National Quality Forum Research Articles

National evaluation of multidisciplinary quality metrics for head and neck cancer.

The National Quality Forum has endorsed quality-improvement measures for multiple cancer types that are being developed into actionable tools to improve cancer care. No nationally endorsed quality metrics currently exist for head and neck cancer. The authors identified patients with surgically treated, invasive, head and neck squamous cell carcinoma in the National Cancer Data Base from 2004 to 2014 and compared the rate of adherence to 5 different quality metrics and whether compliance with these quality metrics impacted overall survival. The metrics examined included negative surgical margins, neck dissection lymph node (LN) yield ≥ 18, appropriate adjuvant radiation, appropriate adjuvant chemoradiation, adjuvant therapy within 6 weeks, as well as overall quality. In total, 76,853 eligible patients were identified. There was substantial variability in patient-level adherence, which was 80% for negative surgical margins, 73.1% for neck dissection LN yield, 69% for adjuvant radiation, 42.6% for adjuvant chemoradiation, and 44.5% for adjuvant therapy within 6 weeks. Risk-adjusted Cox proportional-hazard models indicated that all metrics were associated with a reduced risk of death: negative margins (hazard ratio [HR] 0.73; 95% confidence interval [CI], 0.71-0.76), LN yield ≥ 18 (HR, 0.93; 95% CI, 0.89-0.96), adjuvant radiation (HR, 0.67; 95% CI, 0.64-0.70), adjuvant chemoradiation (HR, 0.84; 95% CI, 0.79-0.88), and adjuvant therapy ≤6 weeks (HR, 0.92; 95% CI, 0.89-0.96). Patients who received high-quality care had a 19% reduced adjusted hazard of mortality (HR, 0.81; 95% CI, 0.79-0.83). Five head and neck cancer quality metrics were identified that have substantial variability in adherence and meaningfully impact overall survival. These metrics are appropriate candidates for national adoption. Cancer 2017;123:4372-81. © 2017 American Cancer Society.

Health Care Quality: Measuring Obesity in Performance Frameworks.

Obesity affects over one-third of Americans and leads to several chronic and costly comorbid conditions. The national movement toward value-based care calls for a refocusing of efforts to address the US obesity epidemic. To help set the stage, the current landscape of obesity-specific quality measures was evaluated. Seven quality measure databases and nine professional societies were searched. Inclusion and exclusion criteria were applied. Measures were then classified by domain and by implementation in national public programs. Eleven obesity-specific quality measures in adults were identified (nine process and two outcome). Three measures received National Quality Forum (NQF) endorsement. Two measures were actively used within Centers for Medicare and Medicaid Services (CMS) programs. Only one measure was both NQF-endorsed and used by CMS. Limitations exist with respect to obesity-specific quality metrics. Such gaps provide opportunities for obesity care specialists to engage and offer valuable insights and pragmatic approaches toward quality measurement.

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.

Target weight achievement and ultrafiltration rate thresholds: potential patient implications

BackgroundHigher ultrafiltration (UF) rates and extracellular hypo- and hypervolemia are associated with adverse outcomes among maintenance hemodialysis patients. The Centers for Medicare and Medicaid Services recently considered UF rate and target weight achievement measures for ESRD Quality Incentive Program inclusion. The dual measures were intended to promote balance between too aggressive and too conservative fluid removal. The National Quality Forum endorsed the UF rate measure but not the target weight measure. We examined the proposed target weight measure and quantified weight gains if UF rate thresholds were applied without treatment time (TT) extension or interdialytic weight gain (IDWG) reduction.MethodsData were taken from the 2012 database of a large dialysis organization. Analyses considered 152,196 United States hemodialysis patients. We described monthly patient and dialysis facility target weight achievement patterns and examined differences in patient characteristics across target weight achievement status and differences in facilities across target weight measure scores. We computed the cumulative, theoretical 1-month fluid-related weight gain that would occur if UF rates were capped at 13 mL/h/kg without concurrent TT extension or IDWG reduction.ResultsTarget weight achievement patterns were stable over the year. Patients who did not achieve target weight (post-dialysis weight ≥ 1 kg above or below target weight) tended to be younger, black and dialyze via catheter, and had shorter dialysis vintage, greater body weight, higher UF rate and more missed treatments compared with patients who achieved target weight. Facilities had, on average, 27.1 ± 9.7% of patients with average post-dialysis weight ≥ 1 kg above or below the prescribed target weight. In adjusted analyses, facilities located in the midwest and south and facilities with higher proportions of black and Hispanic patients and higher proportions of patients with shorter TTs were more likely to have unfavorable facility target weight measure scores. Without TT extension or IDWG reduction, UF rate threshold (13 mL/h/kg) implementation led to an average theoretical 1-month, fluid-related weight gain of 1.4 ± 3.0 kg.ConclusionsTarget weight achievement patterns vary across clinical subgroups. Implementation of a maximum UF rate threshold without adequate attention to extracellular volume status may lead to fluid-related weight gain.

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.

Interprofessional Collaboration to Improve Sepsis Care and Survival Within a Tertiary Care Emergency Department

ProblemSepsis is a leading cause of death in the United States; however, health care providers struggle with timely recognition, diagnosis, and treatment of patients. Both the Centers for Medicare and Medicaid Services and the National Quality Forum have identified this diagnosis as a priority. Presently, many patients with sepsis are identified late, resulting in significant morbidity and death. MethodsIn this project, a collaborative, interprofessional approach was created for screening and early identification of ED patients with possible sepsis. The department has 38 beds with annual patient volumes of more than 40,000 visits. Education was provided about the symptoms and treatment of patients with sepsis. A screening and management algorithm tool was instituted that consisted of early identification triggers and how to intervene according to Surviving Sepsis Campaign recommendations. The tool allowed for assessment of the patient by the ED team; the team worked to determine if sepsis was present and the extent of the illness. ResultsDuring the first 4 months after implementation, more than 240 patients were screened, assessed, and treated according to the algorithm. Project outcomes resulted in an increase in staff knowledge of sepsis, a decrease in length of stay by 3 hours, and a significant decrease in mortality when compared with the previous year’s coded data. Implications for PracticeThis project demonstrates that sepsis education and team collaboration are an integral part of identifying and treating patients with sepsis. An interprofessional collaborative approach could be implemented in other institutions to combat the life-threatening complications of sepsis.Image 1

Trends in aggressive care at the end-of-life for stage IV lung cancer patients.

6614 Background: Prior studies have demonstrated that high-intensity end-of-life care improves neither survival nor quality of life for cancer patients. The National Quality Forum endorses dying from cancer in an acute care setting, ICU admission in the last 30 days of life, and chemotherapy in the last 14 days of life as markers of poor quality care. Methods: Discharge data from the National Inpatient Sample database was analyzed for 3,030,866 acute care hospitalizations of metastatic lung cancer patients between 1998 and 2014. Longitudinal analysis was conducted to determine trends in aggressive care at the end-of-life and multivariate logistic regression was performed to determine associations with age, race, region, hospital characteristics, and aggressive care. Results: In-hospital mortality for metastatic lung cancer patients decreased from 17% to 11%. Among terminal hospitalizations, utilization of radiation therapy and chemotherapy decreased from 4.6% to 3.0% and from 4.8% to 3.0%, respectively. However, the proportion admitted to the ICU increased from 13.3% to 27.9% and invasive procedures increased from 1.2% to 2.0%. Reflecting this aggressive end-of-life care, mean total charges for a terminal hospitalization rose from $29,386 to $72,469, adjusted for inflation. Among patients who died in the inpatient setting, the ICU stay translated into higher total costs (+$16,962, CI: $15,859 to $18,064) compared to patients who avoided the ICU. Promisingly, palliative care encounters for terminal hospitalizations increased during this period from 8.7% to 53.0% and was correlated with a decrease in inpatient chemotherapy (OR = 0.56, CI: 0.47 to 0.68), radiotherapy (OR = 0.77, CI: 0.65 to 0.92), and ICU admissions (OR = 0.48, CI: 0.45 to 0.53) but had only a modest impact on terminal hospitalization cost (-$2,992, CI: -$3,710 to -$2,275). Multivariable analysis showed variation by patient and hospital characteristics in aggressive care utilization. Conclusions: Among patients with metastatic lung cancer there has been a substantial increase in ICU use during terminal hospitalizations, resulting in high cost for the health care system. Inpatient palliative care has the potential to reduce aggressive end-of-life interventions.

Identificación de eventos centinela en atención primaria

ObjectiveTo identify and describe a list of sentinel events (SEs) for Primary Care (PC). MethododologyA structured experts’ consensus was obtained by using two online questionnaires. The participants were selected because of their expertise in PC and patient safety. The first questionnaire assessed the suitability of the hospital SEs established in the National Quality Forum 2006 for use in PC via responses of “yes”, “no”, or “yes but with modification”. In the latter case, a re-wording of the SE was requested. Additionally, inclusion of new SEs was also allowed. The second questionnaire included those SEs with positive responses (“yes”, “yes with modification”), so that the experts could choose between the original and alternative drafts, and evaluate the newly described SEs. ResultsThe questionnaires were completed by 44 out of a total of the 47 experts asked to participate, and a total of 17 SEs were identified as suitable for PC. For the first questionnaire, 12 of the 28 hospital SEs were considered adaptable to PC, of which 11 were re-drafts. Thirty-seven experts proposed new SEs. These mainly concerned problems with medication and vaccines, delay, or lack of assistance, diagnostic delays, and problems with diagnostic tests, and were finally summarised in 5 SEs. In the second questionnaire, ≥65% of the experts chose the alternative wording against the original cases for the 11 SEs suitable for PC. The 5 newly included SEs were considered adequate with a positive response of 70-85%. ConclusionHaving a list of SEs available in PC will help to improve the management of health care risks.

The National Cancer Institute Community Cancer Centers Program (NCCCP): Sustaining Quality and Reducing Disparities in Guideline-Concordant Breast and Colon Cancer Care.

The National Cancer Institute Community Cancer Centers Program (NCCCP) pilot was designed to improve quality of cancer care and reduce disparities at community hospitals. The NCCCP's primary intervention was the implementation of the Commission on Cancer Rapid Quality Reporting System (RQRS). The RQRS is a hospital-based data collection and evaluation system allowing near real-time assessment of selected breast and colon cancer quality of care measures. Building on previous NCCCP analyses, this study examined whether improvements in quality cancer care within NCCCP hospitals early in the program were sustained and whether improvements were notable for minority or underserved populations. We compared changes in concordance with three breast and two colon cancer quality measures approved by the National Quality Forum for patients diagnosed at NCCCP hospitals from 2006 to 2007 (pre-RQRS), 2008 to 2010 (early-RQRS), and 2011 to 2013 (later-RQRS). Data were obtained from NCCCP sites participating in the Commission on Cancer Rapid Quality Reporting System. Logistic regression analyses were performed to identify predictors of concordance with breast and colon cancer quality measures. The sample included 13,893 breast and 5,546 colon cancer patients. After RQRS initiation, all five quality measures improved significantly and improvements were sustained through 2013. Quality of care measures showed sustained improvements for both breast and colon cancer patients and for vulnerable patient subgroups including black, uninsured, and Medicaid-covered patients. Quality improvements in NCCCP hospitals were sustained throughout the duration of the program, both overall and among minority and underserved patients. Because many individuals receive cancer treatment at community hospitals, facilitating high-quality care in these environments must be a priority. Quality improvement programs often improve practice, but the methods are not maintained over time. The implementation of a real-time quality reporting system and a network focused on improving quality of care sustained quality improvement at select community cancer centers. The NCCCP pilot increased numbers of patients receiving guideline-concordant care for breast and colon cancer in community settings, and initial improvements noted in earlier years of RQRS were sustained into later years, both overall and among minority and underserved patients. National initiatives that improve care for diverse patient groups are important for reducing and eliminating barriers to care.

Quality Improvement in Neurology: Dementia Management Quality Measurement Set Update.

Dementia is a neurologic condition manifested by a substantial decline in multiple cognitive abilities that collectively render a person unable to function at expected levels and progressively impede independent ability to perform everyday activities. For decades, public health officials have warned of the coming tsunami of Alzheimer disease (AD), and dementia has even been characterized as the dominant scourge of modern times, replacing cancer.1 Recently, hopeful signs have appeared, including reports from some longitudinal research studies that incidence of dementia is declining,2 and from the federal government that research funding for AD and other dementias will approach $1 billion USD in 2017.3 The authors thank all the Dementia Management Update Quality Measurement Set Work Group members for their dedication, time, energy, contributions and work that supported the development of this manuscript: Amy E. Sanders, MD, MS, FAAN (American Academy of Neurology); Robert Roca, MD (American Psychiatric Association); Piero Antuono, MD (American Academy of Neurology); Kelly Sullivan, PhD (American Academy of Neurology); Karl Goodkin, MD, PhD, DFAPA (American Psychiatric Association); Donovan Maust, MD, MS (American Psychiatric Association); Michael Lubin, MD, MACP (American College of Physicians); Sam Fazio, PhD (Alzheimer's Association); Ann Knutson (Alzheimer's Association); Robert O'Keefe, MA (Alzheimer's Association); Eric Tangalos, MD, FACP, AGSF, CMD (AMDA–The Society for Post-Acute and Long-Term Care Medicine); Glenn Smith, PhD (American Academy of Clinical Neuropsychology and American Psychological Association); Brian Unwin, MD, FAAFP (American Academy of Family Physicians); Joseph Shega, MD (American Academy of Hospice and Palliative Medicine); Dale Strasser, MD (American Academy of Physical Medicine and Rehabilitation); Michele Grigaitis, DNP, FNP-BC, CNRN (American Association of Neuroscience Nurses); Jerry Johnson, MD (American Geriatric Society); Mary Kathleen Owens, RN MSN, C-NE, RAC-CT (American Health Care Association and Gerontological Advanced Practice Nurses Association); Catherine Piersol, PhD, OTR, FAOTA (American Occupational Therapy Association); Lise McCarthy, PT, DPT, GCS (American Physical Therapy Association); Kathleen Welsh-Bohmer, PhD, ABPP (American Psychological Association); David Webster, MD, MBA (Humana); James Galvin, MD, MPH, FANA (Lewy Body Dementia Association); Daniel Marson, PhD, JD (National Academy of Neuropsychology); Richard Fortinsky, PhD (The Gerontological Society of America); Marsden McGuire, MD (Veteran's Affairs); John Absher, MD (American Academy of Neurology Facilitator); James Nininger, MD (American Psychiatric Association Facilitator); Amy Bennett, JD (American Academy of Neurology Staff); Gina Gjorvad (American Academy of Neurology Staff); Erin Hagen (American Academy of Neurology Staff); Becky Schierman, MPH (American Academy of Neurology Staff); Samantha Shugarman, MS (American Psychiatric Association Staff); and Kristin Kroeger (American Psychiatric Association Staff). The authors also thank Jean O'Keefe for participation and the individuals and organizations who offered public comments.

Social Risk Factors and Performance Under Medicare's Value-Based Purchasing Programs.

Report to Congress: Social Risk Factors and Performance Under Medicare’s Value-based Purchasing Programs.1 US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. December 21, 2016. ### Policy Context Value-based purchasing (VBP), or pay-for-performance, comprises a growing portion of Medicare payment and the changes in physician payment enacted in the Medicare and Children's Health Insurance Program Reauthorization Act are likely to accelerate these trends even further.2 Simultaneously, there is growing consensus that social risk factors—such as income, race and ethnicity, and community environment—play a major role in health.3–5 Persistent and meaningful gaps exist in health and even in life expectancy based on these factors.6–9 These 2 issues intersect in VBP. If beneficiaries with social risk factors have worse health outcomes because of factors beyond providers’ control, providers could be unfairly disadvantaged under VBP. On the contrary, if beneficiaries with social risk factors have worse health outcomes because the providers serving them provide low-quality care, the financial incentives and accountability of VBP could be an important strategy for improving care and reducing disparities. In 2014, Congress passed the Improving Medicare Postacute Care Transformation Act (IMPACT),10 which required that the Office of the Assistant Secretary for Planning and Evaluation (ASPE) at the US Department of Health and Human Services complete an empirical report addressing the issue of social risk in Medicare’s current VBP programs to assist Congress in further decision making on this issue. The report covered here is the first component of the required work, which was submitted to Congress in December 2016. The ASPE report may have particular salience to cardiovascular clinicians, who practice every day in an environment significantly impacted by VBP. Many current quality measures in inpatient and outpatient VBP programs are cardiovascular in nature; patients …

Comparing Rural and Urban Cervical and Breast Cancer Screening Rates in a Privately Insured Population

ABSTRACTLow preventive screening varies by region and contributes to poor outcomes for breast and cervical cancer. Previous comparative urban and rural research on preventive screening has focused on government programs. This study quantified and compared rural and urban preventive cancer screening rates for women who were privately insured. National Quality Forum measures were used to calculate rates for women within rural and urban parts of the same Hospital Referral Region (HRR) using claims data. Mammography screening rates for women age 24 to 69 years were 77.1% in 2011 and 76.1% in 2008. Compared to urban women, mammography screening rates for women visiting rural physicians were lower in 42%, higher in 2% and identical in 56% of HRRs. Cervical cancer screening rates for women age 21 to 64 years were 82.9% in 2011 and 83.5% in 2008. Cervical cancer screening rates among women who saw rural physicians were lower in 55%, higher in 4%, and identical in 42% of HRRs. HRRs where rural areas underperformed urban areas increased between 2008 and 2011 for both screenings. Moderate but notable differences in women’s preventive screening rates between rural and urban physicians highlight the need for practical solutions that increase use of screening services and reduce barriers to services in rural areas.

Public Health Response to Diabetes in Delaware through Partnership, Referral, and the Diabetes Self-Management Program.

Diabetes is a major health concern in Delaware, affecting approximately 85,000 adult Delawareans. Diabetes can lead to amputation, blindness, kidney failure, impaired hearing, heart and dental disease, and other complications. The Division of Public Health (DPH) launched a project in collaboration with Quality Insights (QI) to assist physician practices improve their National Quality Forum (NQF) Clinical Quality Measure NQF 0059. QI provides resources and tools to support physicians and their care teams in this quality improvement effort. One initiative invites physician office sites to participate in a free service that mails referral letters to their patient population with diabetes. The referral letter encourages patients to enroll in the state’s free Diabetes Self-Management Program (DSMP) which supports lifestyle modification control efforts.

Qualitative themes underlying potentially avoidable terminal oncology ICU hospitalizations.

101 Background: ICU admissions in the last 30 days of life is a quality measure endorsed by the National Quality Forum. Our prior research has demonstrated that nearly half of terminal oncology ICU hospitalizations are potentially avoidable. Methods: This was a retrospective care series of patients cared for in an academic medical center’s ambulatory oncology practice who died in an ICU during July 1, 2012 to June 30, 2013. Using a standardized assessment tool, an oncologist, intensivist, and hospitalist reviewed each patient’s electronic health record from 3 months prior to hospitalization until death and made a clinical determination of avoidability. Two investigators, blinded to the specialty of the reviewer, used a grounded theory approach to extract clinical themes associated with avoidability from the reviewers’ assessments. Results: The primary themes for avoidability identified and percent by specialty were as follows: failure to initiate appropriate advance care planning in the outpatient setting (68% oncologists, 55% intensivists, 65% hospitalists), failure to integrate understanding of limited prognosis from underlying cancer within the context of acute hospitalization (23% oncologists, 24% intensivists, 26% hospitalists), failure of clinical management (6% oncologists, 21% intensivists, 6% hospitalists), failure to recognize futility of outside hospital transfer (3% oncologists, 0% intensivists, 0% hospitalists), and failure of care coordination (0% oncologists, 0% intensivists, 3% hospitalists). A failure to educate and integrate surrogates into timely medical decision making was a prominent secondary theme for oncologists (22%), intensivists (18%), and hospitalists (29%). Conclusions: The themes identified suggest potential interventions to prevent avoidable terminal oncology ICU hospitalizations, including improved advance care planning in the outpatient setting, inpatient multidisciplinary communication to gain a better understanding of the patient’s underlying malignancy within the context of the acute hospitalization and prevent failures in clinical management, and better education and integration of surrogates in medical decision making.

The challenges of improving peripherally inserted central catheter (PICC) care instructions at hospital discharge.

175 Background: Teaching patients and caregivers to manage a Peripherally Inserted Central Catheter (PICC) line placed during hospitalization is essential to successful outpatient transitions. The aim was to improve written care instructions at hospital discharge (CIHD) given to solid tumor oncology patients with new PICC lines by creating an electronic template in the electronic health record. Methods: Inpatients with newly placed PICC lines discharged from the physician assistants' (PA) oncology teams at Brigham and Women's Hospital were identified through PICC team consult lists. We identified 9 elements of complete line care, modeled on National Quality Forum discharge metrics, to include in a template for PICC line care instructions at discharge. PAs received instruction on template use at their weekly meeting. A retrospective chart review of CIHD (February 19, 2016 and October 13, 2016) was performed. Results: A total of 47 cases were reviewed, 19 cases Pre-introduction and 28 cases Post. Before introduction of the template, 74% of cases lacked PICC care instructions (including 13 cases with no mention of the PICC line), 26% had incomplete care instructions, and none had full instructions. Following the intervention, 64% still lacked care instructions (16 cases with no mention of the PICC line), 21% had incomplete care instructions, and 4 patients (14%) had full instructions. Only those CIHD that used the template had complete care instructions. A c-chart demonstrated special cause variation following the intervention but the process was chaotic. Conclusions: The introduction of a template for PICC care instructions led to modest improvement in the number of patients discharged with full instructions. This project highlights the limitations of solutions that incorporate technical solutions but only weak adaptive ones. The next phase of our work will introduce human factors interventions (e.g. automation and forcing functions) to improve the success rate of this critically important function. [Table: see text]

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.

The Fault in Our Stars: Does the Five-Star System Fall Short?

The Fault in Our Stars: Does the Five-Star System Fall Short?

Patient Safety in Surgical Care

The 1999 report of the Institute of Medicine, To Err Is Human: Building a Safer Health System, made national headlines with its estimates of the frequency and severity of adverse events in health care, including that as many as 98,000 medical error–related deaths occur each year in the United States. The observation that the basic principles of human error are highly applicable to clinical practice has markedly advanced our understanding and willingness to address error in this setting. This review seeks to address the characteristics of systems in general and the system of surgical care in particular. It describes the growing knowledge of factors that affect human performance and how these factors contribute to adverse surgical outcomes. The review also outlines current obstacles to improving safety, identifies systems approaches to making improvements, and discusses ways in which surgeons can take the lead in overcoming these obstacles. An overall goal is that acceptance of error and a willingness to investigate its underlying causes will allow health care professionals to make use of the lessons learned from study of nonmedical systems. Tables include definitions of terms related to patient safety, the operation profile, handoff coordination and communication objectives and relevant strategies, nonmedical system techniques applicable to medical systems, Agency for Healthcare Quality and Research patient safety indicators, National Quality Forum list of health care facility–related serious reportable events, and examples of surgically relevant quality improvement practices appropriate for widespread implementation. Figures include the Swiss Cheese Model representing the relationship between latent and active errors and adverse outcomes, a schematic depiction of the process by which system failures may lead to injury, the Systems Engineering in Patient Safety Model of work system and patient safety, and a depiction of contrasting characteristics of medical practice in the 20th and 21st centuries. This review contains 4 figures, 7 tables, and 165 references.

Start Preparing Now for MACRA Changes to Come

Start Preparing Now for MACRA Changes to Come

Productivity in Pediatric Palliative Care: Measuring and Monitoring an Elusive Metric

ContextWorkforce productivity is poorly defined in health care. Particularly in the field of pediatric palliative care (PPC), the absence of consensus metrics impedes aggregation and analysis of data to track workforce efficiency and effectiveness. Lack of uniformly measured data also compromises the development of innovative strategies to improve productivity and hinders investigation of the link between productivity and quality of care, which are interrelated but not interchangeable. ObjectivesTo review the literature regarding the definition and measurement of productivity in PPC; to identify barriers to productivity within traditional PPC models; and to recommend novel metrics to study productivity as a component of quality care in PPC. MethodsPubMed® and Cochrane Database of Systematic Reviews searches for scholarly literature were performed using key words (pediatric palliative care, palliative care, team, workforce, workflow, productivity, algorithm, quality care, quality improvement, quality metric, inpatient, hospital, consultation, model) for articles published between 2000 and 2016. Organizational searches of Center to Advance Palliative Care, National Hospice and Palliative Care Organization, National Association for Home Care & Hospice, American Academy of Hospice and Palliative Medicine, Hospice and Palliative Nurses Association, National Quality Forum, and National Consensus Project for Quality Palliative Care were also performed. Additional semistructured interviews were conducted with directors from seven prominent PPC programs across the U.S. to review standard operating procedures for PPC team workflow and productivity. ResultsLittle consensus exists in the PPC field regarding optimal ways to define, measure, and analyze provider and program productivity. Barriers to accurate monitoring of productivity include difficulties with identification, measurement, and interpretation of metrics applicable to an interdisciplinary care paradigm. In the context of inefficiencies inherent to traditional consultation models, novel productivity metrics are proposed. ConclusionsFurther research is needed to determine optimal metrics for monitoring productivity within PPC teams. Innovative approaches should be studied with the goal of improving efficiency of care without compromising value.