Health Care Quality Measures Research Articles

PIN81 - Benchmarking HIV Quality Measures Across US Payer Types

Despite advances in antiretroviral therapy (ART), human immunodeficiency virus (HIV) remains a significant issue in the United States. Early diagnosis, continuous treatment access/adherence, and long-term care engagement help patients benefit fully from ART; however, a shortfall in care engagement remains, potentially leading to poorer health outcomes. This analysis benchmarks rates of health care quality and process measures to identify areas for improvement. This retrospective, claims-based, real-world cohort study assessed the percentage of prevalent (existing) and incident (newly diagnosed) patients with HIV with commercial or public health insurance meeting 4 National Quality Forum (NQF)-endorsed, 1 Pharmacy Quality Alliance (PQA), and 3 Centers for Disease Control and Prevention (CDC) measures over a 4-year period. Most prevalent patients consistently met the NQF-endorsed prescribed ART and gaps in visits measures. Longer-term visit frequency measure rates were well below the 90% Joint United Nations Programme on HIV/AIDS target. Proportion of prevalent patients meeting each NQF-endorsed measure was maintained/increased with increasing age in 2015-2016. Substantially fewer incident patients than prevalent patients met NQF-endorsed measures across all measurement periods, particularly for visit frequency (32%-51%). PQA ART adherence was low (36%-73%). CDC receipt of care rates were high (83%-92%), whereas retention in care rates were low (67%-72%) among prevalent patients. For incident patients, linkage to care rates were consistently low (21%-44%). This study benchmarks current US HIV care engagement and highlights the need for improvement in early care engagement, ART adherence and long-term retention of care among patients with HIV.

A Health Plan's Journey to Identifying Meaningful Quality Measures.

The number of quality measures in health care is overwhelming, and reporting requirements are inconsistent. Value-based payments emphasize the need to prioritize quality measures and align across organizations. This article describes the process Humana undertook to reduce the quality measurement burden, refine measure consistency across the organization, ensure alignment with national standards, and relate quality measures to improved health outcomes within the health plan. Of the 1100 measures identified in use at Humana, 699 were duplicative or inconsistent. The biggest challenge was reaching consensus on similar measures while staying within regulatory and accrediting agency constraints. After review, physicians, quality experts, and business leaders prioritized 208 quality measures grounded in evidence, supported by credible organizations, and impactful to health outcomes. A governance committee was created to provide ongoing, proactive quality measure review. These efforts allow Humana to better support value-based payments by reducing complexity and helping physicians focus on meaningful measures.

Benchmarking of aggregated length of stay after open and laparoscopic surgery for cancers of the digestive system.

BackgroundLength of hospital stay (LOS) may serve as a surrogate measure of healthcare quality and resource use, particularly when transfers of care and readmissions are accounted for. This study aimed to benchmark true hospital stay by measuring index, transfer and readmission stays across the range of digestive cancer surgery.MethodsA cohort study of all patients undergoing resection for cancer of the oesophagus, stomach, liver, pancreas, colon or rectum in 2012–2016 was undertaken. Index LOS, transfer and readmission stays were merged into an ‘aggregated’ length of stay (a‐LOS), and compared between organ sites and between open and minimal‐access approaches.ResultsIn total, 24 354 resections were reported (mean age of patients 68·3 years; 51·3 per cent were men). Resections were reported as laparoscopic for 9151 procedures (37·6 per cent), with a further 283 (3·0 per cent) described as converted to open surgery. Use of a‐LOS compared with standard LOS added a median of 5 days for pancreatoduodenectomy, 4 days for major liver resections, 3 days for oesophageal and gastric resections, and 2 days for minor liver, distal pancreatic and rectal resections.ConclusionOverall hospital stay across organ sites and procedures is better described by a‐LOS. The study benchmarks the use of total hospital days during the first 30 days in a universal healthcare system.

Separable covariance models for health care quality measures across years and topics.

Public quality reports for Medicare Advantage health plans include 11 measures of patient experiences reported in the annual Consumer Assessment of Healthcare Providers and Systems surveys. Computing summaries at the health plan level (of multiple measures in multiple years) yields an array-structured random variable. To summarize associations among measures and years, we model the variance-covariance matrix governing the plan-level vectors of yearly quality measures as a Kronecker product of an across-measure matrix and an across-year matrix, or a sum of such Kronecker products. This approach extends separable covariance structure to Fay-Herriot models. In addition, we develop linear combinations of Kronecker products similar to principal components for array random variables. To each Kronecker-product term, we apply post hoc analyses suited to the corresponding dimension of the cross-classification: 1-way factor analysis for the across-measure factor and time-series analysis to the across-year factor. These methods draw out key patterns of variation in the quality measures over time and suggest new strategies for reporting quality information to consumers.

Press Ganey Outpatient Medical Practice Survey Scores Do Not Correlate With Patient-Reported Outcomes After Primary Joint Arthroplasty

BackgroundPatient delivery of care satisfaction surveys have emerged as instruments to assess the quality of health care at both the hospital and provider levels. We evaluated the correlation between these care satisfaction surveys and patient-reported outcomes (PROs). MethodsWe reviewed secondary data on 540 patients with 540 random visits who underwent primary total joint arthroplasty between January 2014 and February 2017. The Press Ganey Outpatient Medical Practice Survey was collected from outpatient clinical encounters to measure patient satisfaction with their experience and matched to PRO measures from the same encounter. The PROs evaluated included the Patient-Reported Outcomes Measurement Information System physical function computerized adaptive test, v1.2, and the Patient-Reported Outcomes Measurement Information System Global 10 health survey. In addition to the random selection, we reviewed separate cross-sections of the data including preoperative visits within 90 days of the index procedure, all postoperative visits at least 1 year from the index procedure, and the magnitude of change in PRO scores from preoperative to a minimum 1-year postoperative visit. Data were evaluated using the Spearman correlation coefficient (rs). ResultsThere was little if any correlation between the Press Ganey scores and PROs at all time points evaluated (all, rs: −0.13 to 0.14). When evaluating knee and hip arthroplasty cases separately, the data demonstrated similar results (all, rs: −0.33 to 0.18). ConclusionWe found little, if any, correlation between a patient’s satisfaction with their care experience and their own perception of physical function and global health measures at all time points evaluated. These data question the utility of these scores as surrogate measures of health care quality, especially when reimbursements become tied to these metrics.

Device Utilization Ratios in Infection Prevention: Process or Outcome Measure?

The purpose of this review is to describe the role of device utilization as a component of surveillance for healthcare-associated infections and describe its potential role as a measurement of healthcare quality. Device utilization, while primarily a process-based measure in the prevention of device-associated infections can also serve as an important outcome in the evaluation of an infection prevention program. Device utilization can be an important and resource-efficient measurement when coupled with measurements of risk-adjusted infection rates. The measurement of the device utilization ratio can provide insight into the risk of device-associated harms, including non-infectious harms, which would not be captured with currently used infection-based surveillance metrics. Further study and validation of standardized, risk-adjusted device utilization measurements is an important area for future exploration.

The New Health Care Federalism on the Ground

This essay, part of a symposium investigating methods of empirically evaluating health policy, focuses on American health care federalism, the relationship between the federal and state governments in the realm of health care policy and regulation. We describe the results of a five year study of the implementation of the Patient Protection and Affordable Care Act (ACA) from 2012-2017. Our study focused on two key pillars of the ACA, which happen to be its most state-centered — expansion of Medicaid and the implementation of health insurance exchanges — and sheds light on federalism in the modern era of nationally-enacted health laws that preserve key roles for state leadership. The full study is detailed in the Stanford Law Review; here, we offer a more accessible snapshot and highlight a key aspect of the research: interviews of approximately twenty high ranking former state and federal officials at the forefront of ACA implementation. The interviews corroborate the study data and substantiate our conclusions about the defining characteristics of the ACA’s implementation from a federalism perspective. Specifically, we found that the ACA’s implementation process has been 1) dynamic; 2) pragmatic; 3) negotiated; and 4) and marked by intrastate politics. We observed waves of engagement and estrangement between states and the federal government, and state decisions to participate in the ACA’s programs have not been binary, in/out choices. Vertical and horizontal negotiation and copying have been near constants. The findings also reveal theoretical and empirical challenges for quantitatively evaluating health care federalism. Does it exist? Is it successful? We found the traditional federalism attributes pop up in inconsistent ways under the ACA and emerge from virtually every structural arrangement of the law. We tried, for instance, to measure how “cooperative” the states were, only to find that concept meaningless. Some states attempted implementation but failed; other states rebelled by refusing to run their own programs at all. The federal government stepped in for both. Were such states equally “cooperative” or “autonomous”? The same challenges occurred for all of the classic federalism metrics. For example, we saw local experimentation emerge from every kind of governance structure under the ACA, including nationalist ones. Our work leads us to a key question: Why choose federalism-oriented health reform models in the first place? In ACA implementation, it sometimes appeared that federalist arrangements did not aim to improve health outcomes but rather reflected “federalism for federalism’s sake”—federalism to advance political or constitutional values, such as reserving power to the states in the interest of sovereignty and balance of power — regardless of the effect on health care coverage, cost, quality, or other measures of health policy success. At other times, it seems federalism was intended as a means to an end — e.g., that state-led health policy is assumed to produce better health outcomes. In the end, we were able to conclude more assuredly that the ACA’s many structural arrangements served state power than that any particular one of those arrangements was more federalist or that any particular one produced better health policy. Clearly, we cannot evaluate federalism — whether it exists, whether it is working, whether it is worth defending — without knowing what it is for in the first place.

Assessing Potentially Preventable Hospitalizations at the County Level: A Comparison of Measures Using Medicare Data and State Hospital Discharge Data.

This study examined the representativeness of the County Health Rankings and Roadmaps (CHR) measure of potentially preventable hospitalizations, which is derived from Medicare inpatient claims data, as an indicator of potentially preventable hospitalizations for adults aged ≥18 years. Potentially preventable hospitalizations were evaluated using rates of ambulatory care sensitive conditions (ACSCs). CHR rates of hospitalization for ACSCs based on Medicare data for 2010, Agency for Healthcare Research and Quality Prevention Quality Indicator #90 Overall Composite (PQI #90 Composite) rates of ACSCs based on hospital inpatient data for adults aged ≥18 years for 2011, and 2011 total mortality rates for adults aged ≥18 years for 212 counties in 3 US states were evaluated. Pearson correlation analyses were used to assess the linear association between the PQI #90 Composite and CHR rates of hospitalization for ACSCs as well as associations of these measures with total mortality. Steiger's Z-test was conducted to examine whether the PQI #90 Composite and CHR measures of health care quality were similarly correlated with total mortality. The age- and sex-adjusted PQI #90 Composite for adults ≥18 years was moderately correlated with the CHR rate of hospitalization for ACSCs. The PQI #90 Composite and CHR measures of hospitalization for ACSCs were similarly correlated with mortality. These findings suggest that in the absence of easily accessible, high-quality data for adults aged ≥18 years, the CHR measure of potentially preventable hospitalizations provides a modest but acceptable approximation of county-level disparities in potentially preventable hospitalizations for the US adult population.

National trends in emergency readmission rates: a longitudinal analysis of administrative data for England between 2006 and 2016

ObjectiveTo assess trends in 30-day emergency readmission rates across England over one decade.DesignRetrospective study design.Setting150 non-specialist hospital trusts in England.Participants23 069 134 patients above 18 years of age who were...

Health care quality measures for children and adolescents in Foster Care: feasibility testing in electronic records

BackgroundPreventive quality measures for the foster care population are largely untested.The objective of the study is to identify healthcare quality measures for young children and adolescents in foster care and to test whether the data required to calculate these measures can be feasibly extracted and interpreted within an electronic health records or within the Statewide Automated Child Welfare Information System.MethodsThe AAP Recommendations for Preventive Pediatric Health Care served as the guideline for determining quality measures. Quality measures related to well child visits, developmental screenings, immunizations, trauma-related care, BMI measurements, sexually transmitted infections and depression were defined. Retrospective chart reviews were performed on a cohort of children in foster care from a single large pediatric institution and related county. Data available in the Ohio Statewide Automated Child Welfare Information System was compared to the same population studied in the electronic health record review. Quality measures were calculated as observed (received) to expected (recommended) ratios (O/E ratios) to describe the actual quantity of recommended health care that was received by individual children.ResultsElectronic health records and the Statewide Automated Child Welfare Information System data frequently lacked important information on foster care youth essential for calculating the measures. Although electronic health records were rich in encounter specific clinical data, they often lacked custodial information such as the dates of entry into and exit from foster care. In contrast, Statewide Automated Child Welfare Information System included robust data on custodial arrangements, but lacked detailed medical information. Despite these limitations, several quality measures were devised that attempted to accommodate these limitations.ConclusionsIn this feasibility testing, neither the electronic health records at a single institution nor the county level Statewide Automated Child Welfare Information System was able to independently serve as a reliable source of data for health care quality measures for foster care youth. However, the ability to leverage both sources by matching them at an individual level may provide the complement of data necessary to assess the quality of healthcare.

Increasing Metered Dose Inhaler Use for Acute Asthma Exacerbations in the Pediatric Emergency Department: A Quality Improvement Challenge

Pediatric asthma is the most common chronic condition in children and results in significant disease burden and healthcare costs. The mainstay of asthma treatment is inhaled albuterol, and different modalities of albuterol delivery have been shown to affect healthcare quality measures. Albuterol delivered via metered-dose inhaler with a valved holding chamber (MDI/VHC) has been shown to be at least as effective as nebulized albuterol while also reducing medication side effects, admission rates, length of stay in the emergency department (ED) and overall costs. However, a culture of nebulized albuterol still predominates in the ED. Quality Improvement methodology is well suited to address this healthcare quality problem. The goal of this article is to utilize The Model for Improvement framework to provide a review and a critique of the literature regarding the transition to MDI/VHCs from nebulizers in the acute care of children with asthma exacerbations.

Developing a set of indicators to monitor quality in ambulatory diabetes care using a modified Delphi panel process.

There is a large evidence to practice gap in diabetes care with limited performance assessments that capture the full spectrum of care delivery. Our study aimed to develop a set of ambulatory diabetes quality indicators across six domains (effectiveness, safety, patient-centered, timely, equitable and efficient) to provide a broad view of quality. A modified Delphi panel process was conducted. Phase I involved compiling a list of indicators through literature review and generation of patient and healthcare provider-derived indicators through interviews and surveys, respectively. Phase II involved panelists rating indicators using the Agency for Healthcare Research and Quality measure attributes on 9-point Likert scale, attending a face-to-face meeting followed by re-rating, and final ranking. This study was conducted across five adult academic medical centers affiliated with the University of Toronto. A multi-disciplinary Delphi panel (n = 16) including patients was assembled. For indicator advancement for ranking, ≥75% of panelists' responses in the top tertile (between 7 and 9) with a median composite score of ≥7 was required. There were 202 indicators included in the Delphi panel process including 171 from a comprehensive literature review, 14 from patient interviews, and 17 from healthcare provider surveys. Following the first round, 40 indicators proceeded directly to ranking, while 162 indicators were re-rated and distilled down to 12 for ranking. In the final ranking round, the 52 indicators were reduced to 35 including 13 effective, 10 safe, 6 patient-centered, 1 equitable, 3 efficient and 2 timely indicators. Thirty-five selected indicators developed with broad stakeholder engagement can be used to monitor quality in diabetes care.

Towards a Triadic Quality Measurement Framework for U.S. Healthcare

ABSTRACTAlthough there are various measures of healthcare quality, such as those used by the Centers for Medicare and Medicaid Services (CMS), an inclusive perspective that considers the patient, the hospital's external and internal relationships, and the nodal organizations is missing. Medical practitioner comments from the authors' interactions, coupled with the findings from their literature review, have motivated the authors to suggest that healthcare quality should be measured using a triadic approach. In this study, the authors offer an overarching conceptual framework for measuring quality in the U.S. healthcare system that utilizes a triadic approach integrating various aspects of quality at three different levels of measurement. At the micro-level, the focus is on patients–admitted and treated–and their perceptions of a hospital's service as well as outcomes. The authors suggest measures related to the healthcare teamwork quality at the meso-level. At the macro- level, in which the organization interacts with external entities, the focus is on the measurement of hospital quality performance. The authors conclude with the managerial implications of the framework and suggest future directions for triadic healthcare quality measurement.

Characteristics of National and Major Regional Percutaneous Coronary Intervention Registries: A Systematic Review

Background: Clinical registries have a growing role in the measurement of healthcare quality, especially with increasing demand for public reporting of outcomes by healthcare regulators. However, it is unclear how many countries utilise registries in assessing quality of care and outcomes of patients undergoing percutaneous coronary intervention (PCI). The aim of this study was to review the characteristics of PCI registries from around the world.

The impact of accreditation on health care quality in hospitals

Background/Aim. Accreditation is considered to be the oldest and most widespread mechanism of independent external evaluation of health care quality and is implemented in over 70 countries worldwide. Despite numerous studies in this field, there is still no solid evidence about its impact on health care quality and patient safety. The goal of this paper was to investigate if the accreditation process has an effect on the difference in values of health care quality indicators. Methods. The study was conducted in two tertiary level health care hospitals, one accredited, the other non-accredited. Values of seven quality indicators in the period before, during and immediately after the completion of accreditation (from 2007?2015), which measure health care quality, patient safety, the efficiency and productivity of the institution, were compared. Results. Of the seven monitored quality indicators, a positive effect of the accreditation process can be attributed to a shorter length of waiting for the first scheduled health check at the institution, shorter length of waiting for the first scheduled surgical check, lower rate of patients with decubitus as well as a decrease of the rate of hospital days per patient with acute myocardial infarction. No effect of accreditation was found on the mortality rate, mortality rate within the first 48 hours of hospitalization, and the average rate of hospital days per patient at the level of the institution. Conclusion. The process of accreditation undoubtedly intensifies activities that contribute to improving health care quality, which results in better health outcomes. Additional research in this field and new evidence about the relationship between accreditation and quality upgrading in health care institutions are required because this could motivate their managers to decide more easily to enter into this process and implement it, despite the additional efforts and financial investments associated with accreditation.

Association Between Perceived Discrimination and Emergency Department Use Among Safety-Net Patients in the Southwestern United States.

Patients' perceptions of how they are treated in their interactions with the healthcare system represent important and valid measures of healthcare quality that may influence health utilization, outcomes, and costs. Perceived discrimination or the sense of being treated unfairly is an important patient perception known to adversely affect health, but the relation of such perceptions to health-seeking behaviors related to low-acuity emergency department (ED) use is unclear. The objectives of this exploratory study were to describe the prevalence and nature of perceived discrimination or perceived unfair treatment (PD/PUT), and to examine the association of PD/PUT with healthcare utilization among adult safety-net patients in the southwestern United States who sought ED treatment for low-acuity conditions. Cross-sectional survey data were collected via self-administered questionnaires completed by adult safety-net patients who were uninsured or covered by Medicaid and who sought ED treatment for low-acuity conditions (N = 310). We used descriptive statistics to describe PD/PUT in the healthcare experiences reported by study participants. We used logistic regression to examine the association between PD/PUT and participants' likelihood to seek health care from ED and non-ED settings. Thirty-eight percent of study participants reported PD/PUT, most frequently attributed to insurance status (being uninsured or covered by Medicaid). Participants who reported PD/PUT in their ability to access medical care or to obtain health insurance were significantly more likely to be frequent (vs nonfrequent) ED users (odds ratio [OR] 3.80, P < 0.001) and to use multiple (vs 1) EDs (OR 3.79, P < 0.001) during a 12-month period. Participants who reported PD/PUT while receiving medical care were more likely to have received care in ED and non-ED settings, as compared with EDs only (OR 2.02, P = 0.012). A substantial proportion of this sample of adult safety-net patients in the Southwest reported experiencing PD/PUT in their healthcare interactions and most frequently attributed such perceptions to their insurance status. Although this study does not establish a causal link between PD/PUT and utilization of care in specific settings, it highlights the need to better understand the underlying causes of PD/PUT across multiple delivery settings and to clarify the extent to which such experiences may influence patients' healthcare-seeking behaviors. Federal and state policies that aim to maintain or expand health insurance coverage for safety-net populations should consider the role of health insurance status in driving perceptions of being discriminated against or treated unfairly.

Quality Indicators for Evaluating Prehospital Emergency Care: A Scoping Review.

A scoping review was conducted through a search of PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA); EMBase (Elsevier; Amsterdam, Netherlands); CINAHL (EBSCO Information Services; Ipswich, Massachusetts USA); Web of Science (Thomson Reuters; New York, New York USA); and the Cochrane Library (The Cochrane Collaboration; Oxford, United Kingdom). To increase the sensitivity of the literature, a search of the grey literature and review of select websites was additionally conducted. Articles were selected that proposed at least one PEC QI and whose aim was to discuss, analyze, or promote quality measurement in the PEC environment. The majority of research (n=25 articles) was published within the last decade (68.0%) and largely originated within the USA (68.0%). Delphi and observational methodologies were the most commonly employed for QI development (28.0%). A total of 331 QIs were identified via the article review, with an additional 15 QIs identified via the website review. Of all, 42.8% were categorized as primarily Clinical, with Out-of-Hospital Cardiac Arrest contributing the highest number within this domain (30.4%). Of the QIs categorized as Non-Clinical (57.2%), Time-Based Intervals contributed the greatest number (28.8%). Population on Whom the Data Collection was Constructed made up the most commonly reported QI component (79.8%), followed by a Descriptive Statement (63.6%). Least reported were Timing of Data Collection (12.1%) and Timing of Reporting (12.1%). Pilot testing of the QIs was reported on 34.7% of QIs identified in the review. Overall, there is considerable interest in the understanding and development of PEC quality measurement. However, closer attention to the details and reporting of QIs is required for research of this type to be more easily extrapolated and generalized. Howard I , Cameron P , Wallis L , Castren M , Lindstrom V . Quality indicators for evaluating prehospital emergency care: a scoping review. Prehosp Disaster Med. 2018;33(1):43-52.

Oral Health Care Quality Measurement and Its Role in Dental Education.

Concerns about health care quality have affected much of the health care delivery system including dentistry and dental education. Believing measurement is the key element in improving quality, the Dental Quality Alliance brought together major stakeholders in oral health care to lead the development of oral health performance measures that can be used to evaluate the performance of dental programs and practices. These measures complement the quality assurance measures dental schools use to ensure compliance with accreditation standards on patient care delivery. This article describes the rationale for and process of developing these performance measures and argues that dental schools should implement quality measurement processes in their clinical programs to improve the clinical practices of the present and better prepare their graduates for their practices of the future.

Portuguese Adaptation and Input for the Validation of the Views on Inpatient Care (VOICE) Outcome Measure to Assess Service Users'Perceptions of Inpatient Psychiatric Care.

Patient satisfaction is an important measure of health care quality. Patients' views have seldom been considered in theconstruction of measures addressing satisfaction with inpatient facilities in psychiatry. The Views on Inpatient Care - VOICE - is a firstservice-user generated outcome measure relying solely on their perceptions of acute care, representing a valuable indicator of serviceusers' perceived quality of care. The present study aimed to contribute to the validation of the Portuguese version of VOICE. The questionnaire was translated into Portuguese and applied to a sample of eighty-five female inpatients ofa psychiatric institution. Data analysis focused on assessing reliability and exploring the impact of demographic and clinical variableson participants' satisfaction. Internal consistency of the questionnaire was high (α = 0.87). Participants' age and marital status were associated withdifferences in scores, with older patients and patients who were married or involved in a close relationship presenting higher satisfactionlevels. The questionnaire demonstrated good internal consistency and acceptability, as well as construct validity. Further studiesshould expand the analysis of the psychometric properties of this measure e.g., test-retest reliability. The Portuguese version of VOICE is a promising tool to assess service users' perceptions of inpatient psychiatric carein Portugal.

Importance of Leadership Style towards Quality of Care Measures in Healthcare Settings: A Systematic Review.

Effective leadership of healthcare professionals is critical for strengthening quality and integration of care. This study aimed to assess whether there exist an association between different leadership styles and healthcare quality measures. The search was performed in the Medline (National Library of Medicine, PubMed interface) and EMBASE databases for the time period 2004–2015. The research question that guided this review was posed as: “Is there any relationship between leadership style in healthcare settings and quality of care?” Eighteen articles were found relevant to our research question. Leadership styles were found to be strongly correlated with quality care and associated measures. Leadership was considered a core element for a well-coordinated and integrated provision of care, both from the patients and healthcare professionals.