National Quality Forum Research Articles

Asynchronous telepsychiatry: A systematic review

Introduction Healthcare providers and systems increasingly utilize telehealth modalities to address barriers and challenges for healthcare delivery. Specialties, such as psychiatry, are testing asynchronous methods for telehealth delivery. The National Quality Forum (NQF) developed a framework with which to assess the quality of telemedicine according to measures and measure concepts within four domains. This review assesses existing asynchronous telepsychiatry (ATP) research according to the telehealth domains established by NQF, evaluates the prevalence and quality of ATP, and identifies the areas in which more research must be conducted. Methods A systematic review of ATP methods was conducted according to PRISMA guidelines. Studies were categorized according to NQF telehealth domains and subdomains to further examine study outcomes. Results The review initially identified 205 studies that were narrowed down to a final sample of 11 articles. Of the final articles, most studies addressed the effectiveness of ATP or users’ experience with ATP. Discussion The initial investigation of published ATP literature suggests promising results. ATP studies suggest that these services improve access to care, can be feasibly implemented by the clinical team, maintain patient/family satisfaction, and potentially reduce the cost of services. The limited sample of published literature necessitates further study of the practice in order to assess ATP according to the quality domains identified by NQF, especially access to care for patients and caregivers, the financial costs incurred by both providers and patients, and barriers to uptake.

Recommended quality measures for health-system pharmacy: 2019 update from the Pharmacy Accountability Measures Work Group.

Pharmacists are accountable for medication-related services provided to patients. As payment models transition from reimbursement for volume to reimbursement for value, pharmacy departments must demonstrate improvements in patient care outcomes and quality measure performance. The transition begins with an awareness of quality measures for which pharmacists and pharmacy personnel can demonstrate accountability across the continuum of care. The objective of the Pharmacy Accountability Measures (PAM) Work Group is to identify measures for which pharmacy departments can and should assume accountability. The National Quality Forum (NQF) Quality Positioning System (QPS) was queried for NQF-endorsed medication-related measures. Included measures were curated into a data set of 6 therapeutic categories: antithrombotic safety, cardiovascular control, glucose control, pain management, behavioral health, and antimicrobial stewardship. Subject matter expert (SME) panels assigned to each area analyzed each measure according to a predetermined ranking system developed by the PAM Work Group. Measures remaining after SME review were disseminated during a public comment period for review and ballot. Over 1,000 measures are captured in the NQF QPS; 656 of the measures were found to be endorsed and medication use related or impacted by medication management services. A single reviewer categorized 140 measures into therapeutic categories for SME review; the remaining measures were unrelated to those clinical domains. The SME groups identified 28 measures for inclusion. An understanding of the endorsed quality measures available for public reporting programs provides an opportunity for pharmacists to demonstrate accountability for performance, thus improving quality and safety and demonstrating value of care provided.

Returns to Operating Room After Neurosurgical Procedures in a Tertiary Care Academic Medical Center: Implications for Health Care Policy and Quality Improvement.

Return to the operating room (ROR) has been put forth by the National Quality Forum and the American College of Surgeons as a surgical quality indicator. However, current quality metrics fail to consider the nature and etiology of the ROR. To provide a comprehensive description of all reoperations after neurosurgical procedures and assess the validity of ROR as a quality measure in neurosurgery. We retrospectively analyzed all neurosurgical procedures performed in a high-volume, tertiary care academic medical center between June 1, 2014 and December 31, 2016. Based on a system constructed and validated at our institution, we classified RORs into (a) unplanned related, (b) planned return due to complications, (c) planned-staged return, or (d) unrelated return. A total of 9200 unique neurosurgical cases were identified, of which 788 had an ROR within 45 d (8.6%). Median time to ROR (interquartile range) was 9 d (4-15). Specifically, 4.2% were planned-staged returns, 3.4% were unplanned related, 0.3% were unrelated, and 0.6% were planned because of previous complications. Cranial procedures had the highest unplanned ROR rate (4.2%), followed by spinal (2.8%) and peripheral nerve (0.4%). The most common reason for an unplanned ROR was wound complication/surgical site infection (34.3%), followed by hematoma evacuation (13.9%) and cerebrospinal fluid (CSF) leak (11.3%). Unplanned RORs were relatively rare and most commonly associated with wound complication, postoperative hematoma, and CSF leak. To better reflect surgical quality, ROR metrics should indicate whether the return was planned or unrelated.

Teaching medical students to recognise and report errors

BackgroundMedical student error reporting can potentially be increased through patient safety education, culture change and by teaching students how to report errors. There is scant literature on what kinds of...

Contraceptive Quality Measures: Population-Level Protection Using the Contraceptive Protection Index [1H

INTRODUCTION: National Quality Forum (NQF) endorsed contraception metric is now available to assess the proportion of women with reproductive capacity who are using highly effective contraception. The NQF measure does not assess the protection of the population from pregnancy based on the effectiveness of the methods and the distribution of method choice by age. The Contraceptive Protection Index (CPI) does incorporate these variables and can be calculated using the NQF measure data and may be instructive in monitoring population health over time. METHODS: We compare two observational cohorts (2013 and 2017) use of contraceptive methods in 54 agencies with some 200 health centers across the state of California. CPI was calculated using efficacy rates from clinical trials. Changes in CPI were evaluated by age group, race, ethnicity, and type of health center (Federally Qualified Health Centers, Health Departments, Planned Parenthoods, university and community clinics). RESULTS: Between 2013 and 2017, CPI increased for all groups. Teens (15-17), young adults (18-20) and women over 44 years old demonstrated the largest shift in CPI (increasing 1.4, 1.3, 1.6 respectively). This due to combination of decreases in condom or no method use with concomitant increases in LARC use. Federally Qualified Health Centers and Health Departments demonstrated the largest increases in CPI (1.4 and 1.9 respectively). CONCLUSION: Much of the shift in contraceptive use occurred within the group already using highly effective methods. Larger shifts in CPI are observed when women move from no method or condom use to highly effective methods, especially LARC use.

PCV82 FACTORS ASSOCIATED WITH UNPLANNED 30-DAY HEART FAILURE READMISSION RATES AMONG MEDICARE AND MEDICAID PATIENTS IN TEXAS

The study aimed to determine an association between unplanned 30-day Heart Failure (HF) readmission rates and factors outside of hospital’s control among Medicare and Medicaid patients in Texas. We used the Texas Hospital Inpatient Research Data File (RDF) to select Medicare and Medicaid patients discharged with a principal diagnosis of heart failure (HF) during the January 1st, through December 31st, 2014. We applied an endorsed measure by the National Quality Forum (NQF) to develop analytic sample. Multi-level logistic regression analyses examined patient-level and community-level characteristics. The unplanned 30-day HF readmission rates were 20.76% in Medicare (5,392 readmission/25,978 HF admission) vs. 30.63% in Medicaid (939 readmission/3066 HF admission). Controlled for other factors, Medicaid patients were 1.51 times more likely to be readmitted within 30 days than Medicare patients. (OR: 1.51 95% CI 1.38 - 1.65, p< 0.001). Patients lived in area with higher median household income were less likely to be readmitted (OR: 0.89, 95% CI 0.83 - 0.95, p < 0.001). The odds ratios were significantly lower in counties with higher density of health professionals (Primary care physician per 100K - OR: 0.89, 95%CI 0.80 - 0.99, p=0.025, Ratio general practitioner to specialist – OR: 0.89 95%CI 0.80 - 0.99, p=0.025, Hospital bed per 100K – OR: 0.90, 95%CI 0.83 - 0.99, p=0.032). Policy makers should consider a multidisciplinary strategy to help hospitals serving higher composition of patients with lower socioeconomic status or lower access to care to achieve higher performance.

A Meta-Analysis of the Associations Between the Nurse Work Environment in Hospitals and 4 Sets of Outcomes.

The nurse work environment is theorized to influence the quality of nursing care, nurse job outcomes, and patient outcomes. The aim of this meta-analysis was to evaluate quantitatively the association of the work environment with job and health outcomes. Relevant studies published through September 2018 were identified. Inclusion criteria were use of a nationally endorsed work environment measure and reporting of odds ratios (ORs) and 95% confidence intervals from regression models of 4 outcome classes: nurse job outcomes, safety and quality ratings, patient outcomes, and patient satisfaction. Pooled ORs and confidence intervals were estimated for each outcome using fixed or random effects models. Of 308 articles reviewed, 40 met inclusion criteria. After excluding 23 due to sample overlap or too few observations to meta-analyze, a set of 17 articles, comprising 21 independent samples, was analyzed. Cumulatively, these articles reported data from 2677 hospitals, 141 nursing units, 165,024 nurses, and 1,368,420 patients, in 22 countries. Practice Environment Scale of the Nursing Work Index, a National Quality Forum nursing care performance standard. Consistent, significant associations between the work environment and all outcome classes were identified. Better work environments were associated with lower odds of negative nurse outcomes (average OR of 0.71), poor safety or quality ratings (average OR of 0.65), and negative patient outcomes (average OR of 0.93), but higher odds of patient satisfaction (OR of 1.16). The nurse work environment warrants attention to promote health care quality, safety, and patient and clinician well-being.

Using a National Representative Sample to Evaluate the Integrity of the 30-Day Surgical Mortality Metric

The 30-day surgical mortality metric is endorsed by the National Quality Forum for value-based purchasing purposes. However, its integrity has been questioned, as there is documented evidence of hospital manipulation of this measure, by way of inappropriate palliative care designation and changes in patient selection. To determine if there is evidence of potential manipulation, we retrospectively analyzed 1,725,291 surgical admissions from 158 United States hospitals participating in the National Inpatient Sample from 2010 to 2011. As a way of evaluating unnecessary life-prolonging measures, we determined that a significant increase in mortality rate after post-operative day 30 (day 31–35) would indicate manipulation. We compared the post-operative mortality rates for each hospital between Post-Operative Day 26–30 and Post-Operative Day 31–35 using Wilcoxon signed-rank tests. After application of the Bonferroni correction, the results showed that none of the hospitals had a statistically significant increase in mortality after post-operative day 30. This analysis fails to impugn the integrity of this measure, as we did not identify any evidence of potential manipulation of the 30-day surgical mortality metric.

Evaluating mortality outlier hospitals to improve the quality of care in emergency general surgery.

Expected performance rates for various outcome metrics are a hallmark of hospital quality indicators used by Agency of Healthcare Research and Quality, Center for Medicare and Medicaid Services, and National Quality Forum. The identification of outlier hospitals with above- and below-expected mortality for emergency general surgery (EGS) operations is therefore of great value for EGS quality improvement initiatives. The aim of this study was to determine hospital variation in mortality after EGS operations, and compare characteristics between outlier hospitals. Using data from the California State Inpatient Database (2010-2011), we identified patients who underwent one of eight common EGS operations. Expected mortality was obtained from a Bayesian model, adjusting for both patient- and hospital-level variables. A hospital-level standardized mortality ratio (SMR) was constructed (ratio of observed to expected deaths). Only hospitals performing three or more of each operation were included. An "outlier" hospital was defined as having an SMR with 80% confidence interval that did not cross 1.0. High- and low-mortality SMR outliers were compared. There were 140,333 patients included from 220 hospitals. Standardized mortality ratio varied from a high of 2.6 (mortality, 160% higher than expected) to a low of 0.2 (mortality, 80% lower than expected); 12 hospitals were high SMR outliers, and 28 were low SMR outliers. Standardized mortality was over three times worse in the high SMR outliers compared with the low SMR outliers (1.7 vs. 0.5; p < 0.001). Hospital-, patient-, and operative-level characteristics were equivalent in each outlier group. There exists significant hospital variation in standardized mortality after EGS operations. High SMR outliers have significant excess mortality, while low SMR outliers have superior EGS survival. Common hospital-level characteristics do not explain the wide gap between underperforming and overperforming outlier institutions. These findings suggest that SMR can help guide assessment of EGS performance across hospitals; further research is essential to identify and define the hospital processes of care which translate into optimal EGS outcomes. Epidemiologic Study, level III.

Trends in Radiation for Bone Metastasis During a Period of Multiple National Quality Improvement Initiatives.

To evaluate trends in fractionation and cost of radiation for bone metastasis during a time period of multiple national quality improvement initiatives that focused on reducing the number of fractions per radiation episode. Using nationwide Medicare claims from 2011 to 2014, we identified radiation episodes for bone metastasis from prostate, lung, and breast cancer. Details regarding fractionation, radiation therapy (RT) modality, and sociodemographic characteristics were abstracted from claims. Time trends in use of 10 or fewer RT fractions per episode were evaluated using the Cochran-Armitage test. Total cost per episode was calculated from a payer's perspective and reported in 2017 dollars; time trends in cost were assessed using linear regression. Generalized linear models identified predictors of treatment with 10 or fewer fractions. Of 51,533 episodes identified, 46,326 used 2D/3D RT, 3,199 used intensity-modulated RT, and 2,008 used stereotactic body RT. The proportion of 2D/3D RT episodes using 10 or fewer fractions increased from 65.5% to 79.7% ( Ptrend < .001), and mean total cost per episode decreased from $6,742 to $6,067 ( Ptrend < .001). Use of single-fraction radiation increased modestly for 2D/3D treatment (6.5% to 8.1%; Ptrend < .001). Predictors of 10 or fewer fractions included treatment in recent years, advanced age (≥ 85 years), and higher comorbidity score. Variation was noted based on geographic region and primary cancer. During a period with quality initiatives launched by the American Society for Radiation Oncology, American Board of Internal Medicine, and National Quality Forum, use of 10 or fewer fractions for bone metastasis increased by 14.2%, but single-fraction regimens increased by only 1.6%, highlighting opportunities for quality improvement.

Good infection prevention practices in three Brazilian hospitals: Implications for patient safety policies

ObjectiveHealthcare-associated infections (HAI) are a serious patient safety problem. There are effective preventive practices, but little information on adherence in Brazilian hospitals. This study aims at assessing adherence to good HAI prevention practices. MethodsA cross-sectional observational study was conducted at 3 different types of hospitals (public-federal, public-state and private) in Rio Grande do Norte state, Brazil. A total of 19 structure and process indicators were measured based on 7 National Quality Forum Patient Safety Practices. ResultsOverall adherence was low, but higher in the private hospital, followed by the public-federal and public-state institutions. There was adequate maintenance of central venous catheters and high vaccine coverage against the influenza virus among health professionals. However, hand hygiene adherence was low, and surgical antibiotic prophylaxis and prevention of multidrug-resistant bacteria transmission, urinary tract infection by urinary catheter and associated with mechanical ventilation were inadequate. ConclusionsDespite the availability of evidence-based recommendations, there is ample room for improvement in adherence to safe practices in the hospitals under study, contributing to the heightened risk of unnecessary harm to patients.

Orthopaedic Trauma Quality Measures for Value-Based Health Care Delivery: A Systematic Review.

To assess the current portfolio of quality measures and candidate quality measures that address orthopaedic trauma surgery. We systematically reviewed the National Quality Forum, the Agency for Healthcare Research and Quality, and the Quality Payment Program for quality measures relevant to fracture surgery. We also searched MEDLINE/PubMed, Embase/Scopus, and Cochrane libraries. Clinical practice guidelines were included as candidate quality measures if their development was in accordance with the Institute of Medicine criteria for development of clinical practice guidelines, were based on consistent clinical evidence including at least one Level I study, and carried the strongest possible recommendation by the developing body. We categorized the measures as structure, process, or outcome domains according to the framework described by Donabedian. From the 3809 articles initially identified and screened, a total of 189 combined quality or candidate quality measures were extracted from our review. With regard to the Donabedian framework, there were a total of 7% (13/189) structure, 52% process (99/189), and 41% (77/189) outcome measures identified. As quality measures progressively inform reimbursement in value-based health care models, quality measures evaluating the care of patients sustaining a fracture will become increasingly relevant to orthopaedic trauma surgeons.

Briefly Noted

A project that began a year ago (see ADAW, Jan. 15, 2018), Shatterproof's rating system of addiction treatment programs took another step last month when the nonprofit announced it would start out with a pilot, now that it has $5 million. Saying the current addiction treatment system is broken, Shatterproof founder and CEO Gary Mendell said the project was made possible by funding from two foundations (the Laura and John Arnold Foundation and the Robert Wood Johnson Foundation) and a coalition of five insurance companies. “People who need help for addiction don't know what to look for or where to turn,” said Sam Arsenault, director of national treatment quality initiatives at Shatterproof, in the Dec. 18 announcement of the project. “We are taking rating system best practices from health care and other business sectors and applying them to addiction treatment. This will not only provide critical information to individuals looking for care but also drive a long overdue transformation of the addiction treatment industry.” The Shatterproof Rating System will utilize data from three sources: insurance claims, provider surveys and consumer experience, with collaboration from the National Quality Forum (NQF), a membership organization composed of payers. Initially, the program will begin with a pilot, with analysis done by RTI International. “Consumers can find information and accurate data on the quality of nursing homes, hospitals, physicians and most other types of providers,” said Tami Mark, director of behavioral health financing and quality measurement at RTI International. “It's time that patients have reliable information on addiction treatment.”

Rethinking high reliability in healthcare: The role of error management theory towards advancing high reliability organizing

US Healthcare, despite its exceptional technology and innovative treatments, is still unsafe and unreliable. It is estimated that medical errors account for an estimated 254,000 inpatient deaths a year and hold the distinction as the third leading cause of death in the US. Despite an aggressive national campaign set by organizations like the National Academy of Medicine, the Institute for Healthcare Improvement, the National Patient Safety Foundation, and the National Quality Forum, efforts to improve the quality and safety of US Healthcare have been unsuccessful, or at best, unsustainable at eliminating preventable patient harm. Historically, US Healthcare has turned to commercial aviation, nuclear energy, oil and gas, and other high reliability industries for lessons on how to avoid harm. In this paper, we join two pre-existing conceptual models: high reliability organizing and error management theory to propose a strategy for embedding and sustaining a preoccupation with failure and commitment to resilience within healthcare to advance a practical and disciplined focus to advance organizational high reliability.

Impact of Accuracy of Survival Predictions on Quality of End-of-Life Care Among Patients With Metastatic Cancer Who Receive Radiation Therapy.

For patients treated with palliative radiation, we examined the association between life expectancy predictions by radiation oncologists and aggressive end-of-life care. We included decedents from a study that assessed the ability of oncologists to predict survival of patients with metastatic cancer who received radiation. We identified patients who died within 12 months of study enrollment to assess accuracy of predictions. Aggressive end-of-life care was defined by the National Quality Forum, ASCO Quality Oncology Practice Initiative metrics, and advanced radiation modalities in the last month of life. Survival predictions were categorized as follows: correct (< 12 months), 12 to 18 months, 18 to 24 months, and more than 24 months. We assessed association between prediction and aggressive end-of-life care using a generalized estimation equation. Of 489 decedents, we identified 467 encounters with survival estimates. Overall, 156 decedents (32%) met at least one metric of aggressive end-of-life care. Factors associated with aggressive end-of-life care included younger age, female sex, primary cancer diagnosis, no brain metastases, and private insurance. In each encounter when an oncologist predicted survival, 363 predictions (78%) were correct (< 12 months), 54 (11%) incorrectly predicted 12 to 18 months, 27 (6%) predicted 18 to 24 months, and 23 (5%) predicted more than 24 months. Compared with patients who had encounters that had correct survival predictions, patients predicted to live more than 24 months were more likely to meet at least one metric of aggressive end-of-life care (odds ratio, 2.55; 95% CI, 1.09 to 5.99; P = .03). Inaccurate survival predictions by oncologists are associated with more aggressive end-of-life care for patients with advanced cancer.

Quality of End-of-Life Care and Its Association with Nurse Practice Environments in U.S. Hospitals.

The purpose of this study is twofold: (1) to describe the quality of end-of-life care in US hospitals from the perspective of hospital nurses; and (2) to evaluate the relationship between the nurse practice environment and end-of-life care quality. Cross-sectional analysis of multiple linked secondary data sources. A total of 12,870 direct care registered nurses in 491 acute-care hospitals. Measures of end-of-life care quality and nurse practice environment were derived from the 2016 RN4CAST-US survey of nurses. Nurses reported on end-of-life care quality for patients for whom death within a year would not be surprising. Nurse practice environment was measured using the Practice Environment Scale of the Nursing Work Index, a National Quality Forum validated scale. Most nurses gave their hospitals an unfavorable evaluation of end-of-life care overall (58%) and said patients often experience painful procedures that were unlikely to change their outcome (53%). The best predictor of poor quality was the nurse practice environment. Nurses in the best environments were 55% less likely than nurses in poor environments to rate their hospital's overall end-of-life care quality unfavorably (odds ratio = 0.45; 95% confidence interval = 0.39-0.52; P < .001). Quality of end-of-life care in US hospitals is imperfect and is significantly worse in hospitals with poor nurse practice environments than in hospitals with the best environments. This study reinforces the importance of nurses in providing high-quality end-of-life care. J Am Geriatr Soc 67:302-308, 2019.

Framework to Advance Oncology-Related Telehealth.

As telehealth is increasingly used across the clinical care spectrum to provide patient-centered care, it is important to have robust measures to assess its impact on patient outcomes and care processes. The National Quality Forum (NQF) developed a Telehealth Framework to organize measures and inform target areas for measure development that includes the following four domains: access to care, financial impact or cost, experience, and effectiveness. Our goal is to identify and categorize within the NQF domains currently existing measures of telehealth applicable to oncology to detect priority areas for future research and measure development. We reviewed telehealth-related measures applied to oncology care reported in systematic reviews and identified NQF-endorsed quality measures related to oncology care potentially amenable to telehealth. We organized identified measures by the NQF domains to inform suggestions for advancing the care of patients with cancer through telehealth. We identified 12 systematic reviews representing 183 studies reporting telehealth-related oncology research. Most studied outcomes related to diagnosis and treatment or user experience and symptom monitoring. Clinical effectiveness measures were most frequently reported (38%), and most were psychosocial. Patient, family, and/or caregiver experience was the next most frequently reported measure. There were only a few other cancer-related clinical effectiveness measures (eg, morbidity). Most NQF-endorsed oncology measures amenable to telehealth applied to the domains of access to care and effectiveness, with a lack of measures informing financial impact or cost and experience. Overall, there has been a lack of quality measures to assess use of telehealth for the care of oncology patients. Future work should focus on developing measures within each of the NQF-identified domains, with special attention to the financial impact or cost domain.

End-of-Life Care Quality Outcomes Among Medicare Beneficiaries with Hematologic Malignancies

Background: Benefits of hospice care for patients with advanced solid cancers have been extensively studied, but they have not been comprehensively documented in hematologic malignancies (HM). Surveys indicate that hematologists harbor concerns about adequacy of hospice services for patients with HM (Odejide et al., Cancer 2017; Hui et al., Ann Oncol 2015). A common perception is that these patients often receive chemotherapy until the very end of life (EOL) and are destined to die in the acute care setting (Sekeres & Gerds, Cancer 2015). They also experience a barrier to hospice use when transfusion dependence develops (LeBlanc et al., Blood 2018). In this context, some authors have questioned whether standard measures of EOL care quality proposed by the National Quality Forum (NQF) should apply to patients with HM, and whether the use of hospice services can improve such measures. Our objective was to describe EOL care quality measures derivable from Medicare administrative claims among patients with HM who did or did not use hospice services.Methods: From the population-based linked SEER-Medicare registry, we selected fee-for-service beneficiaries with leukemias (acute or chronic), myeloma, myeloproliferative neoplasms (MPN), myelodysplastic syndrome (MDS), or lymphoma (any subtype), who died in 2007-2011. We identified beneficiaries who used hospice services, and ascertained claims-based indicators of aggressive EOL care corresponding to select NQF care quality measures: 1) death in acute care hospital, 2) number of days spent in acute care hospital within 30 days of death, 3) intensive care unit (ICU) admission within 30 days of death, 4) use of chemotherapy within 14 days of death, and 5) Medicare spending for care within the last 30 days of life. Binary outcomes were compared in multivariable robust Poisson models (reporting relative risk, RR), count outcomes in negative binomial models, and costs in a log-gamma model. All estimates were reported with 95% confidence intervals (CI). Models were adjusted for age, sex, race, marital status, Medicaid co-insurance (indicator of low socio-economic status), prevalent poverty in the county of residence, comorbidity index, poor performance status indicator, calendar year, and survival from diagnosis.Results: We identified 13,556 decedents with leukemia, 7,910 with myeloma, 9,543 with MPN/MDS, and 22,990 with lymphoma, who had median age at death of 78 years (interquartile range [IQR] 72-84). Overall, 47% of patients used hospice services, enrolling at median 22 months from diagnosis (IQR, 5-59; varying from 13 in leukemia to 28 in lymphoma). Median length of stay on hospice was 9 days (IQR, 3-27), varying from 8 to 10 days between different HM. Overall, 39% of patients died in hospital settings (from 36% in myeloma to 41% in leukemia). Median number of days spent in hospital at EOL was 4 in all types of HM. ICU admissions within the last month of life occurred in 39% of patients, and chemotherapy was administered to 10% in the last 14 days (varying from 7% in MPN/MDS to 13% in leukemia). These measures significantly differed between hospice enrollees and non-enrollees (Table).In multivariable models, use of hospice services was associated with a significant decrease in the aggressiveness of EOL care, as follows: 95% decrease in inpatient deaths (adjusted RR, 0.05; 95%CI, 0.05-0.06), 48% decrease in days spent in hospital (adjusted relative count, 0.62; 95%CI 0.60-0.63), 44% decrease in the risk of ICU stay (adjusted RR, 0.56; 95%CI, 0.54-0.57), 47% decrease in the use of chemotherapy (adjusted RR, 0.53; 95%CI, 0.50-0.57), and 38% decrease in mean Medicare spending at EOL (adjusted relative cost, 0.62; 95%CI, 0.60-0.63).Conclusions: The proportion of Medicare beneficiaries with HM who die in inpatient setting (39%) or are admitted to ICU (39%) in the last month of life is higher than in a contemporary population of Medicare beneficiaries with cancer (22% and 27%, respectively, in 2009 per Teno et al., JAMA 2013). Across the spectrum of HM, which vary in prognosis and clinical course, use of hospice services is associated with markedly improved measures of EOL care quality, as well as lower Medicare spending in the last month of life. However, only 47% of beneficiaries with HM use hospice services (compared with 59% in Teno et al.). Chemotherapy use at EOL was uncommon, challenging the notion that pervasive chemotherapy is a barrier to hospice use in HM. DisclosuresOlszewski:Genentech: Research Funding; Spectrum Pharmaceuticals: Consultancy, Research Funding; TG Therapeutics: Research Funding.

Musculoskeletal-based Patient-reported Outcome Performance Measures, Where Have We Been-Where Are We Going.

While health care evolves from volume to value, there is increasing interest by payors to use patient-reported outcomes (PROs) to determine value and more specifically, quality from the patient's perspective. This article reviews the current state of PROs and discusses future directions. Specifically, this article will review the current history and background of PROs; it will highlight the perspective of the National Quality Forum and review the efforts of the musculoskeletal community related to PROs. Goals, positive aspects, limitations, and barriers related to PROs will be discussed. Additionally, development considerations and strategies will be highlighted. Finally, development recommendations from the American Academy of Orthopaedic Surgery position statement "principles for musculoskeletal based PRO performance measurement development" will be introduced.

Deploying end-of-life utilization measures for oncology patients to assess hospital care quality and value.

106 Background: Addressing utilization near the end of life (EOL) for cancer patients is critical to enhance the value of cancer care. Cancer EOL utilization measures have been widely endorsed, including by the National Quality Forum (chemotherapy in the last 14 days; ICU in the last 30 days; not admitted to hospice; admitted to hospice for &lt; 3 days). However, efforts to use these measures to assess hospital quality and value have been constrained, in part because currently endorsed specifications do not provide a claims-based approach to cohort identification, and do not include a hospital attribution methodology. Methods: Using Medicare fee-for-service claims for adults ≥65 years, and through an iterative process informed by an expert panel, we developed extensible claims-based algorithms to a) identify patients who were deceased from cancer; b) attribute each patient to a responsible hospital; and c) derive hospital-level performance measures. We sought to ensure that these algorithms had strong face validity and were consistent with standard practices for claims-based analyses. Results: We identified 347,452 cancer decedents as those who had a cancer diagnosis associated with ≥2 hospital inpatient (IP), hospital outpatient (OP), or hospice claims, and died between 2011-2014. A decedent’s care was attributed to a hospital if there were ≥2 claims from that institution during the 6 months before death (N = 221,102). If this identified multiple hospitals, one was selected using the following sequence: total majority of all claims; most OP claims; most IP claims; last IP claim before death. Measure performance reflected national published data: 6% received chemotherapy in the last 14 days; 28% admitted to ICU in the last 30 days; and 34% not admitted to hospice. There was significant variation in hospital performance for all measures. Conclusions: Claims-based EOL measures do not define ‘ideal’ performance, but they do provide hospitals with broad utilization data that can help inform value-based cancer care delivery. These methods addressed gaps hindering the application of endorsed cancer EOL measures to hospitals. Companion quality measures to assess goal-concordant care are also needed.