National Quality Measures Clearinghouse Research Articles

Key performance indicators in extracorporeal membrane oxygenation (ECMO): protocol for a systematic review

IntroductionExtracorporeal membrane oxygenation (ECMO) is an intervention used in critically ill patients with severe cardiopulmonary failure that is expensive and resource intensive and requires specialised care. There remains a significant...

Review of Cancer-Specific Quality Measures Promoting the Avoidance of Low-Value Care.

With rising healthcare costs and campaigns aimed at avoiding low-value care, reducing cancer overtreatment has emerged as an important measure of cancer care quality. The extent to which avoidance of low-value care has been incorporated in cancer-specific quality measures is unknown. We aimed to identify and characterize cancer quality measures that promote the avoidance of low-value care, and identify gaps that may guide future measure development. We systematically identified cancer-specific quality measures from leading quality measure organizations [e.g., National Quality Forum (NQF), National Quality Measures Clearinghouse (NQMC)]. We reviewed measures promoting the avoidance of low-value cancer care and subclassified them into disease site- or non-disease site-specific categories and the phase of care they targeted. We reviewed 313 quality measures from six organizations. Of these, 18% (n = 55) focused on avoidance of low-value care. Quality measures focused on end-of-life care were most likely to focus on low-value care [n = 13 (50%)], followed by breast [n = 12 (18%)], lung [n = 9 (31%)], colon [n = 8 (20%)], prostate [n = 5 (38%)], general cancer care [n = 4 (3%)], symptoms and toxicities [n = 2 (40%)], and palliative cancer care [n = 2 (11%)] measures. The phases of care quality measures targeted included low-value screening [n = 5 (9%)], diagnostic testing and staging [n = 7 (13%)], treatment [n = 19 (34%)], surveillance [n = 6 (11%)], and clinical outcomes [n = 18 (33%)]. All categories had a treatment-specific quality measure, but no category had a representative measure for every phase of care. A minority of cancer quality measures are aimed at avoiding low-value care, and multiple evidence-based recommendations targeting low-value care have not been incorporated.

Lessons from Reporting National Performance Measures in a Regional Setting: Washington State Community Cancer Care Report.

105 Background: While many quality metrics are generated and reported at a national level, regionally reported metrics may be more meaningful to stakeholders and more amenable to locally-generated interventions aimed at improving quality. We present the lessons learned from adapting national performance reporting standards to our regional setting. Methods: We linked 2014-2016 Washington State cancer registry records with Medicare and commercial insurance claims, capturing about 70% of the state’s cancer patients. A consortium of payers, oncology providers, and patients selected metrics from national initiatives (QOPI, MACRA, OCM, and the Choosing Wisely Campaign). We then searched the National Quality Forum and the National Quality Measures Clearinghouse for published specifications on those metrics. If none were available or there was a lack of consensus, we constructed algorithms with clinical and technical expert review. We calculated clinic-level risk standardized rates (RSRs) using hierarchical regression modeling to adjust for variation in clinic size and constructed quality composites. Results: We generated 13 quality metrics for 36,900 cancer patients cared for at 27 clinics. Our adaptation of national performance measures and implications include: 1) Many treatment process measures had too few numbers to individually report annually requiring us to group quality metrics and cancer types, and report over a three year period. 2) Although we were able to include tumor characteristics (e.g. AJCC stage) from registry records, risk adjustment was challenged by limitations in the number of risk adjustors due to the smaller number of patients. 3) After applying the hierarchical models, risk adjustment had minimal effect on clinic rankings. 4) The small number of clinics and limited range of clinic RSRs were more accurately captured by a quality composite that reflected clinic level differences to the regional average rather than national quintile groupings. Conclusions: Refinement of national metrics is necessary for public reporting in a regional setting. Further methodological development is critical for robust reporting and applications to value based purchasing.

Developing Resident-Sensitive Quality Measures: A Model From Pediatric Emergency Medicine.

To begin closing the gap with respect to quality measures available for use among residents, the authors sought to identify and develop resident-sensitive quality measures (RSQMs) for use in the pediatric emergency department (PED) setting. In May 2016, the authors reviewed National Quality Measures Clearinghouse (NQMC) measures to identify resident-sensitive measures. To create additional measures focused on common, acute illnesses (acute asthma exacerbation, bronchiolitis, closed head injury [CHI]) in the PED, the authors used a nominal group technique (NGT) and Delphi process from September to December 2016. To achieve a local focus for developing these measures, all NGT and Delphi participants were from Cincinnati Children's Hospital Medical Center. Delphi participants rated measures developed through the NGT in two areas: importance of measure to quality care and likelihood that measure represents the work of a resident. The review of NQMC measures identified 28 of 183 as being potentially resident sensitive. The NGT produced 67 measures for asthma, 46 for bronchiolitis, and 48 for CHI. These were used in the first round of the Delphi process. After two rounds, 18 measures for asthma, 21 for bronchiolitis, and 21 for CHI met automatic inclusion criteria. In round three, participants categorized the potential final measures by their top 10 and next 5. This study describes a template for identifying and developing RSQMs that may promote high-quality care delivery during and following training. Next steps should include implementing and seeking validity evidence for the locally developed measures.

PHP76 - How are we Measuring Access to Healthcare in the US? — an Environmental Scan of Quality Measures

Improving access to healthcare in the US is a recognized priority and a shared goal within national quality improvement efforts. However, despite recognized improvements through the implementation of quality metrics, gaps in healthcare access still exist. To evaluate the current landscape of access quality measurement, we conducted an environmental scan to: 1) categorize identified metrics by type; 2) identify their implementation within public quality improvement programs; and 3) recognize potential gaps in healthcare access quality measurement. In January 2018, we searched for “access” quality measures within the CMS Measure Inventory, the National Quality Measures Clearinghouse, and the NQF Quality Positioning System. We used relevant terms for access, availability, and access to care. We included measures that focused on the concept of accessing care (e.g., % of patients who reported how often they were able to receive needed care). Two independent reviewers screened for relevance. Discrepancies were resolved by a third reviewer. Measures were then classified by domain and by use in national public programs. 95 access quality measures were identified. The majority of metrics focused on the availability of medical services for children. Except for HIV (n=22), adult measures were indistinct, focusing on broad delivery of care (i.e., whether patients received needed care or received care quickly), rather than disease-specific. Less than 10% of the measures are endorsed by the NQF and less than 5% are actively used within CMS programs. Gaps exist in the access quality measure landscape. Current measures are indistinct and lack a focus on high-priority conditions that affect populations with inherent access issues. Moreover, additional evidence is needed to evaluate whether current access metrics have a significant impact on patient care or whether an evolution of the current landscape is needed.

Linking clinical quality indicators to research evidence - a case study in asthma management for children

BackgroundClinical quality indicators are used to monitor the performance of healthcare services and should wherever possible be based on research evidence. Little is known however about the extent to which indicators in common use are based on research. The objective of this study is to measure the extent to which clinical quality indicators used in asthma management in children with outcome measurements can be linked to results in randomised controlled clinical trial (RCT) reports. This work is part of a broader research program to trial methods that improve the efficiency and accuracy of indicator development.MethodsNational-level indicators for asthma management in children were extracted from the National Quality Measures Clearinghouse database and the National Institute for Health and Care Excellence quality standards by two independent appraisers. Outcome measures were extracted from all published English language RCT reports for asthma management in children below the age of 12 published between 2005 and 2014. The two sets were then linked by manually mapping both to a common set of Unified Medical Language System (UMLS) concepts.ResultsThe analysis identified 39 indicators and 562 full text RCTs dealing with asthma management in children. About 95% (37/39) of the indicators could be linked to RCT outcome measures.ConclusionsIt is possible to identify relevant RCT reports for the majority of indicators used to assess the quality of asthma management in childhood. The methods reported here could be automated to more generally support assessment of candidate indicators against the research evidence.

Continuous quality management for complex blood cancers in Sarah Cannon Blood Cancer Network.

59 Background: Sarah Cannon Blood Cancer Network (SCBCN) is a network of seven markets dedicated to provide high quality and safe care to patients with complex blood cancers. Continuous quality management (QM) and improving patient safety are critical components to the mission of SCBCN. Methods: Four SCBCN disease-specific working groups have developed evidence-based pathways for complex blood cancers. However, there are currently no SCBCN clinical quality of care metrics to monitor value-based care. To address this unmet need, the SCBCN leadership endorsed a team-based approach to measure QM for complex blood cancers, using basic clinical performance metrics proposed by the American Society of Hematology, the American Medical Association-convened Physician Consortium for Performance Improvement, the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality National Quality Measures Clearinghouse, and Centers for Medicare & Medicaid Services. Results: Between 2012 and September 2015, 1221 new adult cases of Acute Myeloid Leukemia (AML) and 253 new adult cases of Myelodysplastic Syndrome (MDS), respectively, were reported within the SCBCN. Based on the volume of cases and to measure QM in AML and MDS, quality indicators were selected based on meaningfulness to program goals and feasibility of data capture, leading to development of quality metrics dashboard for AML and MDS in SCBCN. Also, keeping in mind the changing paradigm of personalized care using new and emerging therapies in AML and MDS, exploratory quality metrics are also proposed to evaluate access to new trials as QM of AML and MDS in SCBCN. Conclusions: SCBCN is a wide network of community hospitals with expertise in managing complex blood cancers. As proof of concept study, the AML and MDS dashboard was developed and chosen as a model for continuous QM for complex blood cancers. This dashboard will initially be tested to evaluate QM at two SCBCN sites to facilitate the overarching programmatic goal of continuous QM for all AML/MDS and other blood cancers presenting within the SCBCN.

Current landscape of acute myeloid leukemia quality measures in the United States.

261 Background: Acute myeloid leukemia (AML) is a rare, but deadly hematological, disease with 20,830 new cases estimated in 2015 in the United States (US). As new treatments emerge, quality measures (QMs) will become important to assess the value of care. Our aim was to evaluate the current US AML QM landscape. Methods: We reviewed literature and online resources (eg, National Quality Measures Clearinghouse, Centers for Medicare & Medicaid Services, etc.) published within the last 5 years to identify AML-specific and AML-related QMs. All QMs were categorized using a “continuum of care” framework according to the 5 stages of AML: 1) symptom assessment, 2) diagnosis/risk stratification, 3) initial treatment, 4) monitoring/additional treatment, and 5) advanced/late stage care. Quality measures were categorized by the measure type (eg, process or outcome measure) and use by the Centers for Medicare & Medicaid Services (CMS). Results: In total, 30 QMs were identified: 1 leukemia-specific QM and 29 general oncology QMs. The leukemia-specific QM is a clinician-level process measure that evaluates the percentage of patients aged ≥ 18 years with a diagnosis of myelodysplastic syndrome or acute leukemia who had baseline bone marrow cytogenetic testing performed. Among the 29 general QMs: 8 are specific to stem cell transplantation, 13 are specific to chemotherapy, and 8 are general to oncology. Across the AML continuum of care: 2 QMs focus on symptom assessment, 1 supports diagnosis/risk stratification, 11 are for initial treatment, 9 for monitoring/additional treatment, and 7 for late-stage care. Twenty-seven QMs are based on process of care: 1 addresses resource utilization and 2 are outcomes based. The single leukemia-specific QM is used in CMS quality improvement programs, along with 3 other oncology-related QMs. Conclusions: While only one identified QM was specific to leukemia, other general oncology QMs may also apply. Unfortunately, QMs addressing AML-related morbidity and mortality are still lacking. Research into patient-centered communication, shared decision-making, patient-reported outcomes and resource use by AML patients may inform development of new QMs. Sponsorship: This research was funded by Astellas Pharma, Inc.

Quality and performance measures of strain on intensive care capacity: a protocol for a systematic review.

BackgroundThe matching of critical care service supply with demand is fundamental for the efficient delivery of advanced life support to patients in urgent need. Mismatch in this supply/demand relationship contributes to “intensive care unit (ICU) capacity strain,” defined as a time-varying disruption in the ability of an ICU to provide well-timed and high-quality intensive care support to any and all patients who are or may become critically ill. ICU capacity strain leads to suboptimal quality of care and may directly contribute to heightened risk of adverse events, premature discharges, unplanned readmissions, and avoidable death. Unrelenting strain on ICU capacity contributes to inefficient health resource utilization and may negatively impact the satisfaction of patients, their families, and frontline providers. It is unknown how to optimally quantify the instantaneous and temporal “stress” an ICU experiences due to capacity strain.MethodsWe will perform a systematic review to identify, appraise, and evaluate quality and performance measures of strain on ICU capacity and their association with relevant patient-centered, ICU-level, and health system-level outcomes. Electronic databases (i.e., MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Web of Science, and the Agency of Healthcare Research and Quality (AHRQ)—National Quality Measures Clearinghouse (NQMC)) will be searched for original studies of measures of ICU capacity strain. Selected gray literature sources will be searched. Search themes will focus on intensive care, quality, operations management, and capacity. Analysis will be primarily narrative. Each identified measure will be defined, characterized, and evaluated using the criteria proposed by the US Strategic Framework Board for a National Quality Measurement and Reporting System (i.e., importance, scientific acceptability, usability, feasibility).DiscussionOur systematic review will comprehensively identify, define, and evaluate quality and performance measures of ICU capacity strain. This is a necessary step towards understanding the impact of capacity strain on quality and performance in intensive care and to develop innovative interventions aimed to improve efficiency, avoid waste, and better anticipate impending capacity shortfalls.Systematic review registrationPROSPERO, CRD42015017931Electronic supplementary materialThe online version of this article (doi:10.1186/s13643-015-0145-9) contains supplementary material, which is available to authorized users.

Comparing clinical quality indicators for asthma management in children with outcome measures used in randomised controlled trials: a protocol

IntroductionClinical quality indicators are necessary to monitor the performance of healthcare services. The development of indicators should, wherever possible, be based on research evidence to minimise the risk of bias...

Quality indicators in continuous renal replacement therapy (CRRT) care in critically ill patients: protocol for a systematic review.

BackgroundRenal replacement therapy is increasingly utilized in the intensive care unit (ICU), of which continuous renal replacement therapy (CRRT) is most common. Despite CRRT being a relatively resource-intensive and expensive technology, there remains wide practice variation in its application. This systematic review will appraise the evidence for quality indicators (QIs) of CRRT care in critically ill patients.MethodsOvid MEDLINE, Ovid EMBASE, CINAHL, and the Cochrane Library including the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials (CENTRAL), and databases from the National Information Center of Health Services Research and Health Care Technology will be searched for original studies involving QIs in CRRT. Gray literature sources will be searched for technical reports, practice guidelines, and conference proceedings. Websites of relevant organizations will be identified, and industry leaders in the development and marketing of CRRT technology and non-profit organizations that represent key opinion leads in the use of CRRT will be contacted. We will search the Agency of Healthcare Research and Quality National Quality Measures Clearinghouse for CRRT-related QIs. Studies will be included if they contain quality measures, occur in critically ill patients, and are associated with CRRT. Analysis will be primarily descriptive. Each QI will be evaluated for importance, scientific acceptability, usability, and feasibility using the four criteria proposed by the United States Strategic Framework Board for a National Quality Measurement and Reporting System. Finally, QIs will be appraised for their potential operational characteristics, for their potential to be integrated into electronic medical records, and on their affordability, if applicable.DiscussionThis systematic review will comprehensively identify and synthesize QIs in CRRT. The results of this study will fuel the development of an inventory of essential QIs to support the appropriate, safe, and efficient delivery of CRRT in critically ill patients.Systematic review registrationPROSPERO CRD42015015530.Electronic supplementary materialThe online version of this article (doi:10.1186/s13643-015-0088-1) contains supplementary material, which is available to authorized users.

The Current State of Behavioral Health Quality Measures: Where Are the Gaps?

This review examined the extent to which existing behavioral health quality measures address the priority areas of the National Behavioral Health Quality Framework (NBHQF) as well as the extent to which the measures have received National Quality Forum endorsement and are used in major reporting programs. This review identified behavioral health quality measures in widely used measure inventories, including the National Quality Measures Clearinghouse, National Quality Forum, and the Center for Quality Assessment in Mental Health. Additional measures were identified through outreach to federal agencies. Measures were categorized by type, condition, target population, data source, reporting unit, endorsement status, and use in reporting programs. The review identified 510 measures. Nearly one-third of these measures address broad mental health or substance use conditions rather than a specific condition or diagnosis. Seventy-two percent are process measures. The most common data source for measures is administrative claims, and very few measures rely on electronic health records or surveys. Fifty-three (10%) measures have received National Quality Forum (NQF) endorsement, and 28 (5%) unique measures are used in major quality reporting programs. Several subdomains of the NBHQF, such as treatment intensification, financial barriers to care, and continuity of care, lack measures that are NQF endorsed. Despite the wide array of behavioral health quality measures, relatively few have received endorsement or are used in reporting programs. Future efforts should seek to fill gaps in measurement and to identify the most salient and strongest measures in each priority area.

The Population Value Of Quality Indicator Reporting: A Framework For Prioritizing Health Care Performance Measures

The Agency for Healthcare Research and Quality (AHRQ) National Healthcare Quality and Disparities Reports contain more than 250 quality indicators, such as whether a patient with a suspected heart attack received an aspirin. The Department of Health and Human Services National Quality Measures Clearinghouse identifies more than 2,100 such indicators. Because resources for making quality improvements are limited, there is a need to prioritize among these indicators. We propose an approach to assess how reporting specific quality indicators would change care to improve the length and quality of life of the US population. Using thirteen AHRQ quality indicators with readily available data on the benefits of indicator reporting, we found that seven of them account for 93percent of total benefits, while the remaining six account for only 7percent of total benefits. Use of a framework such as this could focus resources on indicators having the greatest expected impact on population health.

Health-related quality of life and functional status quality indicators for older persons with multiple chronic conditions.

To explore central challenges with translating self-reported measurement tools for functional status and health-related quality of life (HRQOL) into ambulatory quality indicators for older people with multiple chronic conditions (MCCs). Review. Sources including the National Quality Measures Clearinghouse and National Quality Forum were reviewed for existing ambulatory quality indicators relevant to functional status, HRQOL, and people with MCCs. Seven informants with expertise in indicators using functional status and HRQOL. Informant interviews were conducted to explore knowledge about these types of indicators, particularly usability and feasibility. Nine important existing indicators were identified in the review. For process, identified indicators addressed whether providers assessed functional status; outcome indicators addressed quality of life. In interviews, informants agreed that indicators using self-reported data were important in this population. Challenges identified included concerns about usability due to inability to discriminate quality of care adequately between organizations and feasibility concerns regarding high data collection burden, with a correspondingly low response rate. Validity was also a concern because evidence is mixed that healthcare interventions can improve HRQOL or functional status for this population. As a possible first step, a structural standard could be systematic collection of these measures in a specific setting. Although functional status and HRQOL are important outcomes for older people with MCCs, few relevant ambulatory quality indicators exist, and there are concerns with usability, feasibility, and validity. Further research is needed on how best to incorporate these outcomes into quality indicators for people with MCCs.

Performance measurements in diabetes care: the complex task of selecting quality indicators

To review the literature on the content and development of the sets of quality indicators used in studies on the quality of diabetes care in primary care settings. The MEDLINE (Ovid), PubMed, PsychINFO, Embase and CINAHL databases were searched for relevant articles published up to January 2011. and data extraction We included studies on the quality of adult diabetes care, using quality indicators. We excluded studies focusing on the hospital setting, patient subgroups, specific components of diabetes care and specific outcomes. In total, 102 studies (including 102 sets and 1494 indicators) were analyzed by two independent reviewers, using the criteria of the National Quality Measures Clearinghouse and international guidelines to document the content and selection of the identified indicators. Sets varied greatly in number, content and definitions of quality indicators. Most of the indicators concerned HbA1C, lipids, blood pressure, eye and foot examination and urinalysis. Few sets included indicators on lifestyle counseling, patient experiences, healthcare structure or access to healthcare providers. Seventy sets did not specify explicit selection criteria, and 19 of these did not report the sources of the indicators. Sets of quality indicators are diverse in number, content and definitions. This diversity reflects a lack of uniformity in the concept of diabetes care quality and hinders the interpretation of and comparison between quality assessments. Methodology regarding defining constructs such as the quality of diabetes care and indicator selection procedures is available and should be used more rigorously.

015 Tracking the Impact of the Agency for Healthcare Research and Quality’s (AHRQ) Effective Health Care Program through Uptake by Clinical Practice Guideline and Quality Measure Developers

BackgroundPublic and private funders evaluate health care investments in terms of outcomes and accountability. Citation analysis can approximate the dissemination and impact of funded research outputs.ObjectivesUse references in guidelines and...

Do Clinical Standards for Diabetes Care Address Excess Risk for Hypoglycemia in Vulnerable Patients? A Systematic Review

To determine whether diabetes clinical standards consider increased hypoglycemia risk in vulnerable patients. MEDLINE, the National Guidelines Clearinghouse, the National Quality Measures Clearinghouse, and supplemental sources. Systematic review of clinical standards (guidelines, quality metrics, or pay-for-performance programs) for glycemic control in adult diabetes patients. The primary outcome was discussion of increased risk for hypoglycemia in vulnerable populations. Manuscripts identified were abstracted by two independent reviewers using prespecified inclusion/exclusion criteria and a standardized abstraction form. We screened 1,166 titles, and reviewed 220 manuscripts in full text. Forty-four guidelines, 17 quality metrics, and 8 pay-for-performance programs were included. Five (11 percent) guidelines and no quality metrics or pay-for-performance programs met the primary outcome. Clinical standards do not substantively incorporate evidence about increased risk for hypoglycemia in vulnerable populations.

PC-FACS

PC-FACS

Quality Measures for Primary Care of Complex Pediatric Patients

A well-recognized gap exists in assessing and improving the quality of care for medically complex patients. Our objective was to examine evidence for primary care based on the patient-centered medical home model and to identify valid and meaningful quality measures for use in complex pediatric patients. We conducted literature searches on Medline and the National Quality Measures Clearinghouse for existing measures, as well as evidence to inform the development of new quality measures. We used a 3-step process to select relevant sources from published literature: (1) the titles were screened by 2 independent reviewers; (2) the abstracts were reviewed for quality-of-care contents or constructs; and (3) full-text articles were obtained and reviewed for measure specification. All materials were reviewed for the Oxford Centre For Evidence-Based Medicine level of evidence and for relevance to primary care of complex pediatric patients. A national expert panel was convened to evaluate and rate the measures by using the Rand/University of California Los Angeles Appropriateness Method. We presented 74 quality measures to the expert panel for review and discussion. The panel rated and accepted 35 measures as valid and feasible for assessing primary care quality in complex pediatric patients. The final set of quality measures was grouped in the following domains: primary care-general (14), patient/family-centered care (8), chronic care (2), coordination of care (9), and transition of care (2). By using the patient-centered medical home framework of accessible, continuous, family-centered, coordinated, and culturally effective care, a national expert panel selected 35 primary care quality measures for complex pediatric patients.

Quality improvement in neurology: AAN epilepsy quality measures

Epilepsy is a common neurologic condition with significant personal, societal, medical, and economic burdens. There are considerable gaps in the quality of care delivered. Measuring the quality of care delivered is the first step to its improvement. Performance measures are easily identified and quantitated ways to assess whether specific activities were carried out during a patient encounter. Therefore, epilepsy performance measures were derived through a standardized systematic process and may be the basis for pay-for-performance initiatives and maintenance of certification requirements. Epilepsy measures were developed through the American Medical Association-convened Physician Consortium for Performance Improvement (PCPI) independent measure development process, which marked the first time a medical specialty society followed this process. Guidelines, measures, and consensus papers reviewed for the period 1998 to 2008 using the National Guidelines Clearinghouse, the National Quality Measures Clearinghouse, PubMed, MEDLINE, and the Cochrane Library were evaluated using a framework to determine the acceptability of each guideline or other evidence review document for measures development. Recommendation statements based on level of evidence, importance, validity, and gap in care were developed into candidate measures. A panel of experts from representative organizations vetted the measures. A period of public comment was followed by approval from the American Academy of Neurology and the PCPI. Literature search identified 160 relevant recommendation statements from 19 guidelines and 2 consensus papers. Systematic assessment resulted in 20 recommendation statements that were refined to 8 candidate measures by the expert panel. The measures are relevant to seizure type and frequency, etiology or epilepsy syndrome, EEG, neuroimaging, antiepileptic drug side effects, safety issues, referral for refractory epilepsy, and issues for women of childbearing potential. There is a reasonable evidence base, and consensus for, deriving performance measures for quality of epilepsy care. It is anticipated that implementation of these performance measures will improve care for patients with epilepsy if adopted by providers.