Specific Quality Measures Research Articles

Development and validation of the RQLQ: a Raynaud’s disease–specific measure of health-related quality of life

Introduction/objectivesThe aim of this study was to develop and validate the Raynaud Specific Quality of Life Questionnaire (RQLQ) for assessing health-related quality (HRQOL) of life in patients with Raynaud’s disease (RD).MethodThe questionnaire was developed and validated in three stages. Initially, semi-structured interviews with 28 RD patients identified domains of everyday life affected by RD, leading to the creation of the initial RQLQ. In the first quantitative stage, 101 patients completed the RQLQ, and exploratory factor analysis assessed dimensionality and factor structure. After removing poorly performing items, the final RQLQ was tested with 102 patients. This stage also evaluated convergent, divergent, and discriminant validity, as well as internal reliability.ResultsFrom the interviews, 135 items were generated, with factor analysis refining the measure to 29 items across five subscales, showing good internal consistency. The RQLQ demonstrated significant correlations with self-rated quality of life and physical and mental health outcomes, confirming convergent and divergent validity. It also showed discriminant validity for different levels of disease activity.ConclusionsThe RQLQ is the first specific HRQOL measure for RD patients, proving to be a psychometrically sound, reliable, and valid tool for clinical research and practice.Key Points• The Raynaud Specific Quality of Life Questionnaire (RQLQ) is an important scale that evaluates the quality of life of patients with Raynaud’s disease.• The questionnaire showed good validity and reliability a capturing disease-specific quality of life.• This tool may aid in clinical research and practice.

The influence of therapy quality on outcomes from behavioural activation and guided self-help treatments for depression in adults with intellectual disabilities.

We report the effect of quality of therapy delivery on outcomes in a randomized, controlled trial of behavioural activation (BA) and guided self-help (GSH) for depression in adults with intellectual disabilities. A study specific measure of quality was used in a linear mixed effect model to determine the effects therapy and therapy quality on therapy outcome. There was a significant interaction between quality and treatment type, with lower quality therapy associated with better outcome for GSH but poorer outcome for BA, with little difference in outcomes at higher levels of therapy quality. Factors suggesting high quality in individualized BA may indicate problematic engagement for GSH. More research into processes in therapy for people with intellectual disabilities is required.

The Relationship between Nursing Home Staffing and Health Outcomes Revisited

ObjectiveNursing homes make staffing decisions in conjunction with choosing quality goals, potentially leading to endogeneity bias between staffing and quality. We use instrumental variables (IVs) to explore it. DesignRetrospective statistical analysis of 2017–2019 Payroll-Based Journal, Minimum Data Set, Nursing Home Care Compare, and Long-Term Care Focus. Settings and ParticipantsA total of 11,261 nursing homes nationally. MethodsWe estimated separate models for each of 6 quality measures as dependent variables, and registered nurses (RNs), certified nurse assistants (CNAs), and licensed practical nurses (LPNs) as independent variables, including other control variables associated with quality. The models were estimated using both ordinary least squares (OLS) and 2-stage least squares (2SLS) methods, the latter accounting for endogeneity. The IVs were defined as the average staffing of competing nursing homes in the same market as the index facility. ResultsEstimated coefficients for the quality measures in the 2SLS models were up to 5 times larger than in the OLS models. The 2SLS estimates for antipsychotic medications use increased with higher RN staffing [0.279 (0.004 to 0.553)] and decreased with higher CNAs [−0.125 (−0.198 to −0.052)]. Hospitalizations decreased with more RNs [−1.328 (−1.673 to −0.983)] and LPN staffing [−0.483 (−0.755 to −0.211])] and increased with CNA [0.201 (0.109 to 0.293)] staffing. Emergency room visits decreased with higher RNs [−1.098 (−1.500 to −0.696)] and increased with CNAs [0.191 (0.084 to 0.298)]. Long-stay activities of daily living [−0.313 (−0.416 to −0.209)] and short-stay functioning [−0.481 (−0.598 to −0.364)] improved only with higher CNA staffing and pressure sores improved only with increased RN staffing [−0.436 (−0.836 to −0.035)]. Conclusions and ImplicationsOur findings demonstrate the importance of accounting for endogeneity in studies of staffing and quality. Endogeneity changes conclusions about significance, direction, and magnitude of the relationship between staffing and specific quality measures. These findings highlight the need to further study and understand the nuanced relationship between different staffing types and different health outcomes such as the difference between the relationship of RN and CNA hours per resident day to antipsychotic quality measures.

A Mediterranean diet plan in lactating women with obesity reduces maternal energy intake and modulates human milk composition - a feasibility study.

Maternal obesity is associated with increased concentrations of human milk (HM) obesogenic hormones, pro-inflammatory cytokines, and oligosaccharides (HMOs) that have been associated with infant growth and adiposity. The objective of this pilot study was to determine if adherence to a Mediterranean meal plan during lactation modulates macronutrients and bioactive molecules in human milk from mothers with obesity. Sixteen healthy, exclusively breastfeeding women with obesity (body mass index ≥30 kg/m2) enrolled between 4 and 5 months postpartum. The women followed a 4-week Mediterranean meal plan which was provided at no cost. Maternal and infant anthropometrics, HM composition, and infant intakes were measured at enrollment and at weeks 2 and 4 of the intervention. Thirteen mother-infant dyads completed the study. Additionally, participants from an adjacent, observational cohort who had obesity and who collected milk at 5 and 6 months postpartum were compared to this cohort. Participants' healthy eating index scores improved (+27 units, p < 0.001), fat mass index decreased (-4.7%, p < 0.001), and daily energy and fat intake were lower (-423.5 kcal/day, p < 0.001 and-32.7 g/day, p < 0.001, respectively) following the intervention. While HM macronutrient concentrations did not change, HM leptin, total human milk oligosaccharides (HMOs), HMO-bound fucose, Lacto-N-fucopentaose (LNFP)-II, LNFP-III, and difucosyllacto-N-tetrose (DFLNT) concentrations were lower following the intervention. Infant intakes of leptin, tumor necrosis factor (TNF)-α, total HMOs, HMO-bound fucose, LNFP-III and DFLNT were lower following the intervention. Specific components of the maternal diet (protein and fat) and specific measures of maternal diet quality (protein, dairy, greens and beans, fruit and vegetables) were associated with infant intakes and growth. Adherence to a Mediterranean meal plan increases dietary quality while reducing total fat and caloric intake. In effect, body composition in women with obesity improved, HM composition and infants' intakes were modulated. These findings provide, for the first time, evidence-based data that enhancing maternal dietary quality during lactation may promote both maternal and child health. Longer intervention studies examining the impact of maternal diet quality on HM composition, infant growth, and infant development are warranted.

Institutional Quality and Economic Misery in Nigeria

This paper makes an improvement to the traditional institutional quality-growth hypothesis originally documented in the North’s framework by investigating the implications of the quality of formal institutions on economic misery in Nigeria. The specific measures of institutional quality include economic freedom, liberal democracy, and the corruption perception index, while economic misery is measured using Hanke’s modified misery index. The datasets obtained from the World Bank, Heritage Foundation, Freedom House, Transparency International, and Carto Institute were analysed using descriptive statistics and the autoregressive distributed lag (ARDL) model, which was informed by the evidence of a fractionally integrated series. The findings showed that economic freedom significantly reduced economic misery in the short run. At the same time, evidence of a significant negative effect of liberal democracy on the misery index was established in both the short and long run. This suggests that deepening the democratic process has the potential to mitigate the economic misery faced by Nigerians through increased employment, a decrease in inflationary pressures and interest rates, as well as robust per capita growth. In addition, it was found that the corruption perception index contributed positively to the misery index. This indicates that the pervasive and systemic nature of corruption traps many Nigerians in miserable economic conditions. Owing to the findings, this paper recommends, among others, that policymakers should strengthen the democratic process and promote economic freedom by prioritising credible elections, entrenching the rule of law, and protecting property rights to mitigate the economic distress faced by Nigerians

New CMS Merit-Based Incentive Payment System Value Pathway After Total Knee and Hip Arthroplasty: Preparing for Mandatory Reporting

This article discusses the implementation of a new Merit-Based Incentive Payment System Value Pathway (MVPs) applicable to elective total hip and total knee arthroplasty as created by Medicare and Medicaid Services (CMS) – the Improving Care for Lower Extremity Joint Repair MVP (MVP ID: G0058). We describe specific quality measures, surgeon-hospital collaborations, future developments with Quality Payment Program, and how lessons from early implementation will empower clinicians to participate in the refining of this MVP. The CMS has designed MVPs as a subset of measures relevant to a specialty or medical condition, in an effort to reduce the burden of reporting and improve assessment of care quality. Physicians and payors must be mindful of detrimental effects these measures in their current form may have on surgeons, institutions, and patients, including disincentivizing care for sicker or more vulnerable populations, and increased administrative costs. Early voluntary participation is crucial to gain valuable experience for the orthopedic community and in an effort to work alongside CMS to maximize care while minimizing cost for patients and burden for providers.

Do Innovation and Institutional Quality Elevate Economic Growth? Empirical Evidence from Developing Countries

Research Highlights • An assessment of institutional quality, innovation, and economic growth in developing countries. • Long-run causality from innovation and institutional quality to economic growth is present. • Short-run directions of causality are varied among variables of interest. • Innovation and institutional quality generally positively impact economic growth. Continuous innovation is the lifeblood of a competitive economy. Furthermore, and arguably, the existence of institutions of governance of quality can be a catalyst for emerging economies to transition up the universal innovation value chain. In this context, we investigate temporal causal interactions among institutional quality, innovation, and economic growth for developing countries (DCs) spanning the period of 2005–2020. Employing a vector error-correction model (VECM), we find that for each case and specification (49 instances), there is evidence of the long-run causality from institutional quality and innovation to economic growth. Stated another way, in the long run, institutional quality and innovation Granger-cause economic growth. However, the short-run causality results differ depending on the specific measures of innovation and institutional quality. The strongest short-run conclusion is support for the feedback hypothesis for economic growth and innovation where there is a strong endogenous relationship between innovation, institutional governance, and economic growth. The empirical analysis shows over 70% of our observations support that economic growth and innovation jointly determine each other in the short run. The results suggest that DCs should develop and pursue long-term growth strategies that simultaneously develop innovation and improve institutional governance.

Hospital-physician Integration and Value-based Payment: Early Results From MIPS.

Hospital-physician integration is often justified as a driver of clinical quality improvement due to joint resources covering a broad spectrum of care. Value-based programs, such as the Medicare Merit-Based Incentive Payment System (MIPS), are intended to tie financial incentives to clinical quality, which may confer an advantage on such integrated practices. We assessed the relationship between hospital-physician integration and MIPS performance by comparing hospital-integrated practices and independent practices. This was a cross-sectional study using data from the Quality Payment Program for the performance year 2020. Physician practices with a valid MIPS composite score in performance year 2020. Hospital integration was based on whether at least 75% of a practice's physicians either billed most of their services using hospital outpatient department codes or billed through a hospital tax identifier. The primary outcome was the MIPS quality category score, and the secondary outcomes were the specific quality measures reported by practice groups. Of the 20 most frequently reported measures, 14 were common in both groups. No difference was observed in the quality category score between hospital-integrated practices and independent practices in either unadjusted comparisons or after adjusting for practice characteristics, including practice size, geography, specialty mix, and case mix. In the secondary outcome models for specific quality measures, hospital-integrated practices achieved higher scores on most overlap measures but not all. The findings on quality category score suggest that hospital integration does not confer much advantage in the context of MIPS quality performance.

Evaluation of a Team-Based Flight Risk Assessment Tool in Air Medical Transport

ObjectiveFatigue is common in emergency medical services (EMS) and is exacerbated in air medical transport. There is no gold standard for recognizing high-risk factors contributing to fatigue. Current survey instruments designed to assess fatigue in EMS have limited evidence supporting their reliability and validity. The purpose of this study was to investigate the use of a team-based flight risk assessment tool (FRAT) as an instrument to improve safety and patient care for air medical transport. MethodsThe FRAT factors professional experience, stressors, sleepiness, and work conditions at the beginning of each shift and generates a team-based score. The 1,919 FRAT scores from a single air/ground critical care transport program during 2021 were retrospectively analyzed against measurable operational outcomes and indicators of error, including first-pass intubation success, the presence of quality assurance flags on documentation, and the time spent on scene. ResultsThere were 281 occurrences of a FRAT score that warranted mitigation, and 259 reported mitigation strategies. There were no associations between FRAT score and intubation success, quality assurance flags, and scene time. ConclusionThe team-based FRAT score triggered a mitigation activity on 281 occasions in 2021. There were no associations between the FRAT score and specific quality measures examined.

P355 PATIENT–REPORTED OUTCOME MEASURES IN WILD–TYPE AND VARIANT CARDIAC TRANSTHYRETIN AMYLOIDOSIS: THE ITALY (IMPACT OF TRANSTHYRETIN AMYLOIDOSIS ON LIFE QUALITY) STUDY

Abstract Background Transthyretin amyloidosis (ATTR) is due to TTR tissue accumulation. Both patients without mutations in the TTR gene (wild–type ATTR, ATTRwt) and those with such mutations (variant ATTR, ATTRv) may develop cardiac amyloidosis (CA). ATTR–CA has a deep impact on the quality of life. The ITALY study aimed 1) to create the first patient–reported outcome measures (PROMs) for ATTRv– and ATTRwt–CA, 2) to assess the feasibility of their administration, 3) to investigate the relationship between score values, clinical and laboratory findings, the Kansas City Cardiomyopathy Questionnaire (KCCQ) and Short Form Health Survey 36 (SF–36) scores. Methods Five Italian referral centers were involved (Pisa, Pavia, Ferrara, Florence, Messina). Item selection involved expert clinicians and 2 groups of 10 patients. The questionnaires were administered to consecutive patients evaluated at baseline and 6 months. Results Two 30–items questionnaires were created. Each item has 5 answers graded from 4 (best option) to 0 (worst option). The score ranged from 100 (best condition) to 0 (worst condition). As of November 2022, 82 patients (65 ATTRwt–CA, 17 ATTRv–CA) have completed the follow–up. At baseline, 30% of patients needed help to fill the questionnaire, and 20% at 6 months; 65% completed the questionnaire at baseline and 63% at 6 months. At baseline, median score values were 64 (interquartile range [IR] 54–74) in ATTRwt–CA and 59 (IR 51–71) in ATTRv–CA. ITALY score were correlated with global KCCQ and SF–36 scores at baseline and 6 months (r values from 0.7 to 0.8 in ATTRwt–CA and from 0.5 to 0.7 in ATTRv–CA). In patients with ATTRwt–CA, all KCCQ and SF–36 domains were univariate predictors of ITALY score values at baseline. All the KCCQ and SF–36 domains were independently predictive of ITALY score values in models including age, NYHA class, 6MWT, NT–proBNP; these results were confirmed at 6 months. In ATTRv–CA, All the KCCQ and SF–36 domains were independently predictive of ITALY score values in models including LV ejection fraction, at baseline and at 6 months. Conclusions The ITALY questionnaires are the first specific PROMs for ATTRwt– and ATTRv–CA. They have been created by experts in CA and patients and validated in a multicenter Italian cohort with 2 assessments over 6 months. Questionnaire completion is usually feasible. ITALY scores display close relationships with non–ATTR–specific measures of quality of life (KCCQ and SF–36).

Using FOCUS-PDSA Quality Improvement Methodology Model in Healthcare: Process and Outcomes.

Using FOCUS-PDSA Quality Improvement Methodology Model in Healthcare: Process and Outcomes.

MP48-03 QUALITY MEASURES REPORTED BY UROLOGISTS IN THE MERIT-BASED INCENTIVE PAYMENT SYSTEM

You have accessJournal of UrologyCME1 Apr 2023MP48-03 QUALITY MEASURES REPORTED BY UROLOGISTS IN THE MERIT-BASED INCENTIVE PAYMENT SYSTEM Avinash Maganty, Noah Krampe, Anup Shah, and Vishnukamal Golla Avinash MagantyAvinash Maganty More articles by this author , Noah KrampeNoah Krampe More articles by this author , Anup ShahAnup Shah More articles by this author , and Vishnukamal GollaVishnukamal Golla More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003294.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The majority of urologists are required to participate in merit-based incentive payment system (MIPS) –a Medicare-mandate reporting system in which physicians must track and report quality measures. Medicare adjusts physician reimbursement based on performance across these measures, with the intention to improve the quality of patient care. However, very few MIPS measures are relevant to urology patients and it is unclear what measures urologists are choosing to track and report. METHODS: We performed a cross-sectional analysis of MIPS measures reported by urologists for the most recent performance year. Urologists were categorized by their reporting affiliation (i.e., individual, group, or alternative payment model [APM]). We identified the measures which were most frequently reported by urologists. Among all measures reported, we identified those that were “topped out” (i.e., measures considered indiscriminate by Medicare because high performance is easily achieved) and those which were relevant for patients with urologic conditions (i.e., MIPS urology measures, qualified urologic registry measures, or those relevant to surgical care). RESULTS: 8,297 urologists reported in MIPS during the 2020 performance year, of whom 14% reported as an individual, 56% as a part of a group, and 30% as part of an APM. Among the top 10 most frequently reported measures, none were specific for urologic care (Table 1). 65% of individual urologists, 58% of those in groups, and 92% in APMs reported at least 1 or more “topped out” measures. Only 11% of urologists reported measures that were directly relevant to patients with urologic conditions. CONCLUSIONS: Most measures reported by urologists are not directly relevant to patients with urologic conditions and remain a poor indicator of the quality of urologic care provided. As Medicare transitions MIPS to condition specific quality measures, it will be important for the urology community to develop and submit measures that will be most impactful for patients. Source of Funding: Avinash Maganty is supported by funding from the National Cancer Institute Ruth L. Kirschstein Postdoctoral Award F32 Grant F32 CA275021-01 © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e655 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Avinash Maganty More articles by this author Noah Krampe More articles by this author Anup Shah More articles by this author Vishnukamal Golla More articles by this author Expand All Advertisement PDF downloadLoading ...

Merit-based Incentive Payment System Quality Reporting in Urology Practices.

Most urologists are required to participate in Merit-based Incentive Payment System-an alternative payment model in which physicians must track and report quality measures. However, Merit-based Incentive Payment System measures are urology-specific, and it remains unclear what measures urologists are choosing to track and report. We performed a cross-sectional analysis of Merit-based Incentive Payment System measures reported by urologists for the most recent performance year. Urologists were categorized by their reporting affiliation (ie, individual, group, or alternative payment model). We identified the measures most frequently reported by urologists. Among reported measures, we identified those that were specific to urological conditions and those that were "topped out" (ie, measures considered indiscriminate by Medicare because high performance is easily achieved). A total of 6,937 urologists reported in Merit-based Incentive Payment System during the 2020 performance year, of whom 14% reported as an individual, 56% as a group, and 30% as an alternative payment model. Among the top 10 most frequently reported measures, none were urology-specific. Eleven percent of urologists reported measures that were directly specific to urological conditions; 65% of individual urologists, 58% of those in groups, and 92% in alternative payment models reported at least 1 or more "topped out" measures. Most measures reported by urologists are not specific to urological conditions, and therefore performance within Merit-based Incentive Payment System may be a poor indicator of the quality of urological care provided. As Medicare transitions Merit-based Incentive Payment System to implement specific quality measures, the urological community will need to develop and submit measures that will be most impactful for urology patients.

Hexagonal-Grid-Layout Image Segmentation Using Shock Filters: Computational Complexity Case Study for Microarray Image Analysis Related to Machine Learning Approaches

Hexagonal grid layouts are advantageous in microarray technology; however, hexagonal grids appear in many fields, especially given the rise of new nanostructures and metamaterials, leading to the need for image analysis on such structures. This work proposes a shock-filter-based approach driven by mathematical morphology for the segmentation of image objects disposed in a hexagonal grid. The original image is decomposed into a pair of rectangular grids, such that their superposition generates the initial image. Within each rectangular grid, the shock-filters are once again used to confine the foreground information for each image object into an area of interest. The proposed methodology was successfully applied for microarray spot segmentation, whereas its character of generality is underlined by the segmentation results obtained for two other types of hexagonal grid layouts. Considering the segmentation accuracy through specific quality measures for microarray images, such as the mean absolute error and the coefficient of variation, high correlations of our computed spot intensity features with the annotated reference values were found, indicating the reliability of the proposed approach. Moreover, taking into account that the shock-filter PDE formalism is targeting the one-dimensional luminance profile function, the computational complexity to determine the grid is minimized. The order of growth for the computational complexity of our approach is at least one order of magnitude lower when compared with state-of-the-art microarray segmentation approaches, ranging from classical to machine learning ones.

Microbiome response in an urban river system is dominated by seasonality over wastewater treatment upgrades

BackgroundMicroorganisms such as coliform-forming bacteria are commonly used to assess freshwater quality for drinking and recreational use. However, such organisms do not exist in isolation; they exist within the context of dynamic, interactive microbial communities which vary through space and time. Elucidating spatiotemporal microbial dynamics is imperative for discriminating robust community changes from ephemeral ecological trends, and for improving our overall understanding of the relationship between microbial communities and ecosystem health. We conducted a seven-year (2013–2019) microbial time-series investigation in the Chicago Area Waterways (CAWS): an urban river system which, in 2016, experienced substantial upgrades to disinfection processes at two wastewater reclamation plants (WRPs) that discharge into the CAWS and improved stormwater capture, to improve river water quality and reduce flooding. Using culture-independent and culture-dependent approaches, we compared CAWS microbial ecology before and after the intervention.ResultsExaminations of time-resolved beta distances between WRP-adjacent sites showed that community similarity measures were often consistent with the spatial orientation of site locations to one another and to the WRP outfalls. Fecal coliform results suggested that upgrades reduced coliform-associated bacteria in the effluent and the downstream river community. However, examinations of whole community changes through time suggest that the upgrades did little to affect overall riverine community dynamics, which instead were overwhelmingly driven by yearly patterns consistent with seasonality.ConclusionsThis study presents a systematic effort to combine 16S rRNA gene amplicon sequencing with traditional culture-based methods to evaluate the influence of treatment innovations and systems upgrades on the microbiome of the Chicago Area Waterway System, representing the longest and most comprehensive characterization of the microbiome of an urban waterway yet attempted. We found that the systems upgrades were successful in improving specific water quality measures immediately downstream of wastewater outflows. Additionally, we found that the implementation of the water quality improvement measures to the river system did not disrupt the overall dynamics of the downstream microbial community, which remained heavily influenced by seasonal trends. Such results emphasize the dynamic nature of microbiomes in open environmental systems such as the CAWS, but also suggest that the seasonal oscillations remain consistent even when perturbed.

Association Between Neonatal Intensive Care Unit Type and Quality of Care in Moderate and Late Preterm Infants

A higher level of care improves outcomes in extremely and very preterm infants, yet the impact of neonatal intensive care unit (NICU) level on moderate and late preterm (MLP) care quality is unknown. To examine the association between NICU type and care quality in MLP (30-36 weeks' gestation) and extremely and very preterm (25-29 weeks' gestation) infants. This cohort study was a prospective analysis of 433 814 premature infants born in 465 US hospitals between January 1, 2016, and December 31, 2020, without anomalies and who survived more than 12 hours and were transferred no more than once. Data were from the Vermont Oxford Network all NICU admissions database. NICU types were defined as units with ventilation restrictions without surgery (type A with restrictions, similar to American Academy of Pediatrics [AAP] level 2 NICUs), without surgery (type A) and with surgery not requiring cardiac bypass (type B, similar to AAP level 3 NICUs), and with all surgery (type C, similar to AAP level 4 NICUs). The primary outcome was gestational age (GA)-specific composite quality measures using Baby-Measure of Neonatal Intensive Care Outcomes Research (Baby-MONITOR) for extremely and very preterm infants and an adapted MLP quality measure for MLP infants. Secondary outcomes were individual component measures of each scale. Composite scores were standardized observed minus expected scores, adjusted for patient characteristics, averaged, and expressed with a mean of 0 and SD of 1. Between May 2021 and October 2022, Kruskal-Wallis tests were used to compare scores by NICU type. Among the 376 219 MLP (204 181 [54.3%] male, 172 038 [45.7%] female; mean [SD] GA, 34.2 [1.7] weeks) and 57 595 extremely and very preterm (30 173 [52.4%] male, 27 422 [47.6%] female; mean [SD] GA, 27.7 [1.4] weeks) infants included, 6.6% received care in type A NICUs with restrictions, 29.3% in type A NICUs without restrictions, 39.7% in type B NICUs, and 24.4% in type C NICUs. The MLP infants had lower MLP-QM scores in type C NICUs (median [IQR]: type A with restrictions, 0.4 [-0.1 to 0.8]; type A, 0.4 [-0.4 to 0.9]; type B, 0.1 [-0.7 to 0.7]; type C, -0.7 [-1.6 to 0.4]; P < .001). No significant differences were found in extremely and very preterm Baby-MONITOR scores by NICU type. In type C NICUs, MLP infants had lower scores in no extreme length of stay and change-in-weight z score. In this cohort study, composite quality scores were lower for MLP infants in type C NICUs, whereas extremely and very preterm composite quality scores were similar across NICU types. Policies facilitating care for MLP infants at NICUs with less complex subspecialty services may improve care quality delivered to this prevalent, at-risk population.

A Novel Approach to PDMP Reporting: Adapting Opioid Quality Measures to PDMP Data.

The SUPPORT Act provided resources for developing prescription drug monitoring programs (PDMPs) capable of reporting on four specific opioid quality measures. Therefore, the objective of this pilot study was to map, test, and adapt these claims-based opioid quality measures specified for health plan performance to PDMP data for state-level performance. Maryland PDMP and claims from Maryland Medicaid beneficiaries continuously enrolled from April 1, 2019, to March 31, 2020. The measure rates as specified using claims data are closely aligned with the measure rates when mapped and adapted to PDMP data. The Concurrent Use of Opioids and Benzodiazepines measure rates were 14.49% and 15.31%, the OHD rates were 12.44% and 13.54%, the OHDMP rates were 0.01% and 0.40%, and the Use of Opioids from Multiple Providers in Persons Without Cancer rates were 0.12% and 3.03% for the claims-based and adapted measures, respectively. This is a novel application that may be replicated in other states to support quality improvement and can have a measurable effect on stemming the drug abuse epidemic. This will facilitate data sharing of the opioid quality measure reporting within the Maryland PDMP and stakeholders responsible for caring for Maryland Medicaid beneficiaries. Owing to the encouragement by the Centers for Medicare and Medicaid Services, other states' PDMPs may require the adaptation of these measures. This will open the door for innovative state-level policy and practice interventions. The quantification of outcomes related to these measures will inform our learning healthcare system and help support the Quintuple Aim.

Specialty specific quality measures needed to improve outcomes in wound care.

Despite the health care community's best efforts, 20% of diabetic patients who develop a diabetic foot ulcer will require some form of amputation. Those undergoing a major lower extremity amputation risk an increase in their five-year mortality rate to 56.6%, which is comparable to or higher than many forms of cancer. Given this perspective, quality measures need to be considered at each patient inflection point to drive increased compliance with best practices in order to redirect patients whose therapies fail. Medicare limited datasets (October 2015 through October 2019) retrospectively analyzed patients with diabetes receiving care for chronic lower extremity diabetic ulcers (LEDUs). The analysis demonstrated that only 21% of Medicare patients with hard-to-heal LEDUs received sharp debridement at intervals of every 7 days and less, while only 40% received sharp debridement at intervals of every 8 to 14 days. This is despite landmark prospective randomized controlled trials showing the benefits of frequent sharp debridement to patients with LEDUs. According to the Medicare data, when patients received debridement at intervals of 7 days or less with concurrently applied skin substitutes, observed amputation rates dropped by 65% to the lowest levels identified among Medicare LEDU episodes (2.1%). Optimal use of debridement and adjunctive use of skin substitutes significantly improves outcomes and lowers the use of healthcare resources. Another unexpected finding highlighted in the Medicare data analysis was that wound care providers have not been applying skin substitutes early enough. Clinical guidelines related to LEDUs have long relied on the seminal Sheehan marker study, which identified that diabetic ulcers that have not progressed to at least 53% healing after four weeks of conservative care have only a 9% chance of proceeding to closure by 12 weeks. It is therefore vital that patients move to advanced therapies within 30 to 45 days after initiation of failed conservative care; however, the Medicare claims data shows this is not happening regularly enough (average time to first skin substitute application >69 days) to benefit both the patient and the healthcare system. There is a demonstrable need for quality measures that encourage (1) frequent and adequate debridement throughout wound treatment, (2) earlier adoption of advanced treatments, such as skin substitutes, for LEDUs to align with clinical guidelines, (3) the application of skin substitutes to better align with medical evidence, which is associated with improved patient outcomes, as well as (4) expansion of best practices across all demographic and socioeconomic populations.

S1280 Comparing Outcomes of Decompensated Cirrhosis Management on a Primary Hepatologist-Managed Service versus a Hospitalist-Managed Service at an Urban Hospital

Introduction: While there are treatment guidelines for management of decompensated cirrhosis, limited data exist about adherence to specific quality measures and whether adherence differs based on specialty training (hospitalists versus hepatologists). We aimed to compare outcomes of quality-based practices of hepatology-led versus hospitalist-led services for admissions for management of decompensated cirrhosis. Methods: 2,009 admissions of patients presenting to our institution with a diagnosis of decompensated cirrhosis from 2016 to 2020 were retrospectively reviewed. 547 admissions of patients admitted for management of hepatic encephalopathy (HE), ascites, bleeding esophageal varices (EV), hepatorenal syndrome (HRS), or spontaneous bacterial peritonitis (SBP) were included. Patients were grouped based on service at the time of discharge: hepatology service (HH), hospitalist service (GM), or hospitalist service with hepatology consult (MH). Quality indicators assessed included admission length of stay, intensive care unit (ICU) admission, and death. Stat was used for statistical analysis. Results: Of the 547 admissions included, 168 admissions were on GM, 178 on MH, and 201on HH services. On average, GM patients were younger compared to their MH and HH counterparts (56.1, 59.2, 59.1 years respectively, p = 0.02). Additionally average MELD score at admission was higher on GM (23.1) compared to MH (17.6) and HH (20.3; p< 0.001) services. This was similarly reflected in the Child-Pugh Score at admission [GM (10.3), MH (8.9), and HH (9.6; p< 0.001)]. GM admissions had a longer hospital stay (9.1 days) compared to HH (6.2 days; p< 0.001) admissions, which remained significant when controlling for MELD score and age (p=0.001). GM admissions had a lower incidence of ICU transfers compared to MH and HH (27.2%, 34.8%, 38.0% respectively; p = 0.007). Patients on MH were less likely to expire prior to discharge compared to GM and HH (1% vs 8.4% and 14.9% respectively, p< 0.001). (Table) Conclusion: This study demonstrates differences in baseline characteristics and outcomes for decompensated patients admitted to GM, MH, and HH services for management of decompensations. Overall, this study speaks to shorter hospitalizations and decreased incidence of death for patients presenting with decompensated cirrhosis on HH versus GM services, however, further investigations would be needed to determine the rationale for differing patient outcomes, as this was not reflected in ICU transfers. Table 1. - Comparison of reason for admission between hospitalist led service without a hepatology consult (GM), hospitalist led service with a hepatology consult (MH), and a hepatologist led service (HH) Reason for Admission GM MH HH P value Bleeding esophageal varices (EV) 32.5% 29.8% 37.6% 0.054 Hepatic Encephalopathy (HE) 30.4% 36.2% 33.4% 0.054 Spontaneous Bacterial Peritonitis (SBP) 29.5% 33.7% 36.8% 0.058 Ascites 25.8% 35.0% 39.2% 0.036 Hepatorenal Syndrome (HRS) 28.8% 34.4% 36.7% 0.000

The Role of Social Risk Factors in Dialysis Quality and Patient Outcomes Under a Medicare Quality Incentive Program.

There have been critical improvements in dialysis care and mortality in the last decade. These improvements track with the implementation of the end-stage renal disease (ESRD) Quality Incentive Program (QIP) beginning in 2012, which aligns Medicare payments to dialysis facilities with performance on quality measures. This study explores whether the improvements in dialysis care and patient outcomes under the ESRD QIP have been shared equally among patient groups. Our analyses focus on 4 social risk factors: Black race, Hispanic ethnicity, dual eligibility for Medicare and Medicaid, and rurality. We estimated multivariable regressions using longitudinal Medicare and Consolidated Renal Operations in a Web-Enabled Network data. ESRD QIP payment reductions were more common at dialysis facilities with higher proportions of Black and dual-eligible ESRD patients. Patients with dual eligibility and Black race had persistently worse relative outcomes as the ESRD QIP was implemented. This finding was true for differences in outcomes when comparing patients within and across facilities and was not affected by the addition of specific quality measures to the ESRD QIP measure set. Hispanic patients and patients at rural facilities have generally not had worse outcomes since the start of the ESRD QIP. There is no evidence of widening disparities in dialysis care or patient outcomes across patient groups under the ESRD QIP, which is a longstanding and well-publicized concern with value-based purchasing programs. Relative changes between patient groups since the start of ESRD QIP have not favored any patient group. Many disparities in dialysis quality measures and assessment of dialysis facility payment reductions persist.