Clinical Quality Measures Research Articles

Correction to: 2016 ACC/AHA Clinical Performance and Quality Measures for Adults With Atrial Fibrillation or Atrial Flutter: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures.

In the article by Heidenreich et al, “2016 ACC/AHA Clinical Performance and Quality Measures for Adults With Atrial Fibrillation or Atrial Flutter: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures,” which published ahead of print on June 27, 2016, and appeared in the July 2016 issue of the journal ( Circ Cardiovasc Qual Outcomes. 2016;9:443–488. DOI: 10.1161/HCQ.0000000000000018), several corrections were needed. 1. In response to new data that resulted in changes in the US Food and Drug Administration labeling regarding the use of one of the Factor Xa inhibitors in patients with end-stage kidney disease or on dialysis,1 the Task Force on Performance Measures has removed 2 quality measures. They appeared in Appendix A and are: They are shown below. 2. On page 444, the Table of Contents entries for “QM-6: Atrial Fibrillation: …

Clinical Quality and Patient Experience in the Adult Ambulatory Setting.

Quality and patient experience are important dimensions of care delivery. The extent to which they are related in the adult outpatient setting is unknown. This brief study utilized data from a large integrated health system over a 1-year period in 2015 and measured the degree of correlation between physicians' patient experience scores and 8 standardized quality metrics. These quality measures were paired into similar groups to create 4 composite measures: outcome, screening, vaccination, and adherence. Measures of outcome ( r = 0.20, P = .06), vaccination ( r = 0.12, P = .26), and adherence ( r = -0.04, P = .75) were not significantly correlated with patient experience; screening ( r = 0.29, P = .006) was minimally correlated with patient experience. Overall, this study found minimal correlation between measures of patient experience and clinical quality in the outpatient setting. Measurement of both of these domains is essential to understanding patterns of care.

The Relationship between Costs andQuality in Veterans Health Administration Community Living Centers: An Analysis Using Longitudinal Data.

To examine the relationship between cost and quality in Veterans Health Administration (VA) nursing homes (called Community Living Centers, CLCs) using longitudinal data. One hundred and thirty CLCs over 13 quarters (from FY2009 to FY2012) were studied. Costs, resident days, and resident severity (RUGs score) were obtained from the VA Managerial Cost Accounting System. Clinical quality measures were obtained from the Minimum Data Set, and resident-centered care (RCC) was measured using the Artifacts of Culture Change Tool. We used a generalized estimating equationmodel with facilities included as fixed effects to examine the relationship between total cost and quality after controlling for resident days and severity. The model included linear and squared terms for all independent variables and interactions with resident days. With the exception of RCC, all other variables had a statistically significant relationship with total costs. For most poorer performing smaller facilities (lower size quartile), improvements in quality were associated with higher costs. For most larger facilities, improvements in quality were associated with lower costs. The relationship between cost and quality depends on facility size and current level of performance.

Early Implementation of Malnutrition Clinical Quality Metrics to Identify Institutional Performance Improvement Needs

The Centers for Medicare and Medicaid Services (CMS) is part of the federal government and the largest health care payer in the United States. 1 About CMS. Centers for Medicare and Medicaid Services website. https://www.cms.gov/About-CMS/About-CMS.html. Accessed January 3, 2018. Google Scholar The CMS writes regulations to ensure they only pay for high-quality, safe health care. To better measure quality in the U.S. health care system, the CMS developed electronic clinical quality measures (eCQMs), which became available for voluntary use in 2013. 2 eCQMs. eCQI Resource Center. The Office of the National Coordinator of Health Information Technology, Centers for Medicare and Medicaid Services. https://ecqi.healthit.gov/ecqms. Accessed January 3, 2018. Google Scholar Effective calendar year (CY) 2016, hospitals are required to electronically report clinical quality measures (CQMs) as a part of hospital inpatient quality reporting (IQR) and the electronic health record (EHR) incentive programs (more commonly known as “meaningful use” of the EHR). Hospitals that successfully submit eCQM data will fulfill the Medicare requirements for both programs with one submission. The CMS approves which eCQMs are accepted for any given CY, as well as the minimum number on which a hospital must report. Starting in CY 2017, there were 15 available eCQMs from which to choose, and hospitals were required to report on a minimum of eight. This has changed to four for CY 2018. 3 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the LongTerm Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2018 Rates; Quality Reporting Requirements for Specific Providers; Medicare and Medicaid Electronic Health Record (EHR) Incentive Program Requirements for Eligible Hospitals, Critical Access Hospitals, and Eligible Professionals; Provider-Based Status of Indian Health Service and Tribal Facilities and Organizations; Costs Reporting and Provider Requirements; Agreement Termination Notices. Fed Regist. 2017; 82 (Updated August 14, 2017. Accessed January 3, 2018): 38001https://www.gpo.gov/fdsys/pkg/FR-2017-08-14/pdf/2017-16434.pdf Google Scholar

Development of the American College of Rheumatology Electronic Clinical Quality Measures for Gout.

Electronic clinical quality measures (eCQMs) are increasingly used by health registries and third parties to evaluate and improve the quality of health care. To complete these eCQMs, data are extracted from electronic health records (EHRs). The treatment of gout has been an area identified with gaps in quality of care. On behalf of the American College of Rheumatology (ACR), we sought to develop and test eCQMs to evaluate gout care. Drawing from the 2012 ACR gout guidelines, a working group developed candidate gout process measures that were evaluated by an interdisciplinary panel of health care stakeholders, the ACR Quality Measures Subcommittee (QMS), and ultimately the ACR Board of Directors for formal validity testing. For each of the selected gout eCQMs, 3 clinical sites using different EHR systems tested the scientific feasibility and validity of the measures. Measures appropriate for accountability were presented for national endorsement. Of the 10 proposed eCQMs, 4 were endorsed by the ACR QMS, 3 were incorporated into the ACR's Rheumatology Informatics System for Effectiveness (RISE) Registry, and 2 were endorsed by the National Quality Forum. The 3 eCQMs incorporated into RISE (evaluating indications for urate-lowering therapy [ULT]), monitoring serum urate, and treat-to-target outcome) demonstrated high validity and reliability. Proportions of patients passing these 3 eCQMs in RISE and at the 3 clinical testing sites ranged between 32% and 58%, indicating significant room for improvement in care. Three eCQMs have been validated and implemented into RISE. Two of these measures (evaluating indications for ULT and monitoring serum urate) are available for use in federal quality reporting programs. Performance on these measures suggests there is significant room for improvement in the management of gout.

Primary Care Practices' Abilities And Challenges In Using Electronic Health Record Data For Quality Improvement.

Federal value-based payment programs require primary care practices to conduct quality improvement activities, informed by the electronic reports on clinical quality measures that their electronic health records (EHRs) generate. To determine whether EHRs produce reports adequate to the task, we examined survey responses from 1,492 practices across twelve states, supplemented with qualitative data. Meaningful-use participation, which requires the use of a federally certified EHR, was associated with the ability to generate reports-but the reports did not necessarily support quality improvement initiatives. Practices reported numerous challenges in generating adequate reports, such as difficulty manipulating and aligning measurement time frames with quality improvement needs, lack of functionality for generating reports on electronic clinical quality measures at different levels, discordance between clinical guidelines and measures available in reports, questionable data quality, and vendors that were unreceptive to changing EHR configuration beyond federal requirements. The current state of EHR measurement functionality may be insufficient to support federal initiatives that tie payment to clinical quality measures.

2018 ACC/AHA Clinical Performance and Quality Measures for Cardiac Rehabilitation: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures.

The American College of Cardiology (ACC)/American Heart Association (AHA) performance measurement sets serve as vehicles to accelerate translation of scientific evidence into clinical practice. Measure sets developed by the ACC/AHA are intended to provide practitioners and institutions that deliver cardiovascular services with tools to measure the quality of care provided and identify opportunities for improvement. Writing committees are instructed to consider the methodology of performance measure development1 and to ensure that the measures developed are aligned with ACC/AHA clinical guidelines. The writing committees also are charged with constructing measures that maximally capture important aspects of care quality, including …

Is bigger better? Assessment of self-reported and researcher-collected data on maternal health care quality among high-case-load facilities in Uttar Pradesh: a mixed-methods study

Abstract Background India's most populous state, Uttar Pradesh, has the country's second highest maternal mortality ratios, at 285 compared with the national maternal mortality ratio of 167. Reports of disrespect, abuse, and other types of mistreatment are also commonly reported by both the scientific community and popular media. Across nearly 750 facilities in Uttar Pradesh, the SPARQ Quality-Plus (Q+) study aims to understand which high-case-load facilities provide maternal health care and why. Our objective was to identify whether better quality at facilities varied by the measures used to assess maternal health clinical quality and person-centred care quality in Uttar Pradesh. We compared self-reported government data with delivery patient survey and health provider interview data on maternal health infrastructure, service delivery, and person-centred care outcomes. Methods The study sites were sampled based on self-reported performance data, stratified by facility type and geography. Study materials included a health service readiness checklist completed by 727 health facilities during early 2017 and caesarean section and delivery outcome data by quarter from these facilities for 2015 and 2016. Both sources are reported by the Uttar Pradesh National Health Mission (NHM). These secondary data sources were analysed to create a composite quality score used to select 20 high-performing and 20 low-performing sites from among 246 high-volume facilities (>200 deliveries/month). At these 40 sites, quality was assessed using quantitative and qualitative primary data collection with delivery patients (n=2018) and providers (n=251) and health service readiness checklists (n=40). Findings Across all the study facilities (n=40), little correlation existed between the self-reported and researcher-collected measures of clinical quality. Yet self-reported measures do not necessarily report levels of quality. For example, our researcher-collected data showed that facility-reported emergency obstetric care was more common than self-reported emergency obstetric care (n=29 [73%] vs n=21 [54%] in the government reported data). We found a strong negative correlation (t=–2·05; p Interpretation Although district hospitals and other higher-level referral facilities provide clinical care than smaller centres and hospitals in Uttar Pradesh, they provide worse patient-centred care and are more likely to be sites of abuse and disrespect. Delayed health-seeking during pregnancy and resistance to referral to higher-level facilities is a serious issue in Uttar Pradesh. Improving patient care in larger maternity centres is therefore both important and has the potential to address an underlying driver of morbidity and mortality. On the basis of these findings, we intend to work with the Uttar Pradesh NHM to enhance person-centred care to mothers and their newborn babies in high-volume facilities and to ultimately improve overall maternal and neonatal health outcomes in Uttar Pradesh and across India. Funding Bill & Melinda Gates Foundation.

Meeting Quality Measures for Adolescent Preventive Care: Assessing the Perspectives of Key Stakeholders

Health plans are increasingly implementing quality improvement strategies aimed at meeting adolescent clinical quality measures, yet clinics often struggle to meet these measures. This qualitative study was conducted to explore how efforts to meet the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) performance measure for adolescent well-care visits were perceived by a multidisciplinary group of stakeholders. The research team conducted 26 in-depth, semistructured interviews with participants from three stakeholder groups: clinic staff with direct patient contact, health care institutional leaders, and representatives of a payer organization. Interviews were about 45 minutes in duration, audio-recorded, and professionally transcribed. Framework analysis was used to identify and organize emergent themes, and Atlas.ti was used to facilitate data management and analysis. Stakeholder groups diverged in their opinions regarding strategies for achieving adolescent quality measures. Stakeholders with no direct patient interaction touted transactional quality improvement strategies that directly incentivized patients and families. In contrast, clinic staff with direct patient contact believed that incentive-based efforts undermined patient-provider relationships and the clinics' focus on wellness. A considerable disconnect exists between stakeholders with and without patient contact with regard to approaches to the delivery of well care and quality improvement strategies for meeting the adolescent well-care visit performance measure. Efforts to reconcile discordant perspectives and promote a mutual understanding between payers, institutional leaders, and clinic staff could inform the development of creative initiatives that are sustainable and effective at achieving adolescent and family engagement, as well as clinical performance benchmarks.

The Association of Patient-centered Medical Home Designation With Quality of Care of HRSA-funded Health Centers: A Longitudinal Analysis of 2012-2015.

(1) To evaluate the relationship between Patient-centered Medical Home (PCMH) recognition and quality of clinical care among health centers, and (2) to determine whether the duration of recognition is positively associated with cumulative quality improvement over time. Data came from the 2012 to 2015 Uniform Data System, health centers' PCMH recognition status, and the Area Resource File. Health center was the unit of observation. The outcome variables included 11 measures of clinical quality. We pooled all years of data and modeled longitudinal data with generalized estimating equations to examine the degree of improvement in health care quality in health centers with and without PCMH recognition over the years 2012-2015. Health centers with PCMH recognition generally performed better on clinical quality measures than health centers that did not have PCMH recognition for all years studied. After accounting for health center and county-level potential confounders, health centers with longer periods of PCMH recognition were more likely to have improved their clinical quality on 9 of 11 measures, than health centers with fewer years of PCMH recognition. Health centers' length of time with PCMH recognition was positively associated with additive quality improvement. Adoption of the PCMH model of care may serve as a strategy to enhance quality of primary care services.

Circling the Dragon-Taming Health IT Systems to Measure What Matters (TH367)

•Identify the challenges hospice and palliative care programs face when trying to use electronic health records and other IT systems to improve quality and meet requirements of quality payment programs.•Describe the mission and evolution of the AAHPM/HPNA Measuring What Matters Electronic Clinical Quality Measures (eCQMs) Working Group.•Describe the eCQM Group's progress to date on developing specifications for Measuring What Matters measures as electronic Clinical Quality Measures that can be integrated into electronic health records and clinical data registries and outline the work group's future priorities. In this team presentation, leaders from AAHPM and HPNA will showcase the work of the Measuring What Matters Electronic Clinical Quality Measures (eCQMs) Working Group. They will identify the challenges hospice and palliative care programs face when trying to use electronic health records (EHRs) and other IT systems to measure and improve quality. They will discuss how electronic systems have helped or presented challenges in meeting requirements of quality payment programs and describe how the eCQM Group is tackling them. In particular, presenters will explain why electronic clinical quality measures are necessary for interoperability and integration into a myriad of electronic health records and clinical data registries. Discussion may focus on what a data sheet looks like, how to engage with an EHR vendor, etc. They will highlight the committee's work to date to harness IT systems to measure what matters to patients and families living with serious illness. They will also outline the work group's future priorities and provide ample time for audience questions and comments.

National Assessment of Quality Programs in Emergency Medical Services

Objective: This study aims to understand the adoption of clinical quality measurement throughout the United States on an EMS agency level, the features of agencies that do participate in quality measurement, and the level of physician involvement. It also aims to barriers to implementing quality improvement initiatives in EMS. Methods: A 46-question survey was developed to gather agency level data on current quality improvement practices and measurement. The survey was distributed nationally via State EMS Offices to EMS agencies nation-wide using Surveymonkey©. A convenience sample of respondents was enrolled between August and November, 2015. Univariate, bivariate and multiple logistic regression analyses were conducted to describe demographics and relationships between outcomes of interest and their covariates using SAS 9.3©. Results: A total of 1,733 surveys were initiated and 1,060 surveys had complete or near-complete responses. This includes agencies from 45 states representing over 6.23 million 9-1-1 responses annually. Totals of 70.5% (747) agencies reported dedicated QI personnel, 62.5% (663) follow clinical metrics and 33.3% (353) participate in outside quality or research program. Medical director hours varied, notably, 61.5% (649) of EMS agencies had <5 hours of medical director time per month. Presence of medical director time was correlated with tracking of QI measures. Air medical [OR 9.64 (1.13, 82.16)] and hospital-based EMS agencies [OR 2.49 (1.36, 4.59)] were more likely to track quality measures compared to fire-based agencies. Agencies in rural only environments were less likely to follow clinical quality metrics. (OR 0.47 CI 0.31 −0.72 p < 0.0004). For those that track QI measures, the most common are; Response Time (Emergency) (68.3%), On-Scene Time (66.4%), prehospital stroke screen (64.6%), aspirin administration (64.5%), and 12 lead ECG in chest pain patients (63.0%). Conclusions: EMS agencies in the United States have significant practice variability with regard to quality improvement resources, medical direction and specific clinical quality measures. More research is needed to understand the impact of this variation on patient care outcomes.

Failure to Meet Nurse Staffing Standards: A Litigation Case Study of a Large US Nursing Home Chain.

Large for-profit nursing home chains in the United States have generally reported low nurse staffing levels. This historical case study examined a class action litigation case regarding staffing levels, resident rights, and quality outcomes in 12 Arkansas nursing homes owned by a large for-profit chain. The questions were as follows: (1) How did the residents’ care needs compare with actual nurse staffing levels? (2) How did the staffing levels compare with federal and state nurse staffing requirements and professional staffing standards? (3) Did the facilities comply with state and federal residents’ rights and quality of care requirements? The findings showed staffing levels marginally above state minimum standards, staffing shortages that violated state standards, staffing levels not adjusted for resident acuity, and shortages that resulted in omitted care. Staffing levels were lower than needed according to nursing directors, lower than average facilities in the state, and lower than professional standards. The findings showed many resident grievances regarding basic care and residents’ rights, clinical measures of poor quality, and state deficiencies. A large settlement was agreed on to compensate the residents. The case shows that chain’s management, as well as the regulatory system, failed to ensure adequate staffing levels that took into account regulatory requirements and professional standards and resulted in violations of residents’ rights, health, safety, and well-being.

The Hyperbaric Oxygen Therapy Registry: Driving quality and demonstrating compliance

To provide an update on the status of provider participation in the US Wound Registry (USWR) and its specialty registry the Hyperbaric Oxygen Therapy Registry (HBOTR), which provide much-needed national benchmarking and quality measurement services for hyperbaric medicine. Providers can meet many requirements of the Merit-Based Incentive Payment System (MIPS) and simultaneously participate in the HBOTR by transmitting Continuity of Care Documents (CCDs) directly from their certified electronic health record (EHR) or by reporting hyperbaric quality measures, the specifications for which are available free of charge for download from the registry website as electronic clinical quality measures for installation into any certified EHR. Computerized systems parse the structured data transmitted to the USWR. Patients undergoing hyperbaric oxygen (HBO₂) therapy are allocated to the HBOTR and stored in that specialty registry database. The data can be queried for benchmarking, quality reporting, public policy, or specialized data projects. Since January 2012, 917,758 clinic visits have captured the data of 199,158 patients in the USWR, 3,697 of whom underwent HBO₂ therapy. Among 27,404 patients with 62,843 diabetic foot ulcers (DFUs) captured, 9,908 DFUs (15.7%) were treated with HBO2 therapy. Between January 2016 and September 2018, the benchmark rate for the 1,000 DFUs treated with HBO₂ was 7.3%, with an average of 28 treatments per patient. There are 2,100 providers who report data to the USWR by transmitting CCDs from their EHR and 688 who submit quality measure data, 300 (43.6%) of whom transmit HBO₂ quality data.

Patient-Centered Medical Home Implementation and Improved Chronic Disease Quality: A Longitudinal Observational Study.

To examine associations between clinics' extent of patient-centered medical home (PCMH) implementation and improvements in chronic illness care quality. Data from 808 Veterans Health Administration (VHA) primary care clinics nationwide implementing the Patient Aligned Care Teams (PACT) PCMH initiative, begun in 2010. Clinic-level longitudinal observational study of clinics that received training and resources to implement PACT. Clinics varied in the extent they had PACT components in place by 2012. Clinical care quality measures reflecting intermediate outcomes and care processes related to coronary artery disease (CAD), diabetes, and hypertension care were collected by manual chart review at each VHA facility from 2009 to 2013. In adjusted models containing 808 clinics, the 77 clinics with the most PACT components in place had significantly larger improvements in five of seven chronic disease intermediate outcome measures (e.g., BP<160/100 in diabetes), ranging from 1.3 percent to 5.2 percent of the patient population meeting measures, and two of eight process measures (HbA1c measurement, LDL measurement in CAD) than the 69 clinics with the least PACT components. Clinics with moderate levels of PACT components showed few significantly larger improvements than the lowest PACT clinics. Veterans Health Administration primary care clinics with the most PCMH components in place in 2012 had greater improvements in several chronic disease quality measures in 2009-2013 than the lowest PCMH clinics.

Medicare Advantage and Fee-for-Service Performance on Clinical Quality and Patient Experience Measures: Comparisons from Three Large States.

To compare performance between Medicare Advantage (MA) and Fee-for-Service (FFS) Medicare during a time of policy changes affecting both programs. Performance data for 16 clinical quality measures and 6 patient experience measures for 9.9million beneficiaries living in California, New York, and Florida. We compared MA and FFS performance overall, by plan type, and within service areas associated with contracts between CMS and MA organizations. Case mix-adjusted analyses (for measures not typically adjusted) were used to explore the effect of case mix on MA/FFS differences. Performance measures were submitted by MA organizations, obtained from the nationwide fielding of the Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) Survey, or derived from claims. Overall, MA outperformed FFS on all 16 clinical quality measures. Differences were large for HEDIS measures and small for Part D measures and remained after case mix adjustment. MA enrollees reported better experiences overall, but FFS beneficiaries reported better access to care. Relative to FFS, performance gaps were much wider for HMOs than PPOs. Excluding HEDIS measures, MA/FFS differences were much smaller in contract-level comparisons. Medicare Advantage/Fee-for-Service differences are often large but vary in important ways across types of measures and contracts.

Interview with Deborah DiSanzo of IBM Watson Health

Interview with Deborah DiSanzo of IBM Watson Health

Association Between Medicare's Mandatory Hospital Value-Based Purchasing Program and Cost Inefficiency.

The Patient Protection and Affordable Care Act instituted pay-for-performance programs, including Hospital Value-Based Purchasing (HVBP), designed to encourage hospital quality and efficiency. While these programs have been evaluated with respect to their implications for care quality and financial viability, this is the first study to assess the relationship between hospitals' cost inefficiency and their participation in the programs. We estimate a translog specification of a stochastic cost frontier with controls for participation in the HVBP program and clinical and outcome quality for California hospitals for 2012-2015. The program-participation indicators' parameters imply that participants were more cost inefficient than their peers. Further, the estimated coefficients for summary process of care quality indexes for three health conditions (acute myocardial infarction, pneumonia, and heart failure) suggest that higher quality scores are associated with increased operating costs. The estimated coefficients for the outcome quality variables suggest that future determination of HVBP payment adjustments, which will depend solely on mortality rates as measures of clinical care quality, may not only be aligned with increasing healthcare quality but also reducing healthcare costs.

Hospital Quality and Demand: An Analysis of German Hospitals Using Distance-Metric Approach

Bu makalede, zorunlu olarak yayimlanan kalite raporlarindan elde edilen cesitli kalite olculeri kullanilarak, Alman hastaneleri icin bir toplam talep modeli tahmin edilmistir. Bu tahmin yapilirken, Mesafe-Metrigi yaklasimi benimsenmistir. Sonuclara gore, kadin dogum alaninda talep, bazi klinik kalite olculerine karsi duyarlidir. Son olarak ampirik sonuclar hastane talebinde, yakinlardaki rakip hastanelerin klinik kalitesinden ortaya cikan zayif tasma etkilerine isaret etmektedir

2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures.

The American College of Cardiology (ACC)/American Heart Association (AHA) performance measure sets serve as vehicles to accelerate translation of scientific evidence into clinical practice. Measure sets developed by the ACC/AHA are intended to provide practitioners and institutions that deliver