Health Care Quality Measures Research Articles

Patient-reported outcomes in cancer care - hearing the patient voice at greater volume.

Recording of patient-reported outcomes (PROs) enables direct measurement of the experiences of patients with cancer. In the past decade, the use of PROs has become a prominent topic in health-care innovation; this trend highlights the role of the patient experience as a key measure of health-care quality. Historically, PROs were used solely in the context of research studies, but a growing body of literature supports the feasibility of electronic collection of PROs, yielding reliable data that are sometimes of better quality than clinician-reported data. The incorporation of electronic PRO (ePRO) assessments into standard health-care settings seems to improve the quality of care delivered to patients with cancer. Such efforts, however, have not been widely adopted, owing to the difficulties of integrating PRO-data collection into clinical workflows and electronic medical-record systems. The collection of ePRO data is expected to enhance the quality of care received by patients with cancer; however, for this approach to become routine practice, uniquely trained people, and appropriate policies and analytical solutions need to be implemented. In this Review, we discuss considerations regarding measurements of PROs, implementation challenges, as well as evidence of outcome improvements associated with the use of PROs, focusing on the centrality of PROs as part of 'big-data' initiatives in learning health-care systems.

Continuing Education Meets the Learning Organization: The Challenge of a Systems Approach to Patient Safety.

Since the release of the report of the Institute of Medicine on medical errors and patient safety in November 1999, health policy makers and health care leaders in several nations have sought solutions that will improve the safety of health care. This attention to patient safety has highlighted the importance of a learning approach and a systems approach to quality measurement and improvement. Balanced with the need for public disclosure of performance, confidential reporting with feedback is one of the prime ways that nations such as the United States, Canada, the United Kingdom, and Australia have approached this challenge. In the United States, the Quality Interagency Coordination Task Force has convened federal agencies that are involved in health care quality improvement for a coordinated initiative. Based on an investment in a strong research foundation in health care quality measurement and improvement, there are eight key lessons for continuing education if it is to parlay the interest in patient safety into enhanced continuing education and quality improvement in learning health care systems. The themes for these lessons are (1) informatics for information, (2) guidelines as learning tools, (3) learning from opinion leaders, (4) learning from the patient, (5) decision support systems, (6) the team learning together, (7) learning organizations, and (8) just-in-time and point-of care delivery.

Quality of Information Addressing Prostate Specific Antigen Screening on NCI Cancer Center and Public Health Organization Websites

To survey accessibility and quality of prostate-specific antigen (PSA) screening information from National Cancer Institute (NCI) cancer center and public health organization websites. We surveyed the December 1, 2016 version of all 63 NCI-designated cancer center public websites and 5 major online clearinghouses from allied public/private organizations (Cancer.gov, Cancer.org, PCF.org, USPSTF.org, and CDC.gov). Websites were analyzed according to a 50-item list of validated healthcare information quality measures. Websites were graded by two blinded reviewers. Inter-rater agreement was confirmed by Cohen’s kappa coefficient. Ninety percent of websites addressed PSA screening. Cancer center sites covered 45% of topics surveyed, while organization websites addressed 70%. All organizational webpages addressed the possibility of false positive screening results; 41% of cancer center webpages did not. Forty percent of cancer center webpages also did not discuss next steps if a PSA test was positive. Only 6% of cancer center webpages were rated by our reviewers as “superior” (e.g. addressing > 75% of the surveyed topics), versus 20% of organizational webpages. Inter-rater agreement between our reviewers was high (kappa coefficient = 0.602). NCI-designated cancer center websites publish lower quality public information about PSA screening than sites run by major allied organizations. Nonetheless, information and communication deficiencies were observed across all surveyed sites. In an age of increasing patient consumerism, prospective prostate cancer patients would benefit from improved online PSA screening information from provider and advocacy organizations. Validated cancer patient web educational standards remain an important, understudied priority.

Racial Disparities and Effect on Quality of Care Among Hospitalized Patients With Inflammatory Bowel Disease: Findings From the National Health Discharge Survey

Introduction: Racial and ethnic disparities play a major role in the quality of healthcare delivery and outcomes in chronic diseases including Inflammatory Bowel Disease (IBD). Studies have shown that compared with other racial groups, whites have a higher prevalence and incidence of IBD while blacks experience significantly higher IBD-related hospitalizations and deaths relative to their prevalence. However, the role of race on the quality of care in IBD is unclear. Using length of hospital Stay (LOS), a validated surrogate measure of healthcare quality and efficiency, we sought to determine the impact of ethnicity on quality of care among hospitalized patients with IBD. Methods: We sampled 120 patients aged 18-90 years who had a primary admitting diagnosis of IBD (ulcerative colitis and Crohn's disease). LOS was modeled as a binary variable (< median LOS, ≥ median LOS). Multivariable logistic and linear regression was used to estimate the median LOS and odds ratio (OR) of increased duration of hospital stay by race/ethnicity, adjusted for health insurance status, age and sex. Results: Of the 120 sampled patients (mean age = 42 ± 14 years; 58% female; 81% white; 13% blacks) with admitting diagnosis of IBD, the median length of stay for the entire sample was 5 days across all racial groups. There was no significant difference in the median LOS when we compared the three racial categories, Whites (median 5 days; IQR: 6, 3) vs Blacks (median 5 days; IQR: 6, 3) vs others (median 5.5 days; IQR: 7, 4). The odds ratio for a median LOS of 5 days or more when adjusted for age and sex was higher in Blacks (OR 1.30, 95% CI: 0.43, 3.91) compared to whites, though this was not statistically significant. Similarly, the OR for a median LOS of 5 days or more when adjusted for age and sex was higher in other race/ethnic groups (OR 1.59 CI: 0.27, 9.31) compared with whites. Conclusion: To our knowledge, no study has examined the impact of race/ethnicity on LOS in hospitalized patients with IBD. In contrast to other outcome measures like mortality, racial disparity does not appear to have an effect on duration of hospital stay in IBD. We believe that the disproportionately high IBD related-mortality seen in blacks is not likely due to the quality of care during hospital admission as measured by the LOS. More studies should explore biologic and environmental factors which may likely impact disparities in IBD severity and mortality outcomes.

Pediatric-Specific End-of-Life Care Quality Measures: An Unmet Need of a Vulnerable Population.

We must ensure that the 20,000 US children (age 0 to 19 years) who die as a result of serious illness annually receive high-quality end-of-life care. Ensuring high-quality end-of-life care requires recognition that pediatric end-of-life care is conceptually and operationally different than that for adults. For example, in-hospital adult death is considered an outcome to be avoided, whereas many pediatric families may prefer hospital death. Because pediatric deaths are comparatively rare, not all centers offer pediatric-focused palliative care and hospice services. The unique psychosocial issues facing families who are losing a child include challenges for parent decision makers and young siblings. Furthermore, the focus on advance directive documentation in adult care may be less relevant in pediatrics because parental decision makers are available. Health care quality measures provide a framework for tracking the care provided and aid in agency and provider accountability, reimbursement, and educated patient choice for location of care. The National Quality Forum, Joint Commission, and other groups have developed several end-of-life measures. However, none of the current quality measures focus on the unique needs of dying pediatric patients and their caregivers. To evolve the existing infrastructure to better measure and report quality pediatric end-of-life care, we propose two changes. First, we outline how existing adult quality measures may be modified to better address pediatric end-of-life care. Second, we suggest the formation of a pediatric quality measure end-of-life task force. These are the next steps to evolving end-of-life quality measures to better fit the needs of seriously ill children.

From Concepts and Codes to Healthcare Quality Measurement: Understanding Variations in Value Set Vocabularies for a Statin Therapy Clinical Quality Measure.

Objective:To understand the impact of distinct concept to value set mapping on the measurement of quality of care.Background:Clinical quality measures (CQMs) intend to measure the quality of healthcare services provided, and to help promote evidence-based therapies. Most CQMs consist of grouped codes from vocabularies – or ‘value sets’ – that represent the unique identifiers (i.e., object identifiers), concepts (i.e., value set names), and concept definitions (i.e., code groups) that define a measure’s specifications. In the development of a statin therapy CQM, two unique value sets were created by independent measure developers for the same global concepts.Methods:We first identified differences between the two value set specifications of the same CQM. We then implemented the various versions in a quality measure calculation registry to understand how the differences affected calculated prevalence of risk and measure performance.Results:Global performance rates only differed by 0.8%, but there were up to 2.3 times as many patients included with key conditions, and differing performance rates of 7.5% for patients with ‘myocardial infarction’ and 3.5% for those with ‘ischemic vascular disease’.Conclusion:The decisions CQM developers make about which concepts and code groups to include or exclude in value set vocabularies can lead to inaccuracies in the measurement of quality of care. One solution is that developers could provide rationale for these decisions. Endorsements are needed to encourage system vendors, payers, informaticians, and clinicians to collaborate in the creation of more integrated terminology sets.

From Concepts and Codes to Healthcare Quality Measurement: Understanding Variations in Value Set Vocabularies for a Statin Therapy Clinical Quality Measure

From Concepts and Codes to Healthcare Quality Measurement: Understanding Variations in Value Set Vocabularies for a Statin Therapy Clinical Quality Measure

Health Equity and Quality of Care Assessment: A Continuing Challenge.

Reducing racial and/or ethnic disparities in a variety of health outcomes from neonatal, infant, and adult mortality to premature birth rates has been a hospital, state, and national goal. One area of focus has been differences in the types of care (or quality of care) that patients from minority racial/ethnic groups receive compared with non-Hispanic white patients. Profit et al1 provide new evidence of this potential issue as applied to perinatal medicine. By using data from >100 perinatal hospitals in California, the authors document substantial differences in the care quality received by non-Hispanic African American and Hispanic patients compared with non-Hispanic white patients. The magnitude of these differences as assessed by the Baby-MONITOR care tool varied between hospitals, with some hospitals showing higher quality of care in minority racial and/or ethnic patients and other hospitals showing much lower quality. Beyond these important findings, though, this research also highlights the substantial challenge when combining health equity goals with the measurement of health care quality. Researchers and policy makers can take 1 of 3 approaches to assess the care quality differences that may underlie health disparities. Profit et al1 use the most common mechanism: apply a set of previously validated quality measures … Address correspondence to Scott A. Lorch, MD, MSCE, Department of Pediatrics, Roberts Center for Pediatric Research, 2716 South St, Floor 10, Room 10215, Philadelphia, PA 19146. E-mail: lorch{at}email.chop.edu

Prioritizing quality measure concepts at the interface of behavioral and physical healthcare.

Integrated healthcare models can increase access to care, improve healthcare quality, and reduce cost for individuals with behavioral and general medical healthcare needs, yet there are few instruments for measuring the quality of integrated care. In this study, we identified and prioritized concepts that can represent the quality of integrated behavioral health and general medical care. We conducted a literature review to identify candidate measure concepts. Experts then participated in a modified Delphi process to prioritize the concepts for development into specific quality measures. United States. Expert behavioral health and general medical clinicians, decision-makers (policy, regulatory and administrative professionals) and patient advocates. Panelists rated measure concepts on importance, validity and feasibility. The literature review identified 734 measures of behavioral or general medical care, which were then distilled into 43 measure concepts. Thirty-three measure concepts (including a segmentation strategy) reached a predetermined consensus threshold of importance, while 11 concepts did not. Two measure concepts were 'ready for further development' ('General medical screening and follow-up in behavioral health settings' and 'Mental health screening at general medical healthcare settings'). Among the 31 additional measure concepts that were rated as important, 7 were rated as valid (but not feasible), while the remaining 24 concepts were rated as neither valid nor feasible. This study identified quality measure concepts that capture important aspects of integrated care. Researchers can use the prioritization process described in this study to guide healthcare quality measures development work.

Adapting Healthcare Quality Measures to Transgender Individuals.

The healthcare system's rapid shift toward value-based payment poses unique quality measurement challenges and new foci for researchers and policy makers. Quality measures that use sex-specific criteria may inappropriately include or exclude transgender individuals. More large-scale studies must be conducted to incorporate transgender individuals into measures that use sex-specific criteria, and "measure stewards" should consider the existing clinical guidelines and recommendations regarding transgender individuals when developing measures. Systems designed only for cisgender individuals will exacerbate existing transgender healthcare disparities unless they are revamped and flexible to transgender individuals' needs.

Political Context, Organizational Mission, and the Quality of Social Services: Insights from the Health Sector in Lebanon

Summary Non-state actors are important providers of social welfare. In parts of the Middle East, South Asia, sub-Saharan Africa, and other regions, religious charities and parties and NGOs have taken on this role, with some preceding independent statehood and others building parallel or alternative welfare infrastructure alongside the modern state. How well do these groups provide welfare goods? Do some exhibit a “welfare advantage,” or a demonstrated superiority in the quality and efficiency of providing social services? In this paper, we explore whether distinct organizational types are associated with different levels of the quality of care. Based on a study in Greater Beirut, Lebanon, where diverse types of providers operate health centers, we propose and test some hypotheses about why certain organizations might deliver better services. The data indicate that secular NGOs, rather than religious, political or public sector providers, the other main types of providers in the charitable sector, exhibit superior measures of health care quality, particularly with respect to objective provider competence and subjective measures of patient satisfaction. In Lebanon, where religious and sectarian actors dominate politics and the welfare regime and command the most extensive resources, this appears to be a counterintuitive finding. Our preliminary explanation for this outcome emphasizes the ways in which the socio-political context shapes the choices of more qualified or professional doctors to select into secular providers, in part because of their organizational missions, and why citizens might perceive these providers to be better, irrespective of the actual quality of services delivered.

Measuring cancer care experiences: Introducing SEER-CAHPS.

6595 Background: Care experience ratings are recognized as measures of healthcare quality. Here we introduce a new, public data resource, SEER-CAHPS, which links cancer registry data from the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) program with Medicare claims and the Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) survey. Methods: The SEER-CAHPS resource includes cancer registry data from 1973-2011 (diagnosis, incidence, mortality, and sociodemographic data), Medicare CAHPS survey data from 1998-2013 (sociodemographic, health status, and care experience ratings), and Medicare fee-for-service (FFS) claims data from 2002-2013. The survey includes global ratings of overall care, personal doctor, specialist, health plan, and prescription drug plans, and composite ratings of doctor communication, care coordination, getting needed care, and getting care quickly. Data also contain survey weights to account for the Medicare CAHPS sampling design. Cross-sectional and longitudinal analyses are possible. Results: Currently, SEER-CAHPS includes 205,339 individuals with a history of cancer documented in SEER (FFS: 26,802 with a survey before cancer diagnosis, and 55,231 with a survey after cancer diagnosis; Medicare Advantage [MA]: 57,227 with a survey before cancer diagnosis and 71,436 with a survey after cancer diagnosis). The data resource also includes 724,965 MCAHPS respondents without cancer in SEER regions (FFS: 282,592; MA: 447,358). The data provide insights on topics including experiences of cancer patients in their last year of life; experiences of cancer survivors; and the associations of guideline-concordant follow-up care with patient experiences among cancer survivors. We will demonstrate project sample-size estimation and present instructions for submitting data access applications. Conclusions: SEER-CAHPS, a new, publicly available resource, provides population-based, cancer-specific data on patient experiences, health outcomes and healthcare utilization.

The role of the European Structural and Investment Funds in Financing Health System in Lithuania: Experience from 2007 to 2013 funding period and implications for the future

European Structural and Investment Funds (ESIF) are a major source of investments in the newer EU member states. In Lithuania’s health sector, the amount for the 2007–2013 funding period reached more than €400 million. In this paper we aim to (i) identify the key areas in the health sector which were supported by ESIF, (ii) determine the extent to which ESIF assisted the implementation of the ongoing health system reform; and (iii) assess whether the use of funds has led to expected improvements in healthcare. We review the national strategic documents and legislation, and perform calculations to determine funding allocations by specific area, based on the available data. We analyse changes according to a set of selected indicators. We find that implementation of programmes funded by the ESIF lacks formal evaluation. Existing evidence suggests that some improvement has been achieved by 2013. However, there are persisting challenges, including failure to reach a broad agreement on selection of health and healthcare indicators, lack of transparency in allocations, and absence of coherent assessment measures of healthcare quality and accessibility.

Coding update of the SMFM definition of low risk for cesarean delivery from ICD-9-CM to ICD-10-CM

In 2015, the Society for Maternal-Fetal Medicine developed a low risk for cesarean delivery definition based on administrative claims-based diagnosis codes described by the International Classification of Diseases, Ninth Revision, Clinical Modification. The Society for Maternal-Fetal Medicine definition is a clinical enrichment of 2 available measures from the Joint Commission and the Agency for Healthcare Research and Quality measures. The Society for Maternal-Fetal Medicine measure excludes diagnosis codes that represent clinically relevant risk factors that are absolute or relative contraindications to vaginal birth while retaining diagnosis codes such as labor disorders that are discretionary risk factors for cesarean delivery. The introduction of the International Statistical Classification of Diseases, 10th Revision, Clinical Modification in October 2015 expanded the number of available diagnosis codes and enabled a greater depth and breadth of clinical description. These coding improvements further enhance the clinical validity of the Society for Maternal-Fetal Medicine definition and its potential utility in tracking progress toward the goal of safely lowering the US cesarean delivery rate. This report updates the Society for Maternal-Fetal Medicine definition of low risk for cesarean delivery using International Statistical Classification of Diseases, 10th Revision, Clinical Modification coding.

The Performance Measures of Primary Health Care Quality: Experiences of Morocco Primary Health Centers during the ‘Quality Contest’ in 2010-2014 (41 Centers Audited)

The Performance Measures of Primary Health Care Quality: Experiences of Morocco Primary Health Centers during the ‘Quality Contest’ in 2010-2014 (41 Centers Audited)

Development and Validation of the Agency for Healthcare Research and Quality Measures of Potentially Preventable Emergency Department (ED) Visits: The ED Prevention QualityIndicators for General Health Conditions.

To develop and validate rates of potentially preventable emergency department (ED) visits as indicators of community health. Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project 2008-2010 State Inpatient Databases and State Emergency Department Databases. Empirical analyses and structured panel reviews. Panels of 14-17 clinicians and end users evaluated a set of ED Prevention Quality Indicators (PQIs) using a Modified Delphi process. Empirical analyses included assessing variation in ED PQI rates across counties and sensitivity of those rates to county-level poverty, uninsurance, and density of primary care physicians (PCPs). ED PQI rates varied widely across U.S. communities. Indicator rates were significantly associated with county-level poverty, median income, Medicaid insurance, and levels of uninsurance. A few indicators were significantly associated with PCP density, with higher rates in areas with greater density. A clinical and an end-user panel separately rated the indicators as having strong face validity for most uses evaluated. The ED PQIs have undergone initial validation as indicators of community health with potential for use in public reporting, population health improvement, and research.

Family-Centered Care Measurement and Associations With Unmet Health Care Need Among US Children

ObjectiveFamily-centered care (FCC), including shared decision making (SDM), has become increasingly emphasized in pediatric health care delivery. Past studies using national surveys have used different FCC measurement approaches without determining their validity. We, therefore, sought to develop an FCC measurement model with Medical Expenditure Panel Survey (MEPS) items previously used to assess FCC or SDM; and to determine temporal associations of FCC with unmet health care need. MethodsFour longitudinal MEPS data files (2007–2011) were combined. The study sample included 15,764 US children aged 0 to 17 years. Eight items assessed FCC, and 5 items assessed unmet health care need. We performed exploratory factor analyses to develop an FCC measurement model and fit a cross-lagged structural equation model to determine temporal associations between FCC and unmet health care need. ResultsResults supported a 2-factor FCC model including family–provider communication and SDM. The family–provider communication factor was indicated by items reflecting general communication between the child's doctor and family. The SDM factor was indicated by items reflecting decision-making about the child's health care. Adjusted cross-lagged structural equation model results showed family–provider communication and SDM were associated with a reduced likelihood of unmet health care need the following year. Unmet health care need was not significantly associated with family–provider communication or SDM the subsequent year. ConclusionsStudy results support differentiating between family–provider communication and SDM as interrelated aspects of FCC in future pediatric health care quality measurement and improvement. Family–provider communication and SDM may reduce the likelihood of unmet health care need the following year among US children.

Factors That Matter to Low-Income and Racial/Ethnic Minority Mothers When Choosing a Pediatric Practice: a Mixed Methods Analysis.

Pediatric practices' scores on healthcare quality measures are increasingly available to the public. However, patients from low-income and racial/ethnic minority populations rarely use these data. We sought to understand potential barriers to using quality data by assessing what factors mattered to women when choosing a pediatric practice. As part of a randomized trial to overcome barriers to using quality data, we recruited women from a prenatal clinic serving an underserved population. Women reported how much 12 factors mattered when they chose a pediatric practice (5-point Likert scale), what other factors mattered to them, and which factors mattered the most. We assessed whether factor importance varied with selected participant characteristics and qualitatively analyzed the "other" factors named. Participants' (n=367) median age was 23years, and they were largely Hispanic (60.4%), white (21.2%), or black (16.9%). Insurance acceptance "mattered a lot" to the highest percentage of women (93.2%), while online information about what other parents think of a practice "mattered a lot" to the fewest (7.4%). Major themes from our qualitative analysis of "other" factors that mattered included physicians' interpersonal skills and pediatrician-specific traits. Factors related to access "mattered the most" to the majority of women. Pediatrician characteristics and factors related to access to care may be more important to low-income and racial/ethnic minority women than more commonly reported quality metrics. Aligning both the content and delivery of publicly reported quality data with women's interests may increase use of pediatric quality data. Clinicaltrials.gov NCT01784575.

Measuring quality: caries-related emergency department visits and follow-up among children.

This study validated two Dental Quality Alliance system-level measures of oral healthcare quality for children - caries-related emergency department (ED) visits and timely follow-up of those visits with a dentist - including formal validation of diagnosis codes used to identify caries-related ED visits and measurement of follow-up care. The measures were specified for implementation with administrative claims data and validated using data from the Florida and Texas Medicaid and Children's Health Insurance Programs. Measure specification testing and measure score validation used administrative data for 7,007,765 children. We validated the diagnosis codes in claims data by comparisons with manual reviews of 300 records from a Florida hospital ED and calculation of the kappa statistic, sensitivity, and specificity. Overall agreement in caries-related ED visit classifications between the claims data and record reviews was 87.7 percent with kappa = 0.71, sensitivity = 82 percent, and specificity = 90 percent. The calculated measure scores using administrative data found more than four-fold variation between programs with the lowest and highest caries-related ED visit rates (6.90/100,000 member months and 30.68/100,000 member months). The percentage of follow-up visits within 7 days and 30 days ranged from 22-39 percent and 34-49 percent, respectively. These National Quality Forum endorsed measures provide valid methodologies for assessing the rate of caries-related ED visits, an important system-level outcome indicator of outpatient prevention and disease management, and the timeliness of follow-up with a dentist. There is significant variation in caries-related ED visits among state Medicaid programs, and most ED visits do not have follow-up with a dentist within 30 days.

Sexual Minority Women's Satisfaction with Health Care Providers and State-level Structural Support: Investigating the Impact of Lesbian, Gay, Bisexual, and Transgender Nondiscrimination Legislation

PurposeStructural discrimination is associated with negative health outcomes among sexual minority populations. Recent changes to state-level and national legislation provide both the opportunity and the need to further explore the impact of legislation on the health indicators of sexual minorities. Using an ecosocial theory lens, the present research addresses the relationship between structural support or discrimination and satisfaction with one's health care provider among sexual minority women. MethodsData were drawn from an online survey of sexual minority women's health care experiences. Using the Andersen Behavioral Model of Health Services Utilization to operationalize the variables in our model, we examined the relationship between state-level nondiscrimination legislation and satisfaction with provider—a widely used measure of health care quality—through regression analysis. FindingsParticipants in structurally supportive states (i.e., those with nondiscrimination legislation) were more likely to disclose their sexual identity to their providers and to report higher satisfaction with their providers. The absence of nondiscrimination legislation was associated negatively with satisfaction with providers. ConclusionsResults of our study show that the external environment in which sexual minority women seek health care, characterized by structural support or lack thereof, is related to perceived quality of health care.