Clinical Quality Measures Research Articles

Enhancing Identification and Management of Hospitalized Patients Who Are Malnourished: A Pilot Evaluation of Electronic Quality Improvement Measures

Malnutrition in hospitalized patients has long been recognized as a contributor to poor patient outcomes; malnutrition often leads to higher costs of care. Thus, it is important to improve the identification of patients who are at risk for malnutrition or already malnourished and to initiate treatment to optimize outcomes. The Malnutrition Quality Improvement Initiative (MQii) is based on a dual-pronged approach consisting of a set of four electronic clinical quality measures and a Quality Improvement Toolkit that support delivery of high-quality malnutrition care by clinicians including nurses, registered dietitian nutritionists, and physicians. A large pilot hospital validated the four malnutrition electronic clinical quality measures (screening for nutrition risk, assessment, care plan, diagnosis), demonstrating their value in support of continuous quality improvement for hospital-based malnutrition care with the ultimate goal of better patient outcomes while reducing health care costs. Funding/SupportPublication of this supplement was supported by Abbott. The Academy of Nutrition and Dietetics does not receive funding for the MQii. Avalere Health's work to support the MQii was funded by Abbott.

Engagement of the Academy’s Dietetic Practice Groups with MQii

Raise awareness of Malnutrition Quality Improvement Initiative (MQii) efforts and recruitment in the Learning Collaborative among the Academy’s Dietetic Practice Groups (DPGs). As efforts of the Malnutrition Quality Improvement Initiative (MQii) were underway it became apparent to MQii Partners, Academy of Nutrition and Dietetics and Avalere Health, that engagement with the Academy’s DPG Leaders is critical in order to advance objectives of the initiative which include:Advance adoption of malnutrition electronic clinical quality measures (eCQMs);Improve effectiveness and timeliness of malnutrition care through an interdisciplinary toolkit; andSupport availability of tools that can be integrated into EHR systems to improve care quality. Three major strategies were identified and operationalized to advance the noted objectives. First, a Lunch and Learn event was held for DPG Leaders at the Food & Nutrition Conference & Expo™ (FNCE) 2017 to brief them on current MQii activities. Second, a series of MQii follow-up webinars with DPG leaders got underway in order to provide MQii updates and provide opportunity for attendees to ask questions. Lastly, a Malnutrition Quality Improvement survey was deployed to 26 DPG memberships to gain member interest level with participation in the MQii Learning Collaborative. Over 100 participants attended the MQii Lunch and Learn event at FNCE Chicago 2017. Attendees received a customized malnutrition communication packet to share with their DPG membership focusing on how to get started using malnutrition eCQMs, obtaining C-suite and clinical care team support, and overcoming barriers. Four separate DPG engagement webinars occurred from February to March 2018. During the webinars DPG leaders were updated on MQii progress and engaged in a discussion to share their insights on where their memberships have opportunities to be involved with MQii. The Malnutrition Quality Improvement survey indicated that 20% of respondents were interested in participating in the MQii Learning Collaborative. DPGs play a unique role of facilitating dietetic practitioners to connect with fellow like-minded colleagues. Targeting the 26 DPGs allowed the Academy to significantly increase recruitment efforts for the MQii Learning Collaborative. A total of 119 adult in-patient acute-care hospitals expressed interest in joining the MQii Learning Collaborative.

The Malnutrition Quality Improvement Initiative: A Multiyear Partnership Transforms Care

The Academy of Nutrition and Dietetics, representing credentialed nutrition and dietetics practitioners—registered dietitian nutritionists (RDNs) and nutrition and dietetics technicians, registered, and students and interns and professionals holding nutrition and dietetics undergraduate and advanced degrees—and Avalere Health, a Washington, DC–based strategic advisory services firm, have led the charge in closing malnutrition gaps with the Malnutrition Quality Improvement Initiative (MQii), a national nutrition-focused quality improvement initiative. The initiative’s journey from 2013-2019 utilized technical advisors and stakeholders to improve care and outcomes for hospitalized adults age 65 and older with a series of innovations. These innovations include the development of the first malnutrition electronic clinical quality measures (eCQMs) and a complementary interdisciplinary quality improvement toolkit and establishing the first nutrition-focused national Learning Collaborative. MQii’s vision for future directions and applications in 2020 and beyond will explore partnerships to include the malnutrition eCQM in available clinical data registries. Qualified Clinical Data Registries will provide a pathway for collecting nutrition data relevant to RDNs because as of 2020, payments for Medicare Part B nutrition services and quality improvement are available for eligible RDNs participating in the Centers for Medicare and Medicaid Services Quality Payment Program. The MQii Toolkit’s technical specification manuals, data dictionaries, and implementation guides will help RDNs integrate the malnutrition quality measures into existing electronic health records and lead nutrition data collection and analysis. RDNs’ continued advancement with information technology leaders to incorporate terminology and clinical standards into electronic health record platforms will provide for malnutrition data transfer across care settings. Funding/SupportPublication of this supplement was supported by Abbott. The Academy of Nutrition and Dietetics does not receive funding for the MQii. Avalere Health's work to support the MQii was funded by Abbott.

Evaluation of a Nutrition Screening Tool to Identify Patients at Risk for Malnutrition

Determine if a nutrition screening tool (NST) successfully identified at-risk patients. The proposed malnutrition electronic clinical quality measure (eCQM) for screening is Completion of a Malnutrition Screening within 24 hours of Admission. It is necessary to evaluate NSTs to ensure accurate identification of at-risk patients. In a community hospital with an average census of 180 patients, registered nurses (RNs) complete an NST in the electronic health record on admission to determine the presence and significance of weight loss using the following questions:Have you had recent weight loss? Y/NIf Yes, was it intentional? Y/NWeight loss amount (lb)?Time frame? 1 week, 1 month, 3 months, 6 months, 1 yearUsual weight (lb)?If loss is significant according to the following scale, the RDN is automatically consulted.2% in 1 week5% in 1 mo7.5% in 3 mo10% in 6 mo20% in 1 yr In CY 2018, for patients diagnosed with malnutrition by a registered dietitian nutritionist (RDN), the RDN recorded the method by which the nutrition consult was triggered, and reasons why the NST did not trigger a consult. Of the 961 patients diagnosed with malnutrition upon initial assessment, the NST triggered a consult in only 393 (40.9%). Other triggers included:BMI < 19 247 (25.7%)MD/RN referral 167 (17.4%)Length of stay screening 48 (5.0%)NPO/clear liquid status 32 (3.3%)Patient care rounds 28 (2.9%)Braden score < 18 17 (1.8%)Ventilator protocol 16 (1.7%)Consult entered in error 13 (1.4%) Malnourished patients were not identified by the NST for the following reasons:Unknown (presumably the RN did not ask the weight loss question, or the patient indicated they hadn’t lost weight when they had) 250 (44.0%)Patient did not have weight loss 182 (32.0%)Unable to obtain information 81 (14.3%)Weight loss not significant 31 (5.5%)NST completed incorrectly or not at all 24 (4.2%) The NST did not identify a majority (59.1%) of malnourished patients. Of those not identified, 37.5% did not have significant weight loss. Further, the most common trigger after weight loss was low BMI. This suggests that an NST with only questions about weight loss will be insufficient in identifying patients at risk for malnutrition, especially those with chronic malnutrition, i.e. no recent loss but significant muscle/fat wasting and/or low BMI.

The Importance of Nutrition Post-Discharge Interventions

To discuss the benefits of utilizing a quality improvement process to identify gaps and opportunities in an established malnutrition initiative. Malnutrition initiatives were implemented to improve the quality of malnutrition care, standardize practices, and increase awareness of the importance of the care of malnourished patients. Health care is always changing, and established initiatives or programs need to be evaluated often to stay relevant to current trends. The Malnutrition Quality Improvement Initiative (MQii) Toolkit was used to review current practices and ensure key points were in place including the electronic clinical quality measures, establishing key stakeholders on the interdisciplinary team, and education. The Malnutrition Care Assessment and Decision Tool was used to review current malnutrition initiatives across several hospitals in the health care system. The tool identified the discharge planning process as an area for improvement and further investigation. A process and data collection were developed that focused on all patients diagnosed by the registered dietitian nutritionist (RDN) with severe malnutrition in a two month period. Their charts were reviewed by an RDN and included collection of prescribed RDN nutrition recommendations, discharge location, and information obtained through follow-up phone calls that focused on compliance with RDN recommendations. Follow-up phone calls were performed on only those patients discharged home. Preliminary data indicates favorable and unanticipated findings. Patients called via the protocol established were well versed on the recommendations from the inpatient RDN and the vast majority were following instructions based on nutrition prescription. Of those who could not verbalize recommendations were able to reference written discharge instructions that were entered into the medical record by the RDN and reviewed by the discharging nurse prior to returning home. What was surprising was the number of patients that did not meet criteria for follow-up calls. Patients discharged to short/long term care facilities, skilled nursing facilities or other institutions comprised the majority of the Severe Malnutrition diagnosis list. Using the Malnutrition Care Assessment and Decision Tool provided by the MQii was helpful in highlighting opportunities to improve the discharge piece of malnutrition initiatives. The process of nutrition assessment with RDN-driven patient education regarding diet modifications and oral nutrition supplement use, followed by RN reinstruction and written guidelines provided at discharge, is helpful to aid in memory retention of nutrition recommendations. Patients tend to understand the importance of diet and supplements and follow nutrition prescriptions. The majority of severely malnourished patients are not discharged home but are discharged to other facilities requiring a deeper dive into these discharge processes as they comprise a greater proportion of malnourished patients.

RDN Assessment within Twenty-Four Hours of Nutrition Screening Referral is Feasible

Determine the average amount of time it took for the registered dietitian nutritionist (RDN) to complete an initial assessment for referrals triggered from the nutrition screening tool (NST). Faster response times to assess patients identified as at risk for malnutrition from the NST can translate to more timely implementation of nutrition interventions to prevent or treat malnutrition. The 2nd step of the Malnutrition Quality Improvement Initiative (MQii) is assessment, and the 2nd proposed electronic clinical quality measure (eCQM) is completing a nutrition assessment within 24 hours of receipt of a referral. Many practitioners have expressed concern that it is not feasible to complete an assessment within 24 hours due to perceived inadequate clinical nutrition staffing. The facility in this study has an average census of 180, is staffed with 3.4 full-time equivalent RDNs, and weekend coverage includes both Saturday and Sunday. The medical records of all patients with a positive trigger from an NST during the months of January-June 2018 were reviewed. Data collected included dates and times for the following: hospital admission, completion of nutrition screen by registered nurses (RNs), and completion of nutrition assessment by RDNs. Time to place a nutrition referral after completion of the screen was not recorded, as the referral was generated automatically when the form containing the NST was signed electronically. Of the 145 referrals received from the NST, the RDNs average response time was 15 hours and 35 minutes. One hundred thirty-three (91.7%) of the patients were assessed by an RDN within 24 hours of receiving a referral. The average time from admission to completion of the NST by the RN was 8 hours and 4 minutes. Therefore, on average, patients were seen by the RDN within 24 hours of admission (average time 23 hours and 39 minutes). Completing a nutrition assessment within 24 hours of receiving a referral triggered by the NST should be feasible in facilities with similar clinical nutrition staffing.

Development of quality measures for use of self-injectable biologic therapy in inflammatory bowel disease: An integrated specialty pharmacy initiative.

The development of a tool to measure medication safety, therapeutic efficacy, and other quality outcomes in patients receiving self-injectable biologic therapy for the management of inflammatory bowel disease (IBD) at a health-system specialty pharmacy is described. Through a collaborative initiative by pharmacists, gastro-enterologists, and representatives of a pharmacy benefit manager and a pharmaceutical company, a set of clinical and specialty pharmacy quality measures was developed. The clinical measures are intended for use in assessing patient safety, disease status, treatment efficacy, and healthcare resource utilization during 3 assessments (pre-treatment, on-treatment, and longitudinal). The specialty pharmacy measures can be used to assess medication adherence, medication persistence, specialty pharmacy accreditation, and patient satisfaction. The proposed quality measures provide a foundation for evaluating the quality of IBD care and improving patient outcomes within a health-system specialty pharmacy. Future efforts to validate and implement the tool in clinical practice are planned. The proposed quality measures provide a foundation for future inquiry regarding the appropriateness and feasibility of integrating the measures into clinical care. Further work is needed to implement and validate these quality measures and determine their impact in optimizing health outcomes.

A Randomized Trial of External Practice Support to Improve Cardiovascular Risk Factors in Primary Care

We conducted a randomized controlled trial to compare the effectiveness of adding various forms of enhanced external support to practice facilitation on primary care practices' clinical quality measure (CQM) performance. Primary care practices across Washington, Oregon, and Idaho were eligible if they had fewer than 10 full-time clinicians. Practices were randomized to practice facilitation only, practice facilitation and shared learning, practice facilitation and educational outreach visits, or practice facilitation and both shared learning and educational outreach visits. All practices received up to 15 months of support. The primary outcome was the CQM for blood pressure control. Secondary outcomes were CQMs for appropriate aspirin therapy and smoking screening and cessation. Analyses followed an intention-to-treat approach. Of 259 practices recruited, 209 agreed to be randomized. Only 42% of those offered educational outreach visits and 27% offered shared learning participated in these enhanced supports. CQM performance improved within each study arm for all 3 cardiovascular disease CQMs. After adjusting for differences between study arms, CQM improvements in the 3 enhanced practice support arms of the study did not differ significantly from those seen in practices that received practice facilitation alone (omnibus P = .40 for blood pressure CQM). Practices randomized to receive both educational outreach visits and shared learning, however, were more likely to achieve a blood pressure performance goal in 70% of patients compared with those randomized to practice facilitation alone (relative risk = 2.09; 95% CI, 1.16-3.76). Although we found no significant differences in CQM performance across study arms, the ability of a practice to reach a target level of performance may be enhanced by adding both educational outreach visits and shared learning to practice facilitation.

Primary Care Practices’ Ability to Report Electronic Clinical Quality Measures in the EvidenceNOW Southwest Initiative to Improve Heart Health

The capability and capacity of primary care practices to report electronic clinical quality measures (eCQMs) are questionable. To determine how quickly primary care practices can report eCQMs and the practice characteristics associated with faster reporting. This quality improvement study examined an initiative (EvidenceNOW Southwest) to enhance primary care practices' ability to adopt evidence-based cardiovascular care approaches: aspirin prescribing, blood pressure control, cholesterol management, and smoking cessation (ABCS). A total of 211 primary care practices in Colorado and New Mexico participating in EvidenceNOW Southwest between February 2015 and December 2017 were included. Practices were instructed on eCQM specifications that could be produced by an electronic health record, a registry, or a third-party platform. Practices received 9 months of support from a practice facilitator, a clinical health information technology advisor, and the research team. Practices were instructed to report their baseline ABCS eCQMs as soon as possible. The main outcome was time to report the ABCS eCQMs. Cox proportional hazards models were used to examine practice characteristics associated with time to reporting. Practices were predominantly clinician owned (48%) and in urban or suburban areas (71%). Practices required a median (interquartile range) of 8.2 (4.6-11.9) months to report any ABCS eCQM. Time to report differed by eCQM: practices reported blood pressure management the fastest (median [interquartile range], 7.8 [3.5-10.4] months) and cholesterol management the slowest (median [interquartile range], 10.5 [6.6 to >12] months) (log-rank P < .001). In multivariable models, the blood pressure eCQM was reported more quickly by practices that participated in accountable care organizations (hazard ratio [HR], 1.88; 95% CI, 1.40-2.53; P < .001) or participated in a quality demonstration program (HR, 1.58; 95% CI, 1.14-2.18; P = .006). The cholesterol eCQM was reported more quickly by practices that used clinical guidelines for cardiovascular disease management (HR, 1.35; 95% CI, 1.18-1.53; P < .001). Compared with Federally Qualified Health Centers, hospital-owned practices had greater ability to report blood pressure eCQMs (HR, 2.66; 95% CI, 95% CI, 1.73-4.09; P < .001), and clinician-owned practices had less ability to report cholesterol eCQMs (HR, 0.52; 95% CI, 0.35-0.76; P < .001). In this study, time to report eCQMs varied by measure and practice type, with very few practices reporting quickly. Practices took longer to report a new cholesterol measure than other measures. Programs that require eCQM reporting should consider the time and effort practices must exert to produce reports. Practices may benefit from additional support to succeed in new programs that require eCQM reporting.

Assessing quality improvement capacity in primary care practices

BackgroundHealthy Hearts Northwest (H2N) is a study of external support strategies to build quality improvement (QI) capacity in primary care with a focus on cardiovascular risk factors: appropriate aspirin use, blood pressure control, and tobacco screening/cessation.MethodsTo guide practice facilitator support, experts in practice transformation identified seven domains of QI capacity and mapped items from a previously validated medical home assessment tool to them. A practice facilitator (PF) met with clinicians and staff in each practice to discuss each item on the Quality Improvement Capacity Assessment (QICA) resulting in a practice-level response to each item. We examined the association between the QICA total and sub-scale scores, practice characteristics, a measure of prior experience with managing practice change, and performance on clinical quality measures (CQMs) for the three cardiovascular risk factors.ResultsThe QICA score was associated with prior experience managing change and moderately associated with two of the three CQMs: aspirin use (r = 0.16, p = 0.049) and blood pressure control (r = 0.18, p = 0.013). Rural practices and those with 2–5 clinicians had lower QICA scores..ConclusionsThe QICA is useful for assessing QI capacity within a practice and may serve as a guide for both facilitators and primary care practices in efforts to build this capacity and improve measures of clinical quality.Trial registrationThis trial is registered with www.clinicaltrials.gov Identifier# NCT02839382, retrospectively registered on July 21, 2016.

Organizational characteristics associated with high performance on quality measures in pediatric primary care: A positive deviance study.

Pediatric health care quality in the United States varies, but the reasons for variation are not fully understood. Differences in pediatric practices' organizational characteristics, such as organizational structures, strategies employed to improve quality, and other contextual factors, may contribute to the variation observed. To assess the relationship between organizational characteristics and performance on clinical quality (CQ) and patient experience (PE) measures in primary care pediatric practices in Massachusetts. A 60-item questionnaire that assessed the presence of selected organizational characteristics was sent to 172 pediatric practice managers in Massachusetts between December 2017 and February 2018. The associations between select organizational characteristics and publicly available CQ and PE scores were analyzed using analysis of variance; open-ended survey questions were analyzed using qualitative content analysis. Eighty-six practices (50.0%) responded; 80 (46.5%) were included in the primary analysis. Having a quality champion ( p = .03), offering co-located specialty services (e.g., behavioral health; p = .04), being a privately owned practice ( p = .04), believing that patients and families feel respected ( p = .03), and having a lower percentage of patients (10%-25%) covered by public health insurance ( p = .04) were associated with higher CQ scores. Higher PE scores were associated with private practice ownership ( p = .0006). Qualitative analysis suggested organizational culture and external factors, such as health care finance, may affect quality. Both modifiable organizational practices and factors external to a practice may affect quality of care. Addressing differences in practice performance may not be reducible to implementation of changes in single organizational characteristics. Pediatric practices seeking to improve quality of care may wish to adopt the strategies that were associated with higher performance on quality measures, but additional studies are needed to better understand the mechanisms behind these associations and how they relate to each other.

Relationship Between Clinical Measures of Upper Limb Movement Quality and Activity Poststroke

Background. Understanding the relationship between movement quality (impairment) and performance (activity) in poststroke patients is important for rehabilitation intervention studies. This has led to an interest in kinematic characterization of upper limb motor impairment. Since instrumented motion analysis is not readily clinically available, observational kinematics may be a viable alternative. Objective. To determine if upper limb movement quality during a reach-to-grasp task identified by observation could be used to describe the relationship between motor impairments and the time to perform functional tasks. Methods. Cross-sectional, secondary analysis of baseline data from 141 participants with stroke, age 18 to 85 years, who participated in a multicenter randomized controlled trial. Clinical assessment of movement quality using the Reaching Performance Scale for Stroke (RPSS–Close and Far targets) and of performance (activity) from the Wolf Motor Function Test (WMFT–7 items) was assessed. The degree to which RPSS component scores explained scores on WMFT items was determined by multivariable regression. Results. Clinically significant decreases (>2 seconds) in performance time for some of the more complex WMFT tasks involving prehension were predicted from RPSS–Close and Far target components. Trunk compensatory movements did not predict either increases or decreases in performance time for the WMFT tasks evaluated. Overall, the strength of the regression models was low. Conclusions. In lieu of kinematic analysis, observational clinical movement analysis may be a valid and accessible method to determine relationships between motor impairment, compensations and upper limb function in poststroke patients. Specific relationships are unlikely to generalize to all tasks due to kinematic redundancy and task specificity.

Risk Adjustment in Clinical Quality Measures: What Is Needed Next?

Risk Adjustment in Clinical Quality Measures: What Is Needed Next?

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.

Preliminary psychometric analyses of the International Spinal Cord Injury Quality of Life Basic Data Set.

Secondary psychometric analysis of cross-sectional previously collected data. Explore the floor and ceiling effects, convergent, and divergent validity of the International Spinal Cord Injury Basic Quality of Life Data Set (SCI QoL-BDS) in a sample of people with spinal cord damage (SCD) from different countries, with different causes (both traumatic and non-traumatic), and different settings. Community dwellers with SCD in Australia, Brazil, India, The Netherlands, and USA, and inpatient rehabilitation: India. Adults (>18 years) with chronic SCD with either traumatic or non-traumatic aetiologies living in the community (n = 624), in inpatient rehabilitation following the onset of SCI (India; n = 115) and able-bodied controls (Australia; n = 220) had the following data collected by survey or face-face interview: SCI QoL-BDS, demographic and clinical characteristics (e.g., age, gender, years post SCI/SCD, education, employment) and reference measures of quality of life, disability and depression. For the whole sample, there were no notable floor or ceiling effects, internal consistency was good (Cronbach's alpha = 0.84) and the corrected item-total correlations generally were acceptable (all > 0.3 except for in Brazilian cohort). Convergent and divergent validity were largely confirmed though there were some aspects of validity that were suboptimal. Only minor psychometric issues were identified. This preliminary analysis suggests that there are no reason for concern about the use of the SCI QoL-BDS for clinical or research purposes, notwithstanding the need for further studies.

Mapping the Functional Independence Measure to a multi-attribute utility instrument for economic evaluations in rehabilitation: a secondary analysis of randomized controlled trial data

Purpose: To test whether the Functional Independence Measure (FIM) could be mapped to the EQ-5D-3L to give researchers a viable but “second-best” option for calculating quality-adjusted life-years (QALYs) and conducting a cost-utility analysis when only clinical outcomes have been collected.Materials and methods: Secondary analysis of repeated measures data collected during a randomized controlled trial (n = 3506 observations) at two inpatient rehabilitation centres. Participants had a mean age of 74 (SD 13) years, 63% were women and 58% were admitted with an orthopaedic diagnosis. Ordinary least-squares regression and adjusted limited dependent variable mixture models were used to estimate regression-based mappings. Performance was evaluated based on mean absolute error and the proportion of errors in excess of the minimally important difference.Results: In orthopaedic and neurological patients, high mean absolute errors (0.2 on the quality-adjusted life years scale) and a high proportion of errors (60%) in excess of the minimally important difference suggest that predicted EQ-5D-3L values provided a poor substitute for observed EQ-5D-3L values.Conclusions: Regression-based mappings from the FIM to the EQ-5D-3L are error-prone and unsuitable for calculating QALYs in rehabilitation patients. Researchers and rehabilitation professionals should therefore include a multi-attribute utility instrument such as the EQ-5D as well as the FIM to evaluate the effect of rehabilitation interventions and in rehabilitation registries. This will provide additional information on health-related quality of life and support cost-utility analyses.Implications for rehabilitationThe Functional Independence Measure (FIM) cannot be used to calculate quality-adjusted life-years (QALYs) for cost-utility analyses.Predicting QALYs from FIM data is a poor substitute for direct measurement of QALYs in orthopaedic or neurological rehabilitation populations.Multi-attribute utility instruments (MAUIs) allow direct measurement of QALYs, as well as providing a patient-reported measure of clinical quality and outcomes in rehabilitation.A MAUI should be included routinely in clinical practice by rehabilitation professionals as well as in rehabilitation trials and registries to track patient outcomes and improve clinical practice.

The validity of synthetic clinical data: a validation study of a leading synthetic data generator (Synthea) using clinical quality measures

BackgroundClinical data synthesis aims at generating realistic data for healthcare research, system implementation and training. It protects patient confidentiality, deepens our understanding of the complexity in healthcare, and is a promising tool for situations where real world data is difficult to obtain or unnecessary. However, its validity has not been fully examined, and no previous study has validated it from the perspective of healthcare quality, a critical aspect of a healthcare system. This study fills this gap by calculating clinical quality measures using synthetic data.MethodsWe examined an open-source well-documented synthetic data generator Synthea, which was composed of the key advancements in this emerging technique. We selected a representative 1.2-million Massachusetts patient cohort generated by Synthea. Four quality measures, Colorectal Cancer Screening, Chronic Obstructive Pulmonary Disease (COPD) 30-Day Mortality, Rate of Complications after Hip/Knee Replacement, and Controlling High Blood Pressure, were selected based on clinical significance. Calculated rates were then compared with publicly reported rates based on real-world data of Massachusetts and United States.ResultsOf the total Synthea Massachusetts population (n = 1,193,439), 394,476 were eligible for the “colorectal cancer screening” quality measure, and 248,433 (63%) were considered compliant, compared to the publicly reported Massachusetts and national rates being 77.3 and 69.8%, respectively. Of the 409 eligible patients, 0.7% of died within 30 days after COPD exacerbation, versus 7% reported in Massachusetts and 8% nationally. Using an expanded logic, this rate increased to 5.7%. No Synthea residents had complications after Hip/Knee Replacement (Massachusetts: 2.9%, national: 2.8%) or had their blood pressure controlled after being diagnosed with hypertension (Massachusetts: 74.52%, national: 69.7%). Results show that Synthea is quite reliable in modeling demographics and probabilities of services being offered in an average healthcare setting. However, its capabilities to model heterogeneous health outcomes post services are limited.ConclusionsSynthea and other synthetic patient generators do not currently model for deviations in care and the potential outcomes that may result from care deviations. To output a more realistic data set, we propose that synthetic data generators should consider important quality measures in their logic and model when clinicians may deviate from standard practice.

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,

The impact of quality and accessibility of primary care on emergency admissions for a range of chronic ambulatory care sensitive conditions (ACSCs) in Scotland: longitudinal analysis

BackgroundHospital admissions for Ambulatory Care Sensitive Conditions (ACSC) are those that could potentially be prevented by timely and effective disease management within primary care. ACSC admissions are increasingly used as performance indicators. However, key questions remain about the validity of these measures. The evidence to date has been inconclusive and limited to specific conditions. The aim of this study was to test the robustness of ACSC admissions as indicators of the quality of primary care. It is the first study to examine a wide range of ACSCs using longitudinal data which enables us to control for unmeasured characteristics which differ by practice but which are constant over time.MethodsUsing longitudinal data at the practice level, from 907 Scottish practices for the time period 1/4/2005 to 31/32012, we explored the relationships between the quality of primary care, and hospital admissions for multiple ACSCs controlling for a wide range of covariates including characteristics of GP practices, characteristics of the practice population, hospital effects and year effects. We examined the impact of two dimensions of quality of care: clinical quality of and access to daytime general practice. Generalised Estimating Equations taking the form of Negative Binomial regression models with the practice population included as the exposure term were estimated.ResultsWe found that higher achievement on some clinical quality measures of primary care was associated with reduced ACSC emergency admissions. We also show that access to primary care was associated with ACSC emergency admissions. However, the effects were small and inconsistent and ACSC emergency admissions were associated with several confounding factors such as deprivation, rurality and distance to the hospital.ConclusionsThe results suggest caution in the use of crude ACSC admission rates as a performance indicator of quality of primary care.

Variation in Surgeons’ Requests for General Anesthesia When Scheduling Carpal Tunnel Release

Background: Carpal tunnel release (CTR) can be performed with a variety of anesthesia techniques. General anesthesia is associated with higher risk profile and increased resource utilization, suggesting it should not be routinely used for CTR. The purpose of this study was to examine the patient factors associated with surgeons' requests for general anesthesia for CTR and the frequency of routine use of general anesthesia by Veterans Health Administration (VHA) surgeons and facilities. Methods: National VHA data for fiscal years 2015 and 2017 were used to identify patients receiving CTR. Mixed-effects logistic regression was used to evaluate patient, procedure, and surgeon factors associated with requests by the surgeon for general anesthesia versus other anesthesia techniques. Results: In all, 18 145 patients underwent CTR performed by 780 surgeons in 113 VHA facilities. Overall, there were 2218 (12.2%) requests for general anesthesia. Although some patient (eg, older age, obesity), procedure (eg, open vs endoscopic), and surgeon (eg, higher volume) factors were associated with lower odds of requests for general anesthesia, there was substantial facility- and surgeon-level variability. The percentage of patients with general anesthesia requested ranged from 0% to 100% across surgeons. Three facilities and 28 surgeons who performed at least 5 CTRs requested general anesthesia for more than 75% of patients. Conclusions: Where CTR is performed and by whom appear to influence requests for general anesthesia more than patient factors in this study. Avoidance of routine use of general anesthesia for CTR should be considered in future clinical practice guidelines and quality measures.