Clinical Performance Measures Research Articles

Personality Traits Are Associated with Academic Achievement in Medical School: A Nationally Representative Study.

This nationally representative study sought to identify personality traits that are associated with academic achievement in medical school. Third-year medical students, who completed an initial questionnaire in January 2011, were mailed a second questionnaire several months later during their fourth year. Controlling for sociodemographic characteristics and burnout, the authors used multivariate logistic regressions to determine whether Big Five personality traits were associated with receiving honors/highest grade in clinical clerkships, failing a course or rotation, and being selected for the Alpha Omega Alpha or Gold Humanism Honor Society. The adjusted response rates for the two surveys were 61 (n=564/919) and 84% (n=474/564). The personality trait conscientiousness predicted obtaining honors/highest grade in all clinical clerkships. In contrast, students high in neuroticism were less likely to do well in most specialties. Students with higher conscientiousness were more likely to be inducted into the Alpha Omega Alpha Honor Society, while students high in openness or agreeableness traits were more likely to be inducted into the Gold Humanism Honor Society. Burnout was not associated with any clinical performance measures. This study suggests the importance of personality traits, particularly conscientiousness, in predicting success during the clinical years of medical school. Medical educators should consider a nuanced examination of personality traits and other non-cognitive factors, particularly for psychiatry.

Mannequin-Based Immersive Simulation Improves Resident Understanding of a Clinical Decision Rule

Objective.Simulation-based medical education may aid to standardize clinical performance measures, though there is little evidence for using an immersive, mannequin-based simulation for knowledge acquisition. We predicted that residents who had participated in an immersive simulation exercise illustrating the use of a clinical decision rule plus routine instructional methods (experimental group) would understand and implement this tool better than interns who participated in an immersive simulation focused on traumatic brain injury with intracranial hypertension plus routine instructional methods (control group 1). We further predicted that interns in the experimental group would understand and implement this tool as well as senior residents with more clinical experience (control group 2). Methods. This was a single center, prospective, simulation-based, randomized controlled trial. Pediatric interns were randomly assigned to clinically integrated teaching, plus a single, immersive simulation and structured debrief aimed at teaching this tool in minor head trauma (intervention), or clinically integrated teaching plus a related simulation on intracranial hypertension. Senior residents were used as an historical control arm and did not participate in a simulated encounter. Results. 20 interns (ten per group) participated in the study. Senior residents (n=40) served as historical comparisons. Interns in the intervention group scored similar to senior residents on a structured clinical observation score (median 64% vs. 57%), and better than interns in the placebo group (median 64% vs. 43%). Conclusions. In this study, a single immersive simulation improved resident learning and application of a clinical prediction rule when compared to standard resident education.

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

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

New York State’s Path to Behavioral Health Integration

New York State’s Path to Behavioral Health Integration

New clinical performance measures for contraceptive care: their importance to healthcare quality

ObjectivesThe National Quality Forum (NQF) recently endorsed the first clinical performance measures for contraceptive care. We present data demonstrating that the measures meet the NQF's criterion “importance to measure and report.” Study designWe summarized national contraceptive care initiatives, epidemiologic data documenting the reproductive health burden and the scientific literature examining the association between contraceptive use and unintended pregnancy. In addition, we analyzed contraceptive use data from the National Survey of Family Growth (2013–2015) and the Pregnancy Risk Assessment Monitoring System (2012–2013). ResultsFive Federal agencies lead national initiatives, and two Institute of Medicine reports highlight the centrality of reproductive health outcomes for the health of women and infants. Two literature reviews demonstrate that the type of contraception used is associated with risk of unintended pregnancy. Fifty-three percent of adolescents (15–19years) and 40% of adult women (20–44years) at risk of unintended pregnancy are not using a most or moderately effective contraceptive method; in the postpartum period, one third of adolescents (≤19years) and 44% of adult women (≥20years) are not using these methods. ConclusionsThe new contraceptive care measures meet the NQF criterion for “importance to measure and report.” The measures are based on evidence that contraceptive use is associated with reproductive health outcomes, and there is a substantial performance gap in the use of most and moderately effective methods. ImplicationsUsing the new contraceptive care measures may motivate providers to increase access to contraceptive care, thereby improving health outcomes.

Use of clinical performance measures for contraceptive care in Iowa, 2013

ObjectivesTo assess feasibility of calculating clinical performance measures for contraceptive care for National Quality Forum submission: the percentage of women aged 15–44 years provided the following: (1) a most or moderately effective contraceptive method (MME) and (2) a long-acting reversible contraceptive (LARC) method. MethodsWe used 2013 Iowa Department of Public Health (IDPH) Title X and Iowa Medicaid data. We stratified Title X data by age and Medicaid data by age and benefit type (family planning waiver (FPW) vs. general Medicaid), and examined variation by residence, public health region and health plan based on program interest. FindingsAmong women attending IDPH Title X clinics in 2013 (N=11,584), 86% of women aged 15–20years and 83% of women aged 21–44years were provided MME; and 20% of women aged 15–20years and 20% of women aged 21–44years were provided LARC. Estimates varied across Title X subrecipient agencies, which receive federal funds from IDPH. Among Medicaid FPW clients (N=30,013), 79% of women aged 15–20years and 73% of women aged 21–44years were provided MME; and 12% of women aged 15–20years and 11% of women aged 21–44years were provided LARC. Among general Medicaid clients (N=14,737), 40% of women aged 15–20years and 28% of women aged 21–44years were provided MME; and 5% of women aged 15–20years and 5% of women aged 21–44years were provided LARC. ConclusionA high percentage of IDPH Title X and FPW clients were provided an MME method. No reporting entity had a LARC percentage less than 1%–2%. ImplicationsMeasure calculation using Title X and Medicaid data is feasible and can potentially be used to identify ways to increase access to contraceptive methods.

The Maternal Quality Improvement Program: A Clinical Data-Driven National Registry for Maternity Care.

Advancing the quality and safety of maternity care should be data-driven. Defining a standard set of clinical data elements, across electronic health record platforms and facilities, could accelerate performance measurement, benchmarking, and identification of better practices. In 2014, the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists launched the Maternal Quality Improvement Program, a data-driven national clinical registry for maternity care. Having an agreed-on set of discrete data elements related to labor and delivery will set the stage for analysis of this care. Through the use of clinical performance measures and data quality metrics, the Maternal Quality Improvement Program will provide an opportunity for health care providers to better understand the overall quality and safety of the maternity care provided within their institution.

Treatment and outcomes of acute coronary syndromes in women: An analysis of a multicenter quality improvement Chinese study

BackgroundVariations in care and outcomes by sex in patients with acute coronary syndrome (ACS) have been reported worldwide. The aims of this study are to describe ACS management according to sex in China and the effects of a quality improvement program in Chinese male and female ACS patients. Methods and resultsClinical Pathways for Acute Coronary Syndromes - Phase 2 (CPACS-2) was a cluster randomized trial to test whether a clinical pathways-based intervention would improve ACS management in China. The study enrolled 15,141 hospitalized patients [4631 (30.6%) were women] from 75 hospitals throughout China between October 2007 and August 2010. The intervention included clinical pathway implementation and performance measurement using standardized indicators with 6 monthly audit-feedback cycles. Eight key performance indicators reflecting in hospital management of ACS were measured. After adjustment for differences in patient characteristics and comorbidities at presentation, women were significantly less likely to undergo coronary angiography when indicated (RR 0.88 [0.85 to 0.92], P<0.001), less likely to receive guideline recommended medical therapies at discharge (RR 0.94 [0.91 to 0.98], P=0.003) and more likely to be hospitalized for shorter (mean difference −0.42 [−0.73 to −0.12] days, P=0.007). However, in-hospital clinical outcomes did not differ by sex. There was no evidence of heterogeneity in the relative effects of the quality improvement initiative by sex. ConclusionsSex disparities were apparent in some key quality of care indicators for patients with suspected with ACS presenting to hospitals in China. The beneficial effect of the quality improvement program was consistent in women and men. Clinical trial registrationhttp://www.anzctr.org.au/default.aspx. Unique identifier: ACTRN12609000491268.

Accuracy of Postresuscitation Team Debriefings in a Pediatric Emergency Department

Guideline committees recommend postresuscitation debriefings to improve performance. "Hot" postresuscitation debriefings occur immediately after the event and rely on team recall. We assessed the ability of resuscitation teams to recall their performance in team-based, hot debriefings in a pediatric emergency department (ED), using video review as the criterion standard. We hypothesized that debriefing accuracy will improve during the course of the study. Resuscitation physician and nurse leaders cofacilitated debriefings after ED resuscitations involving cardiopulmonary resuscitation (CPR) or intubation. Debriefing teams recorded their self-assessments of clinical performance measures with standardized debriefing forms. The debriefing form data were compared with actual performance measured by video review at 2 pediatric EDs over 22 months. CPR performance measures included time to automated external defibrillator pad placement, epinephrine administration timing, and compression pause timing. Intubation measures included occurrences of oxygen desaturation, number of intubation attempts, and use of end-tidal carbon dioxide monitoring. We analyzed 100 resuscitations (14 cardiac arrests, 22 cardiac arrests with intubation, and 64 intubations). The accuracy of debriefing answers was 87%, increasing from 83% to 91% between the first and second halves of the study period (7.7% difference; 95% confidence interval 0.2% to 15%). Debriefings that acknowledged an error in certain performance measures (ie, automated external defibrillator pad placement delay, multiple intubation attempts, and occurrence of oxygen desaturation) had significantly worse performance in those specific measures on video review. Teams in postresuscitation debriefings had a higher degree of debriefing answer accuracy in the final 50 debriefings than in the first 50. Teams also distinguished various degrees of resuscitation performance.

Clinical Performance Measures and Quality Improvement System Considerations for Dental Education

Quality improvement and quality assurance programs are an integral part of providing excellence in health care delivery. The Dental Quality Alliance and the Commission on Dental Accreditation recognize this and have created standards and recommendations to advise health care providers and health care delivery systems, including dental schools, on measuring the quality of the care delivered to patients. Overall health care expenditures have increased, and the Affordable Care Act has made health care, including dentistry, available to more people in the United States. These increases in cost and in the number of patients accessing care contribute to a heightened interest in measurable quality improvement outcomes that reflect efficiency, effectiveness, and overall value. Practitioners and administrators, both in academia and in the "real world," need an understanding of various quality improvement methodologies available in order to select approaches that support effective monitoring of the quality of care delivered. This article compares and contrasts various quality improvement approaches, programs, and systems currently in use in order to assist dental providers and administrators in choosing quality improvement methodologies pertinent to their practice or institution.

Do coursework summative assessments predict clinical performance? A systematic review

BackgroundTwo goals of summative assessment in health profession education programs are to ensure the robustness of high stakes decisions such as progression and licensing, and predict future performance. This systematic and critical review aims to investigate the ability of specific modes of summative assessment to predict the clinical performance of health profession education students.MethodsPubMed, CINAHL, SPORTDiscus, ERIC and EMBASE databases were searched using key terms with articles collected subjected to dedicated inclusion criteria. Rigorous exclusion criteria were applied to ensure a consistent interpretation of ‘summative assessment’ and ‘clinical performance’. Data were extracted using a pre-determined format and papers were critically appraised by two independent reviewers using a modified Downs and Black checklist with level of agreement between reviewers determined through a Kappa analysis.ResultsOf the 4783 studies retrieved from the search strategy, 18 studies were included in the final review. Twelve were from the medical profession and there was one from each of physiotherapy, pharmacy, dietetics, speech pathology, dentistry and dental hygiene. Objective Structured Clinical Examinations featured in 15 papers, written assessments in four and problem based learning evaluations, case based learning evaluations and student portfolios each featured in one paper. Sixteen different measures of clinical performance were used. Two papers were identified as ‘poor’ quality and the remainder categorised as ‘fair’ with an almost perfect (k = 0.852) level of agreement between raters. Objective Structured Clinical Examination scores accounted for 1.4–39.7% of the variance in student performance; multiple choice/extended matching questions and short answer written examinations accounted for 3.2–29.2%; problem based or case based learning evaluations accounted for 4.4–16.6%; and student portfolios accounted for 12.1%.ConclusionsObjective structured clinical examinations and written examinations consisting of multiple choice/extended matching questions and short answer questions do have significant relationships with the clinical performance of health professional students. However, caution should be applied if using these assessments as predictive measures for clinical performance due to a small body of evidence and large variations in the predictive strength of the relationships identified. Based on the current evidence, the Objective Structured Clinical Examination may be the most appropriate summative assessment for educators to use to identify students that may be at risk of poor performance in a clinical workplace environment. Further research on this topic is needed to improve the strength of the predictive relationship.

Using organizational and clinical performance data to increase the value of mental health care.

U.S. health systems, policy makers, and patients increasingly demand high-value care that improves health outcomes at lower cost. This study describes the initial design and analysis of the Mental Health Management System (MHMS), a performance data and quality improvement tool used by the Veterans Health Administration (VHA) to increase the value of its mental health care. The MHMS evaluates access to and quality of mental health care, organizational structure and efficiency, implementation of innovative treatment options, and, in collaboration with management, resource needs for delivering care. Performance on 31 measures was calculated for all U.S. VHA facilities (N = 139). Pearson correlations revealed that better access to care was significantly associated with fewer mental health provider staffing vacancies (r = -.24) and higher staff-to-patient ratios for psychiatrists (r = .19) and other outpatient mental health providers (r = .27). Higher staff-to-patient ratios were significantly associated with higher performance on a number of patient and provider satisfaction measures (range of r = .18-.51) and continuity of care measures (range of r = .26-.43). Relationships observed between organizational and clinical performance measures suggest that the MHMS is a robust informatics and quality improvement tool that can serve as a model for health systems planning to adopt a value perspective. Future research should expand the MHMS framework to measure patient and health systems costs and psychosocial outcomes, as well as evaluate whether quality improvement solutions implemented as a result of using organizational information leads to higher-value mental health care. (PsycINFO Database Record

2016 AHA/ACC Clinical Performance and Quality Measures for Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures.

Paul A. Heidenreich, MD, MS, FACC, FAHA, Chair [‡][1] Nancy M. Albert, PhD, CCNS, CCRN, FAHA[§][2] Paul S. Chan, MD, MSc, FACC[‡][1] Lesley H. Curtis, PhD[‡][1] T. Bruce Ferguson, Jr, MD, FACC[§][2] Gregg C. Fonarow, MD, FACC, FAHA[‡][1] Michelle Gurvitz, MD, FACC[§][2] Corrine Y.

A Comparison of Third-year Medical Student Clinical and Examination Performances in a Traditional Psychiatry Clerkship to a Novel Pilot, LSI Curriculum

Objective: The goal of this study was to compare educational outcomes of medical students who participated in a longitudinal pilot curriculum to those who participated in the existing, traditional curriculum during their third-year of medical school. Method: The authors reviewed clinical evaluations and examination performances of 15 students enrolled in a pilot curriculum to 60 students who participated in the traditional curriculum. The nove Lead.Serve.Inspire. (LSI) curriculum consisted of a longitudinal integrated hybrid of internal medicine, neurology, and psychiatry rotations and didactic instruction spanning nearly four months. Results: The National Board of Medical Examiners (NBME) subject examination class averages of students enrolled in the combined internal medicine, neurology, and psychiatry pilot program were not significantly different compared to students completing these examinations and enrolled in the traditional block rotations during the same time period. On clinical performance measures in psychiatry, students performed above average on clinical measures of medical knowledge, communication skills, and diagnostic assessment and critical analysis skills. Conclusion: Preliminary data from the pilot program is promising, suggesting that the Lead.Serve.Inspire. (LSI) curriculum may offer an equitable alternative to the traditional discipline-specific block rotations.

Hemoglobin of 12 g/dl and above is not associated with increased cardiovascular morbidity in children on hemodialysis

In adults on chronic hemodialysis, achieving a hemoglobin concentration of 12g/dl and above with erythropoiesis stimulating agents leads to increased cardiovascular events and mortality, but this may not be true in children. Therefore, we conducted a retrospective cohort study of pediatric patients (under 18) from the Centers for Medicare and Medicaid Services End Stage Renal Disease (ESRD) Clinical Performance Measures (CPM) project (2000 to 2008) merged with the United States Renal Data System. Hemoglobin was determined from the Clinical Performance Measures data, and beginning annually on January 1st of the next year, patients were followed for up to 1 year. We determined the outcomes (mortality, hospitalization, and cardiovascular events) during follow-up by hemoglobin group at baseline. Models were adjusted for demographic and clinical characteristics of 1569 children studied. The hemoglobin 12g/dl and above group was older, had fewer years of ESRD, and was more often transplanted. Inpatient and outpatient visits for congestive heart failure, cardiomyopathy, and valvular heart disease were most common in the hemoglobin under 10g/dl group and the frequency of these diagnoses decreased with increasing hemoglobin. The hazard ratio of all-cause mortality (0.33, 95% confidence interval 0.14-0.81) and the adjusted relative rate of all-cause hospitalizations (0.81, 0.74-0.89) were significantly lower in the hemoglobin 12 g/dl and above group. Cardiovascular hospitalizations were significantly higher in the hemoglobin under 10g/dl group (1.31, 1.05-1.64). Thus, in children on hemodialysis, hemoglobin 12g/dl and above is not associated with increased cardiovascular visits, mortality, orall-cause and cardiovascular-related hospitalizations.

The ESRD Quality Incentive Program: The Current Limitations of Evidence and Data to Develop Measures, Drive Improvement, and Incentivize Outcomes.

This article describes the current state of facilitating the integration of evidence into practice to support initiatives focused on patients with ESRD. We will use the Centers for Medicare and Medicaid Services (CMS) ESRD Quality Incentive Program (QIP) as an example, including a description of the health information infrastructure needed to support the translation of evidence into practice and some of the challenges encountered. The process from the generation of evidence to integration of this evidence into practice includes policy development leading to clinical practice guidelines, clinical performance measures, and clinical decision support tools. The ESRD QIP is the most mature program outside the hospital initiatives in the CMS Quality Payment Program and currently contains 16 measures. ESRD data to support these measures are aggregated at the dialysis facility level and reported through the CMS Consolidated Renal Operations in a Web-enabled Network (CROWNWeb) and the Centers for Disease Control and Prevention using the National Healthcare Safety Network. We review these measures and the health information infrastructure used to report the data, focusing on the inherent strengths and weaknesses of the ESRD QIP along with opportunities for improvement of the program.

Quantifying selective elbow movements during an exergame in children with neurological disorders: a pilot study.

BackgroundIt is difficult to distinguish between restorative and compensatory mechanisms underlying (pediatric) neurorehabilitation, as objective measures assessing selective voluntary motor control (SVMC) are scarce.MethodsWe aimed to quantify SVMC of elbow movements in children with brain lesions. Children played an airplane game with the glove-based YouGrabber system. Participants were instructed to steer an airplane on a screen through a cloud-free path by correctly applying bilateral elbow flexion and extension movements. Game performance measures were (i) % time on the correct path and (ii) similarity between the ideal flight path and the actually flown path. SVMC was quantified by calculating a correlation coefficient between the derivative of the ideal path and elbow movements. A therapist scored whether the child had used compensatory movements.ResultsThirty-three children with brain lesions (11 girls; 12.6 ± 3.6 years) participated. Clinical motor and cognitive scores correlated moderately with SVMC (0.50–0.74). Receiver Operating Characteristics analyses showed that SVMC could differentiate well and better than clinical and game performance measures between compensatory and physiological movements.ConclusionsWe conclude that a simple measure assessed while playing a game appears promising in quantifying SVMC. We propose how to improve the methodology, and how this approach can be easily extended to other joints.Electronic supplementary materialThe online version of this article (doi:10.1186/s12984-016-0200-3) contains supplementary material, which is available to authorized users.

Study protocol for "Healthy Hearts Northwest": a 2 × 2 randomized factorial trial to build quality improvement capacity in primary care.

BackgroundLittle attention has been paid to quality improvement (QI) capacity within smaller primary care practices which comprise nearly half of all primary care settings. Strategies for external support to build such capacity include practice facilitation (PF), shared learning opportunities, and educational outreach. Although PF has proven effectiveness, little is known about the comparative effectiveness of combining these strategies. Here, we describe the protocol of the “Healthy Hearts Northwest” (H2N) study, a randomized trial designed to address these questions while improving risk factors for cardiovascular disease.Methods/designThe targeted enrollment is 250 smaller primary care practices across Washington, Oregon, and Idaho. The study is utilizing a two-by-two factorial design to assess four different combinations of practice support: PF alone, PF with educational outreach, PF with shared learning opportunities, or PF with both. A mixed methods approach is being used for evaluation and will include data from (1) baseline and follow-up practice and staff surveys; (2) baseline and quarterly clinical performance measurement from each practice on four cardiovascular risk factors: appropriate aspirin use, blood pressure control, lipid management and smoking cessation support; and (3) a quality improvement capacity assessment (QICA) survey used by external practice facilitators to guide improvement efforts.DiscussionResults from this study will inform future large-scale practice improvement initiatives by providing comparisons of promising external practice support strategies and advance our understanding of how to build QI capacity in primary care.Trial registrationClinicalTrials.gov, NCT02839382

Inclusion of Hypoglycemia in Clinical Practice Guidelines and Performance Measures in the Care of Patients With Diabetes

Inclusion of Hypoglycemia in Clinical Practice Guidelines and Performance Measures in the Care of Patients With Diabetes

Ultrafiltration Rate Clinical Performance Measures: Ready for Primetime?

Mounting evidence supports a strong association between fluid management and outcomes among individuals receiving maintenance hemodialysis. The speed of fluid removal during dialysis (ultrafiltration, UF) is a modifiable aspect of fluid management that has attracted recent attention as a potential performance measure for facility fluid management practices. Observational data support an association between higher UF rates and adverse outcomes. This association is supported by the plausible pathophysiologic rationale of hypoperfusion-induced ischemic injury to the heart and other end-organs. However, no published clinical trial has studied the impact of lowering UF rates on clinical and patient-centered outcomes. Lowering UF rates requires interdialytic weigh gain reduction and/or extension of dialysis time. Weight gain reduction has proven difficult despite nutritional programs focused on salt and fluid restrictions, and patients are generally averse to longer treatment times. Thus, imposition of UF rate limitations may lead to failed target weight achievement and volume expansion over time. Despite these potential unintended consequences, the National Quality Forum endorsed an UF rate clinical performance measure in 2015. Prior to implementation of quality measure-imposed UF rate limitations, prospective studies of UF rates and outcomes are needed.