding. High performing hospitals reported increased stress and decreased morale, decreased staff-patient communication and staff shortages; significant changes in ED management and effective use of the whole-of-hospital approach. Moderate performing hospitals reported similar characteristics to a lesser degree, and the perception that 4HR/NEAT did not impact ED practice. Low performing hospitals also reported increased stress and low morale and a less effective whole-of-hospital approach. ED staff also reported a reduction in communication with patients. There was strong evidence of an association between high stress and low morale and the implementation of the 4HR/NEAT across all levels of performance. These adverse consequences of the 4HR/NEAT implementation indicate that a more nuanced approach to efficiency improvements is required. This would balance processes measured by 4HR/NEAT against a range of other clinical and organisational performance measures.

Socioeconomic Status And Acute Stroke Care: Has The Inequality Gap Been Closed?

PurposeSocioeconomic inequality in stroke care occurs even in countries with free access to health care. We aimed to investigate the association between socioeconomic status and guideline-recommended acute care in Denmark during the last decade.DesignWe conducted a nationwide, population-based study. We used household income, employment status, and education as markers of socioeconomic status and adjusted the results for relevant clinical covariates. We used weighted linear regression models to analyse empirical log odds of performance measure fulfillment at patient level.SettingPublic hospitals in Denmark.ParticipantsA total of 110,848 consecutive stroke patients discharged between 2004 and 2014.Intervention(s)Acute stroke care according to clinical guidelines.Main outcome measure(s)Guideline-recommended care was defined in two ways based on clinical performance measures: the percentage of fulfilled measures used throughout the study period (m=8) (model 1) and the percentage of fulfilled measures used at the time of discharge (m=8 to 16) (model 2).ResultsCompared with high family income, low income was negatively associated with the guideline-recommended care; odds ratios (95% CI) were 0.89 (0.85–0.93) in model 1 and 0.81 (0.77–0.85) in model 2. Low family income was negatively associated with fulfillment of 14 of the 16 performance measures. In general, the percentage of performance measures fulfilled increased over time from 70% (95% CI 63–76) to 85% (95% CI 83–87).ConclusionSocioeconomic inequality in guideline-recommended stroke care remains despite overall improvements in a setting with free access to care and systematic monitoring of health care quality.

Clinical Performance and Quality Measures for Adults With Acute ST-Elevation Myocardial Infarction in China

Clinical Performance and Quality Measures for Adults With Acute ST-Elevation Myocardial Infarction in China

Next Steps in Wearable Technology and Community Ambulation in Multiple Sclerosis.

Walking impairments are highly prevalent in persons with multiple sclerosis (PwMS) and are associated with reduced quality of life. Walking is traditionally quantified with various measures, including patient self-reports, clinical rating scales, performance measures, and advanced lab-based movement analysis techniques. Yet, the majority of these measures do not fully characterize walking (i.e., gait quality) nor adequately reflect walking in the real world (i.e., community ambulation) and have limited timescale (only measure walking at a single point in time). We discuss the potential of wearable sensors to provide sensitive, objective, and easy-to-use assessment of community ambulation in PwMS. Wearable technology has the ability to measure all aspects of gait in PwMS yet is under-studied in comparison with other populations (e.g., older adults). Within the studies focusing on PwMS, half that measure pace collected free-living data, while only one study explored gait variability in free-living conditions. No studies explore gait asymmetry or complexity in free-living conditions. Wearable technology has the ability to provide objective, comprehensive, and sensitive measures of gait in PwMS. Future research should investigate this technology's ability to accurately assess free-living measures of gait quality, specifically gait asymmetry and complexity.

Review of Cognitive Biases in ACGME Milestones Training Assessments in Post-graduate Medical Education Programs.

The course of study for young physicians for post-graduate training is an exciting and life-changing opportunity, one that is filled with the relentless optimism of intellectual discovery and personal growth and development. The American Council for Graduate Medical Education (ACGME) is a non-profit private council that evaluates and accredits internship, residency, and fellowship programs. The role of the ACGME is to oversee curriculums, training environments, and specialty evaluation standards to ensure satisfactory competency leading to board eligibility and certification in the respected field of study. The ACGME has the monumental task of guiding educational standards that are designed to both protect the public welfare and further educational programs. Many educational standards are objective, such as quantitative performance on examinations, involvement in research, and involvement in systems development and quality improvement. However, key clinical performance measures are based on prior training and experience. Over the last several years, studies examining rates of abuse and discrimination during post-graduate medical training in both the United States and Canadian studies, which have reported alarmingly high rates of 50%. With the increasing utility and availability of social media, such issues have become more transparent to the public. A plethora of studies has been conducted, examining physician biases towards patients, practice changes, insurance company regulations, and evolving healthcare systems. However, a significant amount of evaluation is merited when examining individual institutional cultures and the educational environments that harbor them. We wish to examine the role of ever-evolving specialty-specific ACGME-instituted educational milestones in Internal Medicine and Opthalmology in the context of potential cognitive biases and their implementation within post-graduate training programs.

Establishing a common metric for self-reported anxiety in patients with prostate cancer: Linking the Memorial Anxiety Scale for Prostate Cancer with PROMIS Anxiety.

Anxiety is a common patient concern and clinical endpoint in prostate cancer outcomes research. It is measured using different self-report instruments that are not directly comparable, thereby making clinical trials, clinical performance measurement, and comparative effectiveness research challenging when anxiety is the outcome of interest. The objective of the current study was to enable a common reporting metric of anxiety so that scores on commonly used anxiety measures could be converted into Patient-Reported Outcomes Measurement Information System (PROMIS) scores for ease of application, interpretation, and comparability. Using an internet health panel, a total of 806 men with clinically localized prostate cancer completed items from the National Institutes of Health PROMIS Anxiety Short Form (version 7a) and the 18-item Memorial Anxiety Scale for Prostate Cancer (MAX-PC). A common metric was created using analyses based on item response theory, producing score crosswalk tables. The linking relationships were evaluated by resampling small subsets and estimating confidence intervals for the differences between the observed and linked PROMIS scores. Results of factor analysis and item response theory model fit supported the hypothesis that both scales measure essentially the same concept. Therefore, crosswalk tables appear to be justified and increasingly robust with increasing sample sizes. MAX-PC Anxiety results can be expressed on the PROMIS Anxiety metric for the purposes of clinical performance measurement, clinical trial outcomes, comparative effectiveness research, and other efforts to compare anxiety results across studies that use any one of these measures.

Defining and Adopting Clinical Performance Measures in Graduate Medical Education: Where Are We Now and Where Are We Going?

Assessment and evaluation of trainees' clinical performance measures is needed to ensure safe, high-quality patient care. These measures also aid in the development of reflective, high-performing clinicians and hold graduate medical education (GME) accountable to the public. Although clinical performance measures hold great potential, challenges of defining, extracting, and measuring clinical performance in this way hinder their use for educational and quality improvement purposes. This article provides a way forward by identifying and articulating how clinical performance measures can be used to enhance GME by linking educational objectives with relevant clinical outcomes. The authors explore four key challenges: defining as well as measuring clinical performance measures, using electronic health record and clinical registry data to capture clinical performance, and bridging silos of medical education and health care quality improvement. The authors also propose solutions to showcase the value of clinical performance measures and conclude with a research and implementation agenda. Developing a common taxonomy of uniform specialty-specific clinical performance measures, linking these measures to large-scale GME databases, and applying both quantitative and qualitative methods to create a rich understanding of how GME affects quality of care and patient outcomes is important, the authors argue. The focus of this article is primarily GME, yet similar challenges and solutions will be applicable to other areas of medical and health professions education as well.

Objective Measures of Communication Behavior Predict Clinical Performance

Effective teamwork and communication are critical to patient outcomes, and subjective assessment tools have been studied in predicting team performances. However, inherent biases remain while using subjective assessment tools. This study hypothesizes that objective communication features can assess and predict clinical performance. Forty 3rd-year medical students participated in the Acute Care Trauma Simulation as the role of doctor, teaming up with a nurse confederate and a simulated patient. Participants conducted postoperative patient management, patient care diagnoses, and treatment. Audio from all team members were recorded, speech variables (e.g., speech duration, number of conversations, etc.) were extracted, and statistical analyses were performed to associate communication with clinical performance. This study was performed at the simulation center located at Fairbanks Hall, Indiana University School of Medicine. Data from forty 3rd-year medical students were collected and analyzed. Majority (67%) of the communications were initiated by student. Speech ratio, intensity, and frequency of communications differed when students communicate with nurse than with patient (e.g., student communication to patient had higher intensity than nurse). Increasing frequency of check-backs between student and nurse (p < 0.05) and speech duration from student to patient (p = 0.001) positively associated with student's clinical performance score. Objective communication features can predict medical trainee's clinical performance and provide an objective approach for simulation-based trauma care training.

Abstract 137: Using an Electronic Clinical Support Tool to Improve Anticoagulation in Patients with Atrial Fibrillation/Flutter

Background: It is estimated that atrial fibrillation (AF) impacts between 2.7 to 6.1 million American adults, and this is expected to double by 2050. The outpatient performance measures of the 2016 AHA/ACC Clinical Performance and Quality Measures include: Documentation of CHA2DS2-VASc Risk Score and anticoagulation (AC) prescription, when indicated. To address these outpatient measures, our team integrated a clinical support tool into our electronic medical record (EMR). Objectives: Our quality improvement project aimed to increase the percentage (or proportion) of patients with atrial fibrillation/flutter (AF) who were appropriately prescribed AC in an academic cardiology clinic. Our outcome measure was the frequency our tool was either: acknowledged, cancelled, or completed. Methods: Baseline data was collected via retrospective chart review for patients with documented AF. With the assistance of information technology, we created a pop-up clinical tool in the EMR that recognized if the patient is prescribed AC and provided a semi-automated calculation of the CHA2DS2-VASc score. If the patient had CHA2DS2-VASc ≥ 2 and was not on AC, the tool prompted the physician to select either: a contraindication, refusal or prescribe AC. Before implementing the electronic tool, the cardiologists were educated on the new tool and made aware of future data collection. Results: Baseline data from April 2018 included 104 patients with AF, of which 57.7% were prescribed AC. The frequency of AC prescription for all AF over the next 3 months increased: 76% in May, 69% in June, 86% in July. For these 3 months, when the clinical decision tool was encountered: 69 - 72% of cardiologists cancelled, 11 - 22% acknowledged, and 9-17% used the tool. Conclusion: Our outcome measure to increase AC prescription was achieved following implementation of an electronic clinical tool even though the cardiologists often did not interact with the tool. Similar to prior literature on clinical support tools, the provider’s clinical proficiency plays a large role in use. The tool may have been successful by providing a clinical reminder about AC in these patients . Early results show sustainability in AC prescription. Our clinical tool is now being implemented into a primary care clinic and may have increased use in that setting.

VARIATIONS IN QUALITY MEASURE COMPLIANCE IN PRESCRIPTIONS FOR ATRIAL FIBRILLATION PATIENTS AMONG OUTPATIENT CARDIOLOGY PRACTICES: INSIGHTS FROM THE NCDR PINNACLE REGISTRY®

Among patients with atrial fibrillation (AF), little is known about contemporary compliance with quality measures as outlined in the 2016 ACC/AHA Clinical Performance and Quality Measures for Adults with Atrial Fibrillation or Atrial Flutter. Measures include appropriate oral anticoagulant,

Appraising the value of evidence generation activities: an HIV modelling study

IntroductionThe generation of robust evidence has been emphasised as a priority for global health. Evidence generation spans a wide range of activities including clinical trials, surveillance programmes and health system...

Chinese expert consensus on clinical performance and quality measures for adults with acute ST-segment elevation myocardial infarction

Chinese expert consensus on clinical performance and quality measures for adults with acute ST-segment elevation myocardial infarction

Assessing Performance and Quality After Non-ST Segment Elevation Acute Coronary Syndromes.

This review summarizes and discusses the evidence base supporting current performance and quality measures used in assessing institutions in their care of patients with non-ST segment elevation acute coronary syndromes (NSTE-ACS). Professional societies in the USA and Europe have developed performance and quality measures for NSTE-ACS. These measures are reviewed and updated periodically to reflect the most important evidence from the literature. In the USA, the ACC/AHA Task Force on Performance Measures published the updated 2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction. In Europe, the ESC Acute Cardiac Care Association published the 2017 Quality Indicators for acute myocardial infarction. These documents build on guidelines previously developed and published by the two organizations. They include detailed reviews of current and past studies establishing that adherence with guidelines improves clinical outcomes. Both measure sets provide quantitative methodologies to assess program performance. Institutional programs that focus on these validated measures can increase guideline adherence, streamline and standardize care processes, and reduce morbidity and mortality. Performance and quality measures have become a critical part of healthcare today, allowing patients, providers, administrators, and payors to assess patient care objectively. They are also becoming an important component of value-based payment programs. To be fair, and useful, for internal institutional assessment, in comparing different institutions, and for value-based payments, only validated performance measures such as these should be employed.

Improving Clinical Performance of an Interprofessional Emergency Medical Team Through a One-day Crisis Resource Management Training.

IntroductionErrors are frequent in health care and Emergency Departments are one of the riskiest areas due to frequent changes of team composition, complexity and variety of the cases and difficulties encountered in managing multiple patients. As the majority of clinical errors are the results of human factors and not technical in nature or due to the lack of knowledge, a training focused on these factors appears to be necessary. Crisis resource management (CRM), a tool that was developed initially by the aviation industry and then adopted by different medical specialties as anesthesia and emergency medicine, has been associated with decreased error rates.The aim of the studyTo assess whether a single day CRM training, combining didactic and simulation sessions, improves the clinical performance of an interprofessional emergency medical team.Material and MethodsSeventy health professionals with different qualifications, working in an emergency department, were enrolled in the study. Twenty individual interprofessional teams were created. Each team was assessed before and after the training, through two in situ simulated exercises. The exercises were videotaped and were evaluated by two assessors who were blinded as to whether it was the initial or the final exercise. Objective measurement of clinical team performance was performed using a checklist that was designed for each scenario and included essential assessment items for the diagnosis and treatment of a critical patient, with the focus on key actions and decisions. The intervention consisted of a one-day training, combining didactic and simulation sessions, followed by instructor facilitated debriefing. All participants went through this training after the initial assessment exercises.ResultsAn improvement was seen in most of the measured clinical parameters.ConclusionOur study supports the use of combined CRM training for improving the clinical performance of an interprofessional emergency team. Empirically this may improve the patient outcome.