Medicare Post-Acute Care: Quality Measurement Final Report

Marie Johnson, Danielle Holthaus, Jennie Harvell, Eric Coleman, Theresa Eilertsen and Andrew Kramer

University of Colorado Health Sciences Center

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This report was prepared under contract #HHS-100-97-0010 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and The Urban Institute. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/daltcp/home.htm or contact the ASPE Project Officer, Jennie Harvell, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. Her e-mail address is: Jennie.Harvell@hhs.gov.

The authors thank the following people for helpful comments on earlier drafts of the report: Arlene Bierman, AHQR; John Thomas/Lisa Hines/Carolyn Rimes/Laurence Wilson, HCFA; Joyce Brown-Moore/Ruth Katz/Floyd Brown/Kamal Hijjazi/Henry Krakauer, ASPE.

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I. PURPOSE

The Office of the Assistant Secretary for Planning and Evaluation (ASPE), within the Department of Health and Human Services (HHS), funded this study to develop quality measures for post-acute care services for similar patients with selected conditions. The conditions targeted in this project were stroke, congestive heart failure (CHF), pneumonia, and back and neck conditions. Under this project, four quality measurement instruments, one for each condition, were developed. Each instrument consists of four parts: a medical and post-acute care chart review, and an initial and follow-up patient survey. The instruments, intended for use in future research, could provide information on the extent of case mix and service overlap across post-acute care settings for patients with one of the four identified conditions and their outcomes following post-acute care.

This report is presented in five chapters. Chapter I, Purpose, provides an overview of the project. Chapter II, Rationale, develops the rationale for conducting this project. This chapter reviews the need to understand post-acute care outcomes in view of the historical trends in post-acute care payment and use, recent changes in post-acute care payment policies and the impact of those changes on quality and access, issues regarding the potential overlap in post-acute care patients and services and the need to understand quality of care across settings if such overlap exists. This chapter also presents what is known about post-acute care quality and outcomes, and concludes with a discussion about why is it important to understand post-acute care quality. Chapter III, Quality Measurement Development, describes how quality measures for selected conditions were identified and selected, and how quality measurement instruments were developed and refined. Chapter IV, Conclusions and Policy Implications, summarizes the quality measures chosen for the selected tracer conditions across post-acute care services and the limitations of existing administrative data (including patient assessment information) in measuring outcomes. The last chapter, Chapter V, Next Steps, briefly describes the next phase of the ASPE research strategy to examine post-acute care quality. In that phase, ASPE is funding a study to examine post-acute care outcomes for stroke patients, which will use the patient assessment instrument developed for stroke under the current project. In addition, Chapter V summarizes work that ASPE is funding to develop a conceptual framework that will specify the objectives of collecting patient health and functional information, review methods used in identifying and collecting patient information, and specify next steps for identifying the patient information needed to achieve objectives and methods for data collection and maintenance. Finally, the Appendices include several background and supporting documents, as referenced throughout this report.

II. BACKGROUND

Post-acute care services represent an increasingly important part of the health services used by Medicare beneficiaries. While there is no standardized definition of Medicare post-acute care, for purposes of this report these services are defined as post-hospital services received from a skilled nursing facility (SNF), home health agency (HHA), and/or rehabilitation hospital/unit -- inpatient rehabilitation facilities (IRFs). Medicare expenditures for post-acute care services have increased dramatically, consuming an increasing share of total Medicare expenditures. In response to that trend, legislation was enacted to reduce the amount Medicare pays for post-acute care and change the ways the program pays for these services. These significant changes in payment policy and reductions in amounts Medicare will pay for post-acute care services could have a significant impact on access to and quality of care. There are no studies comparing the outcomes of post-acute care following implementation of these payment policy changes.

Implementation of the new post-acute care payment policies has retained setting specific payment methods and amounts. Such fragmentation may perpetuate inappropriate financial incentives for the admission, transfer, and discharge of patients in post-acute care. It has been presumed that there is considerable overlap in the types of patients treated in and the services provided across post-acute care settings, and thus that such fragmentation in payment policies may not be rational. However, these presumptions are not based in solid evidence. Further, questions have recently been raised about how much overlap really exists in patients and services across post-acute care settings. Some have suggested that, to the extent there was overlap, it has diminished since the implementation of recent payment policy changes.

Medicare expenditures for post-acute care have consumed an increasing share of total Medicare payments. From 1986 to 1996 Medicare payments for post-acute care increased from 3% to 15% of total Medicare expenditures, while Medicare payments for hospital services declined from 61% to 49% of total Medicare payments.¹ The shift in Medicare payments from inpatient hospital to post-acute care services is attributed to several factors, including: the implementation of the diagnosis related group (DRG) hospital prospective payment system (PPS) which resulted in patients being discharged “quicker sicker” from the acute setting to the post-acute arena, technological advances that permitted the delivery of more complex care in “downstream” post-acute care settings, and Medicare post-acute care coverage and payment policies.¹

From 1986 to 1996, Medicare post-acute expenditures increased from $2.5 billion per year to more than $30 billion, growing roughly 25% to 35% per year. The most rapid growth in expenditures was for HHA and SNF care. Contributing to the growth in post-acute care expenditures was the increased numbers of beneficiaries using these types of care, increased utilization of ancillary services (e.g., physical, occupational, and speech therapies, drugs, ventilators, etc.) in SNFs, increased numbers of visits per HHA user, and increased numbers of all types of Medicare certified post-acute care providers.

Approximately 25% of Medicare beneficiaries discharged from a hospital receive post-hospital services in HHAs, SNFs, and/or rehabilitation hospitals/units.² Approximately 17% of those beneficiaries admitted to a post-acute care setting receive post-acute care from more than one post-acute provider. For some conditions, the proportion is much higher. For example, 65% of Medicare beneficiaries hospitalized for stroke receive post-acute care, and almost 20% of stroke patients receive care from multiple post-acute care providers.

III. RATIONALE

A. Post-Acute Care Prospective Payment Systems

In response to the rapidly rising post-acute care expenditures; the Balanced Budget Act (BBA) of 1997 mandated a change from cost-based reimbursement for post-acute care services to prospective payment in all three post-acute settings. The PPSs for each setting differ. It should be noted that, for certain settings, the statute prescribed most of the design of the particular PPS (e.g., the PPS for SNFs), while for other benefits the design of the PPS was subject to considerable administrative discretion (e.g., rehabilitation hospital PPS). The following briefly describes key design elements of recently enacted payment reforms for post-acute care providers.

1. Skilled Nursing Facilities (SNFs)

SNFs are now reimbursed on a per diem basis using case mix groups called Resource Utilization Groups (RUGs). RUGs categories are based on staff time measurement data. Patients are classified into RUGs categories using data from the Minimum Data Set (MDS) collected by facility staff. SNFs are required to complete the MDS on the following days following admission: days 5, 14, 30, and 60. The BBA limited SNF payment rates to amounts paid for these services in 1995, trended forward, and required that SNFs be transitioned to Federal PPS rates over a three-year period. The Balanced Budget Refinement Act (BBRA) of 1999 increased, at least temporarily, SNF PPS payments, effective April 2000, by 20% for 15 RUGs categories to better account for non-therapy ancillary costs for patients in these categories. The BBRA also permitted SNFs to elect to be immediately paid the full Federal PPS rate (rather than being transitioned over three years to the full Federal PPS rate). The Benefits Improvement and Protection Act (BIPA) of 2000 modified the 20% adjustment in response to the concern that some lower cost categories were being overpaid relative to higher cost categories. In addition, BIPA increased the amount of payments for the nursing component of the SNF PPS rates.^a

2. Home Health Agencies (HHAs)

The BBA required that HHAs be paid a case mix adjusted prospective payment rate. Payment rates were to be limited to amounts that would have been paid in fiscal year 2000 -- reduced by 15% -- had the PPS not been implemented. The BBRA and BIPA delayed the application of the 15% reduction on HHA payments. At this time, the 15% reduction will not be implemented until 2001.^a The HHA PPS was effective for all HHAs October 1, 2000 and pays case mix adjusted rates for each 60-day episode of care. Payment rates are established for each case mix group called Home Health Resource Groups (HHRGs) that were derived from the Outcome and Assessment Information Set (OASIS) assessment instrument completed by provider staff upon admission, every 60 days thereafter, and at discharge.

3. Rehabilitation Hospitals and Units

The BBA and BBRA contained legislation requiring Health Care Financing Administration (HCFA) to implement a PPS for IRFs.^a The BBA left the rehabilitation PPS design requirements largely unspecified. However, the BBRA required that a per discharge PPS be established for IRFs based, among other criteria, on factors deemed necessary to improve functional independence measure (FIM) and functional related group methodology (a pre-existing, tested IRF payment methodology). As with the SNF PPS, the BBA required that IRFs transition to the new PPS. However, the BIPA included a provision permitting IRFs to elect to be paid the full PPS rate without such transition. The statute required that the IRF PPS reduce amounts that would have been paid to these providers by 2%. In November 2000, HCFA proposed that IRFs be reimbursed on a per episode basis -- based on case mix groups. The case mix groups were based on patient characteristics collected from the FIMs, a patient assessment instrument voluntarily used by many IRFs. HCFA proposed that patients would be assigned to case mix groups based on patient data derived from a new patient assessment instrument, the MDS for Post-Acute Care (MDS-PAC). The proposed rule would implement the PPS beginning in April 2000. However, HCFA has since announced that implementation will be delayed and a new date has yet to be established. The proposed rule would require IRFs to complete the MDS-PAC on days 4, 11, 30, and 60 after admission; and upon discharge. HCFA is in the process of reviewing comments received on the proposed payment and assessment systems.

B. Impact of Payment Changes

Each of these payment changes -- i.e., the shift to PPS, the option of being paid a blend of PPS and historic cost-based payment rates or the full Federal PPS amount, increases in payment rates for case mix categories, potential reductions in base payment amounts -- may have an impact on the quality of and access to post-acute care. For example, implementation of the acute care hospital PPS in 1983 had a major impact on hospital and post-acute care. One important impact was that the hospital PPS led to decreased lengths of hospital stay. Between 1980 and 1987, the mean length of a hospital stay decreased approximately 13%, from 9.7 days to 8.4 days.^3;4 The discharge of sicker patients earlier in the course of illness⁵ was associated with increased utilization of post-acute care,^4;6 contributing to growth in the use of and expenditures for post-acute care. However, despite shifts in where services were delivered following implementation of the hospital PPS, there was no convincing evidence that the quality of care, as measured by patient outcomes, was significantly affected by the implementation of the hospital PPS, with the exception of premature discharge of patients.⁷ A potential explanation for stability in outcomes is that hospital services were adequately replaced by post-acute care services.

Nonetheless, it is reasonable to anticipate shifts in who receives post-acute care, the settings in which such services are delivered, and the quality of care following implementation of the recent and significant payment changes for SNFs, HHAs, and rehabilitation hospitals. Anticipating the potential effects of multiple post-acute care payment changes is complex, given different payment systems for each post-acute setting, each implemented and modified at different points in time. Key payment design elements that may uniquely affect quality and access to care include differences in the unit of payment (i.e., per episode versus per diem payments), the basis for calculating payments (e.g., resource use versus patient characteristics), and the different payment rates across settings (particularly for patients with potentially similar conditions). In addition, it is less clear what downstream types of care might be necessary or sufficient to fill in voids or decrements in quality that could occur because of the design of the various post-acute care PPSs. Because the PPSs for SNFs, HHA, and rehabilitation hospitals were first and foremost aimed at reducing post-acute care expenditures by limiting reimbursement to providers, there is widespread concern about adverse effects on access and quality of post-acute care if the payment systems create incentives for providers to change admission, treatment, and discharge practices. For example, in recent reports the Office of the Inspector General indicated that high cost patients may have had difficulties accessing SNF and HHA services as a result of payment changes.^8;9 Thus, it is increasingly important to understand and monitor, particularly in view of the recent significant post-acute care payment changes, the extent of overlap in case mix and the quality of care provided in various post-acute care settings.

C. Overlap in Services and Patients

There is presumed to be significant overlap in the characteristics of patients treated across the three post-acute care settings, as well as overlap in the types and intensity of services provided. In its June 1996 report to Congress, ProPAC reported that distinctions among the services provided in post-acute care settings and the patients served by these providers had “blurred.”¹⁰ ProPAC attributed the increasing similarity in post-acute care services to Medicare payment and coverage policies and changes in technology. As previously mentioned, up until the late 1990s, Medicare paid for post-acute care services using cost-based reimbursement methodologies. Coupled with emerging technologies, such payment policies allowed new services to be delivered in post-acute settings. For example, cost-based payment policies permitted payment of high cost intravenous therapy in the home by HHAs. Further, the essentially unlimited reimbursement for therapies and drugs in SNFs permitted these facilities to deliver a more intense level of care than historically was found in hospitals, including rehabilitation hospitals.

Whether or not there was or continues to be similarities in patients and services across post-acute settings requires further study. Analyses of the characteristics of patients treated across post-acute care settings have typically compared post-acute care use and length of stay by preceding hospital DRG and length of stay. In its 1996 report, ProPAC found that there was “significant overlap in the hospital-assigned DRG across [post-acute care] settings.”¹¹ However, in this same report, ProPAC concluded that more information is needed that would “allow meaningful comparisons of the diagnoses, severity, and functional limitations of beneficiaries in all of these settings.”¹² At its December 2000 meeting, MedPAC (the Medicare Payment Advisory Commission which replaced ProPAC) members questioned what is actually known about the overlap in patients and services across post-acute care.¹³ Commission members raised questions about the comparability across post-acute care settings of patients’ severity of illness (i.e., which is in part a function of the length of preceding hospital stay) and functional status, and questioned how other non-clinical factors such as facility ownership, family support, and patient preferences may affect post-acute care use. In addition, Commission members questioned the comparability of services across post-acute care settings. Specifically, they noted that while similar services may be provided across post-acute care settings, the mix and intensity of those services may differ. In an ASPE sponsored study, Liu et al. found that providers, consumer groups, and others reported that following implementation of the SNF PPS, the similarity (i.e., overlap) in patients treated in and services provided by SNFs and rehabilitation facilities had diminished.¹⁴

There is a need for further research that examines the differences and similarities between patients treated by post-acute care providers and the outcomes of this care under the new payment systems. Such information could be used to support the current payment methodologies across post-acute care settings or could provide the foundation for alternative payment approaches. In addition, such research could help provide information on what should be measured in the post-acute care arena to monitor and assure the quality of care.

D. What is Known about Post-Acute Care Access and Outcomes?

There is little extant research comparing the care provided by the three types of post-acute providers, patient characteristics associated with receipt of post-acute care in one setting versus another, patient outcomes as they relate to each post-acute setting, or appropriateness of admission of patients to the various post-acute settings. Several studies have compared outcomes of patients with specific diseases treated in different post-acute settings,^15;16;17;18 and of a cohort of general medical and surgical patients,¹⁹ but there is great need for additional research in this area. In addition, the few extant studies of post-acute care outcomes were conducted before recent changes in payment policy.

Monitoring access to and quality of post-acute care is particularly important, given the reductions in payment and changes to payment policy implemented as a result of the BBA and subsequent legislation. However, each post-acute care setting has its own patient assessment instrument administered at different points during a post-acute care episode. Collecting data at different points in time makes it difficult to compare patient characteristics and outcomes across post-acute settings. In addition, there are significant differences in the data elements contained in existing federally required or proposed patient assessment instruments. For example, in an analysis of the comparability of the MDS, OASIS, MDS-PAC, and FIMs, it was concluded that there “are many differences in the conceptualization of [activities of daily living] and disability terms and definitions.”²⁰ Further, during the September 2000 meeting, MedPAC staff presented preliminary findings from a study that questioned the utility of current administrative data (including patient assessment data) for measuring access to quality health care.²¹

E. Why is it Important to Understand Post-Acute Care Outcomes?

Acute care is defined by a discrete event with a beginning and end, whereas chronic care is defined by long-term, ongoing treatment. However, post-acute care refers to the period of care that follows an acute event. For example, acute stroke care involves diagnosis of the type of stroke and extent of neurologic damage, life support and acute interventions such as thrombolytic agents to minimize the extent of brain damage, and intensive monitoring of neurologic signs. Once a stroke victim is stabilized, post-acute care involves continuation of stroke treatments (e.g., anticoagulation); rehabilitation of physical, cognitive, speech and language impairments; prevention of future stroke; and diagnosis and treatment of associated conditions such as depression.²² Patients needing post-acute care may also require ongoing, chronic care, either due to pre-existing conditions or as a result of the severity of the acute event precipitating the need for post-acute care. For example, chronic care of a stroke victim then involves continued management of the underlying diseases related to stroke, such as hypertension, and long-term management of residual impairment and disability.²²

Because acute, post-acute, and chronic care represent different phases of illness requiring different types of care, a unique set of quality measures is required for each. Emphasis has been placed on measures of acute care quality, including appropriate process criteria for making the diagnosis and treating the acute phase of illness, as well as outcomes such as mortality.²³ Quality measures relating to chronic care include process attributes, such as treating hypertension and arrhythmias to prevent further stroke, and outcomes such as recurrent stroke, rehospitalization for stroke or decline in function and quality of life.^24;25 Because post-acute care has historically been part of extended acute hospital stays, quality measures for post-acute care are less well specified. However, post-acute care quality measures must not only encompass elements of acute treatment, but also aspects of care that are unique to the post-acute period (e.g., maximizing recovery of function).

The structures (i.e., settings) where post-acute care is provided are sometimes the same venues that also provide chronic care, such as SNFs and HHAs, but may also be unique (e.g., rehabilitation hospitals). The processes of post-acute care include continued monitoring of acute illness begun in the hospital and a strong emphasis on rehabilitation services such as physical therapy, occupational therapy, and speech therapy aimed at restoring function and quality of life. Outcome measures thus include both avoidance of acute events leading to rehospitalization and/or death, as well as recovery in physical, cognitive, psychological, and social function with the hope of ultimately restoring a person’s lifestyle prior to the acute event. This multiplicity of care objectives represents one of the major challenges in quality measurement of post-acute care.

The fact that similar types of care and services may be delivered in different settings depending on the characteristics of the individual and the availability of services in the community, renders comparisons of quality across post-acute settings difficult, in part because each setting may rely on different processes to meet the same objectives. For example, institutional providers (SNFs and rehabilitation hospitals) spend more time treating the individual patient, while home health providers may rely more on training caregivers to provide some services and teaching patients exercises to perform independently. However, while the two institutional providers are paid very different rates, differences in processes of care in these settings are less clear. Both SNFs and rehabilitation hospitals provide the range of therapies. It is poorly understood how the mix and intensity of these services vary across provider types and the impact of these differences on length of post-acute care stays, quality of care, and outcomes.

There are several clinical reasons to be concerned about measuring the quality of post-acute care. First, a critical time window exists during which older persons recover function and the capacity to return to their previous lifestyle in the community following acute illness.^15;19 Generally, if this transition does not take place within the first 60-90 days, it will not take place.¹⁵ Second, the highest rehospitalization rate occurs in the period shortly after discharge from the hospital.^26;27 Third, acute hospital lengths of stay have been continually declining for Medicare beneficiaries, dropping an average of two days over the last decade, and thereby increasing the acuity level of patients at the time they begin post-acute care.⁵

In addition, substantial variation in the utilization of post-acute care across geographic regions creates additional challenges in understanding the relative outcomes associated with different post-acute care options.^28;29;30 Our lack of understanding about the relative effectiveness of post-acute care use creates questions regarding the appropriateness of current payment and coverage policies.^29;30 Complicating our ability to evaluate the quality of post-acute care, and determine relationships between post-acute care settings and outcomes, is the fact that a large proportion (17% as of 1996) of Medicare beneficiaries receive post-acute care in more than one setting. Receiving care in multiple settings may jeopardize the quality of care because of the need for clinical information to flow from one provider to another. To the extent needed information is not transmitted to a subsequent provider, services may be replicated or omitted.

IV. QUALITY MEASURE DEVELOPMENT

A. Project Overview

In response to these issues, ASPE funded a national project to develop quality measures for post-acute care that could be used in future research. The project strategy was to first specify quality measures that are most relevant to episodes of post-acute care provided in all three settings, based on extensive literature review and expert consensus.

In this project, we identified a set of quality measures for Medicare post-acute care services for four tracer conditions that are prevalent in the Medicare post-acute population: stroke, CHF, pneumonia, and back and neck conditions. Eight conditions were initially selected based on policy considerations,³¹ such as volume and Medicare utilization criteria (i.e., hospital re-admission rates). These eight conditions were later narrowed to the four tracer conditions based on a framework of clinical criteria,³² the goal of which was to represent different types of illness (chronic vs. acute), different post-acute care settings and services, and different domains of outcome measures. The methods for how the initial eight conditions were selected and how these were narrowed down to the four conditions included in this study are discussed in Appendix A.

Throughout this report, we frequently make reference to the terms quality indicator and quality measure; we often reference these constructs as they relate to outcomes or processes of care. The following definitions clarify the distinction between an indicator and a measure, and between a process and an outcome of care.

• Outcome indicator -- Change (e.g., improvement, decline, recovery) in a health status attribute that reflects a patient outcome, but does not require precise quantification of the outcome. Examples of outcome indicators include improvement in global function, decline in pain, and recovery of ambulation/mobility. Use of certain services can also be considered as outcomes.

• Outcome measure -- A precise quantification of an outcome indicator. For example, the outcome indicator of improvement in global function can be translated into an outcome measure when a scale such as the SF-36 is used at baseline and follow-up time points. The outcome measure might be the change in total score between baseline and follow-up.

• Process indicator -- An attribute of care at the patient level, without specific quantification of the attribute. Examples of process indicators include evaluation of depression, patient education, and use of sedatives/hypnotics.

• Process measure -- A precise quantification of a process indicator. For example, the process indicator of evaluation of depression can be translated into a process measure by establishing a set of criteria for determining the circumstances under which a depression evaluation should be conducted, defining the essential features of the evaluation, and rating the extent to which these are met.

Based on initial review of the medical literature and clinical experience, we generated comprehensive lists of potentially useful quality indicators relevant to post-acute care for each of the four conditions. To provide a basic structure for reviewing the indicators, we organized the indicator lists into domains (e.g., functional outcomes, utilization, process). We then convened four panels of health care providers (i.e., one for each of the four targeted conditions) to rate the importance and feasibility of including each indicator on a post-acute care quality assessment instrument. Based on this first round of panel meetings and the quality measures identified by the panel, draft longitudinal quality measurement tools were assembled for each condition using validated measures wherever possible. These draft instruments were then presented to a second expert panel comprised of experts in the field of post-acute care, research methodologists, and researchers with expertise relevant to each condition. Instruments were revised based on this meeting and subsequently pilot tested for feasibility of administration and time studies. Feasibility testing was limited in scope, taking place in two waves using post-acute care facilities recruited in the Denver metropolitan area. Revisions were made to the instruments based on qualitative experience with the instruments gained during the first wave of testing and input from the second expert panel meeting. A second wave of feasibility testing was then conducted, and final revisions were made to the instruments. The final instruments and users’ manuals produced as the products of this project are the result of the processes described above.

The following sections (Sections B through D) discuss the indicators selected, and instrument development and refinement.

B. Quality Indicator Selection

1. Generation of Initial Set of Quality Indicators

To generate the initial sets of post-acute care quality indicators for each of the four conditions, we conducted an extensive review of the medical literature, which was supplemented by clinical experience. Because our ultimate goal was to compile a comprehensive list of quality indicators relevant to Medicare post-acute care, our goal in selecting these initial sets of indicators was to be as inclusive as possible. Specific determinations as to the degree to which indicators and measures were relevant to a geriatric post-acute population would be made at a later time (both through the expert panels' review and literature review). Similarly, we were less concerned at this stage about the extent to which the indicators we selected would be measurable or feasible to collect; such determinations would be made following the final panel ratings. These lists of quality indicators included both process and outcome indicators. They also included a combination of both global quality indicators (those applicable to all four conditions) and condition/disease-specific quality indicators.

Next, we organized the quality indicators by domain to provide a basic structure for reviewing the indicators. These domains included: physical function outcomes, mental health outcomes, quality of life outcomes, utilization outcomes, physiology outcomes, satisfaction outcomes, and process of care. In order to facilitate review of the indicator lists and to avoid redundancy, each indicator was assigned to only one domain. Though one might reasonably argue that a different domain would be an alternative for a certain indicator, the purpose of the domain structure -- to simplify review -- would be defeated if an indicator were placed in multiple domains. To clarify the types of measures denoted by an indicator and to obtain some review of measures, we also included an illustrative set of potential quality measures corresponding to many of the quality indicators.

2. Selection of First Expert Panel

Participants on the expert panels were selected according to the following criteria: (1) representative of the three major post-acute settings (SNFs, HHAs, and rehabilitation hospitals); (2) representative of both managed care and fee-for-service settings; (3) national in scope; (4) inclusive of both generalists and specialists; and (5) representative of multiple disciplines (medical doctors, therapists and nurses). Our expert panels were ultimately comprised of a geriatrician, physiatrist, psychiatrist, SNF nurse, HHA nurse, rehabilitation nurse, speech therapist (who participated in the stroke panel meeting only), physical therapist, and a nationally recognized specialist for each of the four clinical conditions. The list of panelists is included in Appendix B.

3. Panel Ratings

The expert panel members were mailed background information about the project along with the initial quality indicator rating forms (see sample rating form, Appendix C). The panel members were asked to review the indicators and individually rate them with respect to the importance of each for assessing quality of care for the specified condition. They were asked to review each indicator separately for each condition using the four condition-specific indicator lists. The indicator ratings were based on the following scale:

     0 = of negligible value for assessing quality of care for that condition;
     1 = of definite value for assessing quality of care;
     2 = extremely important for assessing quality of care.

Reviewers were asked to consider the following criteria to determine the value of each quality indicator: (1) the likelihood that a significant portion of individuals with that condition will experience some change for the outcome indicator; and (2) the sensitivity of the indicator to differences in the quality of care received by individuals between sites. For each condition, reviewers assigned a rating of "2" to only 20 indicators. This provided us with each reviewer's "Top 20" quality indicators for each condition. Panel members were also asked to add indicators to the list and to rate these added indicators as well.

In addition to rating the indicators, panel members were asked to rate the quality measures with which they had experience. The measure ratings were based on the following scale:

     R = recommended;
     NR = not recommended;
     Blank = unfamiliar.

Panel members were also asked to add measures to the list and to rate these added measures as well.

4. Consolidation of Ratings

After rating the quality indicators and measures according to the above criteria, the panel members returned their completed rating forms. We calculated an average rating for each indicator and then ranked the indicators in descending order by their average ratings. In preparation for the meetings, we presented this information in two ways for each condition. First, we revised the previously distributed quality indicator rating forms that were organized by domain to include the average rating for each indicator. On this form, we indicated those quality measures that were frequently recommended by panel members. We also included all of the quality indicators and measures that were added by panel members. On a second form, we presented the ranked list of quality indicators in descending order of average rating.

5. Panel Meetings

The panel meetings took place over a period of two days; one half-day was devoted to discussing each of the four conditions. At the meetings, expert panel members were given the quality indicator rating results and a blank rating form pertaining to the condition under discussion. Panel members were, therefore, aware of the ratings each of the indicators received through the initial panel review. The focus of the panel meetings was on the indicators for which there was the least consensus among the panel members. We selected these more "controversial" indicators for discussion prior to the panel meetings by targeting those with the highest variance in ratings.

During the discussions, panel members often decided to redefine or modify some of the specific indicators for each condition; these modifications are delineated in the expert panel meeting notes (see Appendix D). Within each condition's panel meeting discussion, time was also set aside to discuss the additional indicators previously suggested by panel members, as well as some of the recommended quality measures for various indicators. After the discussion for each condition, panel members were asked to again individually rate the quality indicators a second time, this time by selecting the most important 25 quality indicators for the condition. The 25 selected indicators could include any combination of global and disease-specific indicators from any of the seven domains.

6. Final Ratings

We compiled the panels' final ratings, enumerating the indicators for each condition in descending order based on the number of panel members who selected each (see Appendix E). We further refined this list by eliminating the following: (1) indicators that were not direct measures of post-acute quality, (e.g., cost measures or risk factors); (2) indicators that were incorporated in or similar to other indicators (e.g., single elements of larger scales, or redundant constructs), and (3) indicators that were not feasible to collect or not measurable (e.g., requiring hard to access data sources, or dates that are not readily available). The dropped indicators, and our reasons for dropping each, are included in Appendix E.

Appendix F includes the final list of quality indicators that were selected by at least four panel members; it is organized by global indicators (indicators that were selected by four or more panel members for three or four of the conditions) and disease-specific indicators (indicators that were selected by four or more panel members for only one condition). We used this final list of indicators to develop our post-acute care quality assessment instruments for the four conditions.

C. Instrument Development

Following the expert panel proceedings, we reviewed quality measures corresponding to the panels’ most highly rated quality indicators and developed quality assessment instruments for post-acute care. The most highly ranked indicators were in the following areas: Health Related Quality of Life (HRQL), physical function, depression, social/role function, pain, satisfaction, utilization, disease-specific symptom management, and performance of key care processes. In reviewing the panels’ final ratings, it was apparent that emphasis should be placed on global measures of quality applying to all patients served in post-acute care, but selected disease-specific measures were required for each condition.

1. Review of Existing Instruments

Complicating uniform quality measurement across post-acute care settings is the fact that all post-acute care settings use, or in the case of IRFs will use different assessment tools that are nationally mandated. The Federal Government requires that the MDS 2.0 (Minimum Data Set, Version 2.0) be used for all patients in Medicare (and Medicaid) certified nursing facilities and the OASIS be used for all skilled patients treated by Medicare HHAs. As previously mentioned, each of the instruments contains its own elements that are generally non-comparable and different assessment time points.

Clinicians and researchers who were expert panel members for this study identified as important outcomes in the measurement of the quality of post-acute care, outcomes that are not captured by existing federally required patient assessment instruments. For example, these tools do not measure whether a setting maximized a patient’s functioning, prepared him/her to return to and remain in the most independent living environment, and reintegrated him/her into prior lifestyle. Measuring such important outcomes requires input directly from patients or their proxies, as the latter two are subjective and the patient’s perception of those outcomes is, in fact, the measure of the outcome. In fact, many researchers focused on patient-centered outcomes believe that functional outcomes should derive from patients, as their perception of their function is more important than so-called objective measures of function. Patient-perceived functional capacity captures disability by integrating its relevance to the patient. If a difficulty performing a functional task is not related by a patient, it is likely of little importance or relevance to his or her life and needs. Existing patient assessment instruments use facility staff to measure outcomes, often an registered nurse or therapist, and thereby fail to capture the relevance of individual functional measures to the individual patient. Because the goal of rehabilitation is to restore patients to their previous level of function, capturing their perception of function both before and after an acute event in their terms is essential to measuring quality. Further, the expert panelists indicated that many important outcomes cannot be measured within the time frames over which post-acute services are typically provided in most settings. Given that average lengths of Medicare covered stays in the mid-1990s were approximately 25 days in SNFs and 21 days in rehabilitation hospitals,³³ it is not possible to determine whether post-acute care has successfully maximized a patient’s function, allowing sustained return to the most independent living environment, and reintegration into prior activities and lifestyle. Generally, these outcomes take 60-90 days before they begin to plateau.^15;19 In addition, because assessment data is not comparable across settings and whatever data is collected is only collected while the patient is treated by a particular provider type, it is not possible to measure outcomes across episodes of care that include multiple post-acute settings.

During the development of precise measures, data items, and data collection instruments, the limitations of existing data systems for measuring quality across settings were apparent. First, they did not cover many of the important domains and measures determined to be important by the expert panels (e.g., health-related quality of life; role resumption, satisfaction). Second, existing data systems do not use the individual patient as the respondent, but are based exclusively on provider reports. Third, existing instruments do not use uniform time frames that could be compared across settings. Fourth, based on our extensive review of existing patient assessment tools, the elements cannot be rendered comparable from one setting to the next because of differences in data elements, scaling and timing of completion, with the exception of basic demographic variables and an estimate of a Barthel index upon post-acute admission.

2. Provider vs. Patient-Reported Data

In addition to the concerns raised above about the need to assess patient-perceived function, concern also exists about the reliability of provider reported data.³⁴ The primary concern, however, is over validity of provider reports. Based on literature review and expert panel members’ input, the types of measures that are relevant to post-acute care (e.g., HRQL, mental health and depression, physical and social/role function, satisfaction with care) require patient input. While patient-reported data are necessary for appropriate assessment of the above domains, the validity and reliability of this data may be affected by such factors as social desirability and acquiescent response biases.³⁵ In addition, cognitive impairment, which is relatively common in the Medicare post-acute care populations, further complicates collection of patient-reported data. However, even among cognitively impaired subjects, proxy input on such outcome measures is more likely to reflect the needs and values of patients than provider assessment.

3. Selection of Measures

In this section, we provide the rationale for selecting the specific quality measures and data items corresponding to the quality indicators chosen by the expert panels. The selection of measures was guided by several principles. First, the burden of data collection had to be kept to a minimum; shorter versions of questionnaires were chosen whenever feasible. Second, the measures had to be relevant to patient care provided during the post-acute period and relevant to all three provider types, rather than outpatient, acute hospital or long-term care. Third, redundancy within and between measures was to be minimized. Fourth, measures needed to be responsive to the quality of the post-acute care delivered and clinically meaningful change. Finally, where possible, validated and reliable measures were chosen, particularly if they had been evaluated in older, frailer patients and in post-acute settings.

Health Related Quality of Life (HRQL)

The expert panels reached unanimous consensus with regard to the importance of HRQL as a quality measure for post-acute care. Similar to other investigators in this area,^14;36;37 we struggled with how to operationalize HRQL as an outcome measure. Lack of a standardized and precise definition in the literature was a major barrier. Other terms, such as general health status and quality of life, refer to similar concepts.^38;39;40 The panels discussed the utility of several commonly used and validated HRQL instruments. The three most commonly used instruments considered were the Medical Outcomes Study Short Form-36 (MOS SF-36), the Sickness Impact Profile (SIP) (as well as the SIP for nursing home residents (SIP-NH)), and the Quality of Well Being Scale (QWB).^41;42;43;44

The domains encompassed by global health status or HRQL measures such as the MOS SF-36 and the SIP share a high degree of overlap with many of the important quality domains recommended by the panels for inclusion in a quality measurement instrument: physical function, depression, pain, and social/role function. Recognizing this overlap, the question arose as to whether any of these instruments were sufficient in and of themselves as measures for these domains, and whether such an HRQL instrument like the SF-36 would suffice as the entire patient self-report component of the instruments. A number of concerns, however, precluded such an approach. First, these global instruments were not designed for use in older, frailer populations, much less populations receiving post-acute care. Thus, the specific items have varying levels of relevance to the activities and goals of post-acute care. Our concerns about the psychometric performance of these instruments in older populations have been echoed in the medical literature.^45;46;47 This is not a criticism of these instruments, but a recognition that we are dealing with an older, frailer population in a period immediately following an acute event that requires a unique measurement strategy.

Furthermore, the level of detail measured by any of the individual HRQL instruments in a given domain is often limited such that some areas are not given the weight that our panels recommended. For example, while these instruments examine depressive symptoms, they do not allow for adequate assessment of whether depression is present. Because depression was rated very high by the panels for three of the four conditions, ability to measure it more precisely seemed important. Similarly, while pain is examined by all of the aforementioned HRQL instruments, most instruments have only one or two pain questions. As a clinical endpoint, two pain questions may not be adequate for conditions where pain may be the dominant symptom (e.g., back and neck).

Based on these concerns, as well as comments received during the panel discussions, we chose quality measures that are specific to each indicator that the clinical panels supported. Rather than use an existing comprehensive health status instrument, we have combined individual measures and indices of physical function, depression, social/role function and pain to create a more detailed patient report instrument in the areas chosen. Collectively, we believe that our instruments capture the essential elements of HRQL described in the medical literature,¹⁴ while simultaneously providing the level of detail necessary for the patient population served by post-acute care providers.

Physical Function

Numerous physical function measures were discussed. Represented measures were: the MOS SF-36 physical function scale,⁴¹ the FIM score,⁴⁸ the Barthel Index,⁴⁹ the Lawton IADL Index,⁵⁰ the Katz ADL Index,⁵¹ the Kane ADL Index,⁵² and the Basic ADL Index.^53;54 Selection of the final measure was guided by the need for adaptation for use in-person or by telephone (the individual may actually be discharged from post-acute care at time of follow-up), knowledge of prior performance in post-acute populations, and most importantly, relevance of question content. Based on these guiding principles, Wolinsky's Basic ADL Index, a five-item measure that incorporates the ADLs of bathing, dressing, toileting, transferring, and walking 20 feet, was selected for inclusion.^53;54 This assessment of function focuses on self-reported difficulty in ADL performance, which has direct relevance to the provision of post-acute care. It was originally derived using data from the Longitudinal Study on Aging⁵⁵ and has been used extensively in large national studies of older persons and patients receiving post-acute care.^15;56;57 In these post-acute care studies, serial measurement was conducted at baseline corresponding to premorbid period, three, six, nine and twelve months with both in-person and telephone administration. Similar to prior studies that used this instrument in post-acute care, the outcome measure is the number of ADLs recovered to premorbid disability levels.⁵⁸

In addition to an assessment of basic ADLs, we have also included questions about recovery of IADL function⁵⁰ for patients with stroke. The stroke panel strongly advocated for inclusion of IADLs as a responsive measure of the quality of care delivered to persons with stroke. While IADLs are important to the care delivered in the other conditions considered, the burden of additional data collection required limiting inclusion to only those measures identified as essential. In subsequent sections, we further describe efforts to ensure that each instrument is comprised of only those measures of most relevance and significance.

Depression

Numerous instruments have been designed for self-assessment of depression in general populations.^59;60;61 However, only one instrument has been specifically developed for use in the older population, the Geriatric Depression Scale (GDS).⁶² The GDS places greater emphasis on affective aspects of depression over somatic symptoms. Assessing depression in older post-acute patients is particularly challenging and the GDS has been employed in prior studies in this population.^15;63 A shorter version of the GDS has been validated and used successfully. With half as many items, the shorter 15-item version of the GDS poses much less responder burden with minimal loss of sensitivity and specificity.⁶⁴ For the purpose of quality assessment in post-acute care, we will measure change in GDS score over time.

Social/Role Function

These two quality indicators were combined into a single indicator based on the recommendation of the expert panels. The panels believed that change in a measure of social/role function would capture important aspects of functional status not addressed by the traditional measures of function, basic ADLs and IADLs. Though the HRQL instruments noted in earlier sections include items measuring social and role function, the wording and examples in the questions are not always relevant to older post-acute patients and appear not to fully capture the concept as it applies to this patient population or as envisioned by the expert panels.

The Reintegration to Normal Living (RNL) Index⁶⁵ was recommended by several expert panelists and was selected based on the relevance and wording of the items for the population of interest, the development strategy employed in choosing the items, and its brevity. In addition to acceptable psychometric properties, the RNL has been specifically tested in post-acute populations.⁶⁵ The authors of the RNL solicited input from three advisory panels made up of patients with chronic illness, healthy persons, health care providers, psychologists and clergyman to ensure broad-based input and representation.⁶⁶ The final instrument is comprised of eleven items, uses a visual analog scale for response and can be converted to a 100 point score. Because we foresee the need to administer follow-up interviews by telephone to measure outcomes of post-acute care, we have adapted the visual analog scale for telephone use using a five-point Likert scale. Further, several of the questions are concerned with activities of less relevance to measuring quality in the post-acute population. These questions have been removed from the instruments.

Pain

Evaluation of change in pain control was rated highly for back and neck patients. This prompted a search for a validated pain instrument that referred to a time interval relevant to post-acute care (i.e., four weeks or less). Some pain scales we reviewed placed too much emphasis on affective symptoms and thus were redundant with the depression items covered by GDS.^67;68 The McGill Pain Instrument⁶⁹ and the Back Pain Classification Scale⁶⁹ were evaluated, but were perceived to lack face validity for the population under study. The MOS Pain Measure, which has proven to be valid and reliable in varied populations,⁷⁰ was selected for these reasons and because it measures both pain severity and the effects of pain on function. In contrast, the Oswestry Low Back Pain Disability Questionnaire only examines the latter.⁷¹

Satisfaction

The relationship between patient satisfaction and quality of care continues to become more accepted and established among leading methodologists.^72;73;74 The literature on patient satisfaction has been historically dominated by the inpatient hospital setting, followed by the outpatient setting as a distant second site of care. No single instrument has been developed for all three of the post-acute sites of interest for this effort. The instruments designed for satisfaction assessment in nursing homes place more emphasis on living arrangements and autonomy pertinent to a long-term care population rather than time-limited rehabilitation pertinent to post-acute patients. Similarly, questions on instruments used in home care are not easily translated to older patients who are not residing in their homes. The most promising of all satisfaction instruments reviewed was developed by researchers at the Rehabilitation Institute of Chicago.⁷⁵ The main advantage of this instrument stems from the fact that the wording of the individual items allows for administration in all three sites of post-acute care. However, the length of the full instrument limits its utility in our instruments. Fortunately, the individual items have been validated and we have recommended that a representative and relevant sub-group of questions be incorporated into our post-acute care quality measurement instruments. These questions focus on the patient’s perceptions of the care delivered and how well their needs are being met with respect to returning to independent living.

Utilization Measures

Uniformly, the panels recommended inclusion of use of emergency services and rehospitalizations during the post-acute episode as indicators of quality of care. In addition, to account for the possibility that a given patient might use more than one type of post-acute care (e.g., SNF followed by home health care), total post-acute utilization was also recommended as a quality measure. Finally, the panelists recommended including, if applicable, the date of death.

Disease-Specific Measures

The number of disease-specific patient report indicators recommended varied by condition. While these indicators have intuitive appeal, few have been operationalized from the standpoint of quality measurement. In many cases, the disease-specific measures added to the patient report section have not been formally tested. For example, the back and neck panel argued that existing pain and disability instruments did not adequately address change in limb numbness and tingling for patients with back and neck conditions. These symptoms represent important target symptoms that may not be captured under a narrow definition of nociceptive pain. The back and neck instrument has been supplemented with these questions accordingly. Change in symptoms of dyspnea, fatigue and cough for patients with pneumonia were modified from formal instruments.⁷⁶ For CHF, a validated disease-specific quality of life measurement instrument is included to assess the change in how CHF symptoms affect quality of life over time. The first four items of the Chronic Heart Failure Questionnaire have been included specifically to address control of symptoms.⁷⁶

Additional Measures for Risk Adjustment

Additional questions were included to account for important differences in case mix when comparing quality across settings of post-acute care. Potential adjusters that could be derived from patient self-report include cognitive status, social support, and demographics. In addition to these potential self-report risk adjusters, we identify other potential risk adjusters in subsequent sections of this report. The Pfieffer Short Portable Mental Status Questionnaire (SPMSQ) has been shown to be both valid and reliable^77;78 and was selected as a potential cognitive screen. The SPMSQ was developed to provide a rapid screen (approximately two minutes) for cognitive impairment in older patients and has been used extensively in both community and institutional settings.^79;80 The Mini Mental Status Exam (MMSE)⁸¹ was also selected as a potential cognitive screen. The MMSE is longer and more strenuous than the SPMSQ, requiring ten minutes and thirty points. The MMSE is more commonly used as a risk adjuster in qualitative research than the SPMSQ and allows finer delineation between different levels of cognitive dysfunction. The MMSE and SPMSQ will also serve as indicators of when a proxy informant may be required for the patient self-report component of the instruments. Social supports and living arrangements will be assessed using selected items from the Older Americans Resource and Services (OARS) instrument.⁸² Standard demographic data will also be assessed from patient self-report for the purpose of risk adjustment. These characteristics include: age, race, gender, education and marital status.

Process Measures

The process quality measures, both global and disease-specific, were selected by the panels because of an association with high quality care and, in some cases, with defined clinical outcomes (e.g., ACE inhibitor use and mortality in CHF). However, there are some logistical and measurement considerations worth noting. Similar to the patient report symptom measures, some of the indicators rated highly by the panels do not have corresponding validated measures. Other highly rated indicators were not included because measurement was simply not possible (e.g., time to reach clinical stability following pneumonia). Thus, process measures as recommended by the expert panels were incorporated judiciously.

4. Instrument Design and Selected Measures

Patient Report

To measure most of the outcome domains specified above (physical function, social/role function, mental health, and satisfaction with care), two separate patient report instruments were created for each of the four conditions: an admission instrument and a follow-up instrument. The admission instruments were designed to be administered within ten days of post-acute care admission to assess baseline function one month prior to hospitalization. Initially, the section on physical functioning included measurement of perceived physical function at the time of the interview, in addition to the existing questions about function one month prior to the hospitalization. However, during pilot testing, we found qualitative difficulties administering the questions related to function at two distinct time periods, with subjects becoming confused. As a result, the baseline patient interview will not be used to assess function at the time of entry into post-acute care because of the difficulties encountered when trying to ask patients or proxies to describe their functional capacity at two separate time points, both one month prior to hospitalization and at the time of post-acute care admission. A tight time interval between admission and completion of the baseline instruments is not required since the questions largely refer to pre-hospitalization function and status, with the exception of mood related questions encompassed in the GDS. The follow-up instruments were designed to be administered at a pre-determined follow-up time point and to assess recovery to baseline function. For CHF and pneumonia, the follow-up time point chosen was 60 days after post-acute care admission; for stroke and back and neck conditions, the follow-up time point chosen was 90 days after post-acute care admission (see discussion in Section D1).

Provider Report

The source of provider reported data will be the medical and post-acute care record. This component is needed to assess specific process measures advocated by the expert panels, and to obtain information about comorbidity for case mix adjustment.

Risk adjustment: The medical record is a valuable source of information to create comorbidity indices for the purpose of case mix adjustment. Indices such as the Charlson Index⁸³ have been used extensively and are relatively simple to construct. The Charlson Index is comprised of a formula that provides a weighting of chronic illnesses. These diagnoses represent major conditions that would normally be represented in an individual patient’s problem list in the medical record. Additional hospital chart review items to be collected for risk adjustment for patients with pneumonia include evaluation for delirium, blood gas results, abnormal vital signs, and lab parameters.⁸⁴

In addition, the provider reported component includes information obtained from several formal patient assessment instruments, including the MDS, MDS-PAC and OASIS. In an effort to reduce redundancy, relevant items from the MDS and OASIS (and once implemented, the MDS-PAC) will be abstracted. Additional data for case mix adjustment will also be abstracted from these data sources. Data on patient function at the time of post-acute admission can be obtained from these three sources for risk adjustment. Because all three instruments are required upon post-acute care admission and all three have basic function items that allow estimation of a Barthel Index, data from these can be used sparingly to risk adjust for function at the time of post-acute admission. In particular, physical function items from these instruments can be converted to a comparable Barthel Index. Results from a forthcoming validation study conducted by our research team reveal that the MDS 2.0-based Barthel Index compares favorably to an actual independent Barthel measure. Testing and refinement of the MDS-PAC and OASIS conversions are underway. The conversion codes are provided in Appendix G.

Process measures: In addition, selected process measures recommended by the expert panels would be obtained from the medical and post-acute care records.

• Global process measures: With regard to global process quality measures, the panels recommended that regardless of condition or post-acute setting, an evaluation by a licensed physical therapist and occupational therapist are important and essential elements of high quality post-acute care. These were the only two process measures believed to be relevant to all four conditions.

• Disease-specific process measures: The disease-specific quality of care processes reflect a wider range of care.

  • Stroke: For patients with stroke, quality measures include a speech and swallowing evaluation, and management by a multidisciplinary care team. In addition, efforts to educate the patient’s informal caregivers need to be recorded. For patients who experience a non-hemorrhagic stroke, consideration of anticoagulation must be explicitly documented in patient records. The day the patient’s stroke occurred relative to initiation of post-acute care will be determined for the purpose of risk adjustment.

  • CHF: For patients with CHF, those patients with compromised left ventricular function should either be on an ACE inhibitor or have the reason for not using an ACE inhibitor clearly evident in their records. In addition, patients with CHF need to have the frequency of body weight assessment documented in their records as well as an attempt by post-acute care providers to evaluate their medication compliance.

  • Pneumonia: Patients with pneumonia should have documentation of advance directives discussions and immunization status for influenza and pneumococcal pneumonia. Obtaining blood cultures during the acute course of illness was recommended by the pneumonia panel out of concern that this may be overlooked in patients with pneumonia who are not hospitalized before admission to post-acute care. Distinguishing community-acquired pneumonia from nosocomial with regard to antibiotic selection was also included for its relevance to post-acute care.

  • Back and Neck Conditions: For patients with back and neck conditions, the expert panel emphasized the importance of use of prescription analgesic medications. From the perspective of quality measurement, it is not always clear to what degree use of prescription medications is associated with quality. The appropriate selection of medication and dosing is often highly tailored to the individual. Instead, a much stronger case could be made for focusing on whether or not pain was systematically assessed and that a plan of care had been devised and documented. Thus, evidence of a revised plan of care designed to optimize pain control would be considered a high quality process of care.

Utilization Data

While the data needed to measure the utilization outcomes (e.g., emergency services, rehospitalizations, and multiple post-acute care use) would likely be obtained from claims data for patients treated under the Medicare fee-for-service program, these items are included in the instruments to be certain they are collected for HMO patients.

D. Instrument Refinement

1. Expert Panel

Once the four draft instruments were compiled, we convened a second expert panel that included content experts, methodologists, providers, and Federal policy officials (see Appendix H). All expert panel members were asked to comment on the relevance and feasibility of the measures, response burden, sampling issues, definitions of an episode of care, and redundancy with other reporting requirements. Content experts (disease specialists) in the four clinical conditions were also asked to comment on the balance between global and disease-specific measures, the feasibility of constructing a summary performance measure, and risk adjustment. Methodologists, including those with experience in post-acute care quality measurement, were asked to comment on the feasibility of administering the measures, the scaling (i.e., floor and ceiling effects), responsiveness of measures, and risk adjustment.

Prior to the in-person panel meeting, we convened three separate conference calls with disease specialists in the areas of CHF, pneumonia, and back and neck conditions. (Note: We did not convene a separate conference call for stroke because the stroke specialist was present at the in-person panel meeting.) Among the issues discussed during the specialist calls were disease-specific measures, post-acute care episode length, and case mix adjustment. Notes from the three specialist calls are included in Appendix I. One especially significant outcome of the specialist calls was the decision to narrow the back and neck condition down to the more specific condition of lumbar spinal stenosis. The back and neck specialist strongly recommended using lumbar spinal stenosis as a tracer condition for this study because it is a relatively prevalent condition that will yield a more homogeneous patient sample. Therefore, throughout the remainder of this report, we will refer to the former back and neck condition as lumbar spinal stenosis.

For the in-person panel meeting, we compiled a series of key questions (see Appendix J) related to issues such as post-acute care episode length, measure feasibility and responsiveness, response burden, and case mix adjustment, which served as a guide for panel discussion. Following are some highlights of the panel’s recommendations.

• With respect to physical function particularly as it relates to stroke outcomes, panel members recommended including a more thorough assessment of higher order function (i.e., IADLs) in addition to basic ADL function, which would allow better discrimination between patients with varying degrees of functional ability as well as recovery of higher level functions following stroke.

• In defining an episode of post-acute care, (the interval between admission and follow-up assessments), the panel’s objective was to recommend an episode that would allow enough time for most disease-specific outcomes to have occurred, while not encountering any new post-acute care episodes. Panel members therefore recommended a 60-day follow-up for CHF and pneumonia, and a 90-day follow-up for stroke and lumbar spinal stenosis.

• Panel debate centered around the appropriate assessment of satisfaction. Patient confidentiality may be a concern if assessing satisfaction upon admission, especially if the data collector were affiliated with the post-acute facility; whereas poor patient recollection of the post-acute stay may be a concern if assessing satisfaction at follow-up. Mail-in satisfaction surveys were mentioned as a possible alternative; however, difficulties with low response rate to mail-in surveys remains an issue. Consensus was not reached in this area.

• The panel recommended assessing caregiver burden, satisfaction, and patient and caregiver education as outcomes that are reflective of quality of post-acute care.

• Certain processes of care that may be difficult to abstract from post-acute care charts might better be assessed through patient interview at follow-up. For many of these measures, such as caregiver/family education and discussion of advance directives, patients’ perceptions of care processes might be more informative than the facility’s documentation of such processes.

• Another issue discussed during the meeting included disease-specific risk adjustment items (e.g., Rankin Score for stroke and renal disease in CHF).

2. Feasibility Tests

Prior to and concurrent with the second expert panel meeting, we began conducting feasibility tests of the four quality measurement instruments in SNFs, IRFs, and HHAs located in the Denver metropolitan area. We selected facilities based on feedback received from local clinicians regarding volume of admissions and responsiveness of facility staff. Following is a brief summary of the feasibility test issues and findings.

Recruitment Issues

Feasibility testing was conducted in two phases. During the first phase, four SNFs, two HHAs, and two IRFs were enrolled and a social worker or intake person from each facility was asked to identify patients newly admitted with one of the four tracer conditions. Identified patients were subsequently invited to participate and consent was obtained. Interviews, using the instruments developed, were then conducted to determine feasibility of administration of the questions.

In the first phase of piloting, 21 subjects were recruited and interviewed. Of the 21 interviews, 13 were conducted in SNFs, six were conducted in HHAs, and two were conducted in IRFs. Seven of these 21 subjects were admitted to the post-acute facility with pneumonia, five with CHF, two with back and neck conditions, and seven with stroke. Hospital and post-acute care charts were obtained on these subjects and reviewed using the chart review instruments. Revisions were made to the instruments based on insights gained from the first phase of piloting and feedback from the expert panel. A second phase of piloting was then conducted using the newly revised instruments. Four subjects were recruited and interviewed during this phase. Of the four interviews, one was conducted in an SNF, two were conducted in IRFs, and one was conducted in an HHA. One of these four subjects was admitted to the post-acute facility with a back and neck condition and three were admitted with strokes.

During both phases of feasibility testing, ongoing difficulties were encountered in identifying and recruiting patients. Facility staff who were responsible for identifying newly admitted residents for our study indicated on several occasions that there were numerous demands on their time and that they simply did not have the time (or additional staff) necessary to review the facility’s admissions on a regular basis. This issue was of particular concern to staff members in SNFs and HHAs. Although we had been successful with this method of patient recruitment for past studies, many of the facility staff and administrators we spoke with indicated that pressures under PPS had placed increasing demands on their time and available resources.

General Findings

• The time to complete the entire admission interview, after consent was obtained, averaged 25 minutes.

• Approximately 13% of eligible subjects declined to participate.

• Subjects requiring a proxy were not eligible for the pilot study because we did not have IRB approval to use proxies. (Approximately 17% of subjects were below the mental status cut-off.)

• The order of the sections was changed to improve the flow from one section to the next.

• The time to complete the telephone follow-up interview averaged 14 minutes, and the response rate was approximately 63%.

Married, Education, and Race

A question about the duration since married/widowed/divorced was deleted because of uncertain relevance to any of the measured outcomes or as a risk stratifier.

Mental Status

The time necessary to complete the MMSE averaged 10 minutes and some subjects appeared to be annoyed or burdened by the questions. The SPMSQ, used on the stroke and lumbar spinal stenosis instruments, appeared to be less burdensome for subjects to complete, eliciting fewer complaints or difficulties. However, the purpose of mental status testing is three-fold: (1) To determine a subject’s capacity to consent to participate in the study and understand the described risks and benefits; (2) to identify subjects whose memories are impaired and whose responses to questions about past functional capacity may be inaccurate; and (3) to use as a descriptive variable for the study population and risk adjuster in later data analysis. Given these three needs, the MMSE was retained despite the time necessary for completion.

Physical Function

As mentioned, this section was initially expanded to include measurement of perceived physical function at the time of the interview as well as functioning one month prior to the hospitalization. However, we found qualitative difficulties administering the questions related to function at two distinct time periods, with subjects becoming confused. Thus, function at the time of admission to rehabilitation was dropped from the patient survey, because it can be derived from automated patient data in the form of a cross-walked Barthel Index, for the purposes of risk adjustment. While functional items from automated patient data like the MDS are considered adequate for risk adjustment purposes (for function at the time of post-acute admission), recovery of patient-perceived function is the outcome of interest. Recovery of function requires measurement at a fixed time point across all settings and must be obtained from the patient or proxy, as previously discussed.

IADL measures were included in the final stroke instrument to represent higher levels of function as recommended by the panel. However, IADLs with high non-response rates (e.g., due to gender bias) were excluded based on prior IADL measurement experience at the University of Colorado Health Sciences Center.

Social and Role Function

The Re-integration to Normal Living Scale was difficult to administer in an interview format, although the original instrument was used in this context. In particular, the 5-point scale proved to be too cumbersome for subjects to answer. Secondly, the first-person nature of the questions was awkward to use in an interview format. The following changes were therefore made:

• Several questions about role function were deleted prior to the pilot project because they were not relevant to an elderly, post-acute population.

• The first-person narrative was changed to a question format (from “…I moved around my house…” to “were you able to move around your house…”).

• The present tense of the questions as originally written was changed to past tense for the admission interview to allow measurement of social and role function prior to the index event, in concert with the other baseline measurements.

• The answer scale was changed to a yes/no answer, followed by a rating of how bothered the subject is/was by limitations in social/role function if he/she answered “no, they were not able…” to perform a given social/role function.

• Throughout the process of altering the Re-integration to Normal Living Scale, a concerted attempt was made to maintain the essence of the questionnaire in terms of measuring subjects’ function from their perspective, their perceived need to perform a certain function, and how disturbed they are/were by limitations in social and role function.

Pain (Lumbar Spinal Stenosis Instrument Only)

• Questions specifically referring to back/neck or limb pain were removed because subjects’ responses to the general pain questions appeared to be related to back/neck/limb pain and the site-specific questions seemed redundant. In an attempt to shorten the number of pain questions, questions related to numbness were also removed.

• The pain instrument was derived from the MOS pain questionnaire. The original instrument uses a 20-point visual analogue scale. With pilot subjects, the 20-point scale was awkward, and a 10-point scale was more familiar to subjects. A 10-point scale was adopted.

Depression

The GDS questions were easily administered. Question #9 was difficult for several subjects to answer because at the time of the interview they were in a skilled nursing or rehabilitation facility and were therefore limited in their ability to go out. Therefore, it was decided that this question would be asked only of home health patients.

Social Support

Two questions regarding the availability of a willing and able caregiver were added to reflect both short-term and long-term social support networks. The original instrument had similar questions, but they proved to be difficult for subjects to answer in their original format, particularly about the time frame of support availability (“indefinite, short time, now and then”). Some participants answered that all three were true and specified a different person for each. The added questions were adapted from the Longitudinal Study on Aging, but differ in the addition of the two time frames: short and longer term.

Quality of Life (CHF and Pneumonia Instruments)

Questions related to dyspnea were modified. The original questions had a seven-level response ranging from “Not at all short of breath” to “Extremely short of breath.” The response scale was modified to a three-level scale because of subjects’ difficulty responding to the seven-level question. This modification decreases the likelihood of finding the same degree of variability in these questions as well as detecting small amounts of intra-subject change over time. The trade-off between making the questions easier to answer versus decreasing the likelihood of finding change and variability was intended as a discussion point for the expert panel, but there was not ample time to cover this issue. Thus, a decision was made to simplify the questions based on the qualitative experience conducting pilot interviews.

Satisfaction

Patient satisfaction with care was ranked very highly by the original expert panel and considered a necessary component of quality measurement for post-acute care. However, measurement of satisfaction presents several challenging issues. First, when should satisfaction be measured? In the original instrument, satisfaction questions were placed in the follow-up telephone interview. This presents a problem because that interview is scheduled to take place 90 days later. Subjects’ ability to recall the care received 90 days prior may be suspect. Alternatively, measurement of satisfaction early in the post-acute stay via the baseline instrument may reflect satisfaction with acute hospital care, or be too premature for subjects to have formed an opinion. Also, at the baseline interview facility staff will be collecting baseline data, which may bias subjects’ response to satisfaction questions. We have considered an alternative strategy of giving a written satisfaction survey to subjects and asking them to mail it at the end of their post-acute stay. This strategy is subject to selection bias. Ultimately, we decided to ask three satisfaction questions during the 90-day follow-up telephone interview.

E. Instrument Limitations

The four instruments were revised on a continuous basis, based on insights gained from both the expert panel meeting and local pilot testing. Although the instruments underwent several rounds of revisions based on these insights, there remain some limitations with their use. First, the reliability and validity of the instruments require further testing. Pilot test sample sizes for both the admission and telephone follow-up interviews were very small. Second, the instruments rely heavily upon patient-reported information. While patient report measures are necessary in researching such domains as health-related quality of life, mental health, depression, social/role function, and satisfaction with care, it may not be feasible to utilize such measures for ongoing quality monitoring purposes. Third, the validity of the satisfaction measures included in these instruments -- as of all health care satisfaction measures -- is subject to factors such as the subject’s reluctance to discuss quality of medical care, reduced expectations, unwillingness to complain, and fear of retaliation. In addition, as previously mentioned, the time point (admission, follow-up, or other) at which satisfaction should be assessed is unclear. And finally, although these instruments contain both global and disease-specific components for the four conditions, they are weighted more heavily toward global measures of quality. Although some may argue that more disease-specific measures should be incorporated, the ratings of the expert panel members indicated that more emphasis should be placed on global measures that are relevant to all patients served in post-acute care settings.

V. CONCLUSIONS AND POLICY IMPLICATIONS

Understanding the quality of post-acute care is more important and has become more challenging than ever before. The multiple and ongoing changes to Medicare post-acute care payment policies create a dynamic environment in which measuring the effect of service delivery is particularly difficult. The statute requires new PPSs for each post-acute care provider type. Each PPS varies in terms of key design features such as the unit of payment (per diem, per discharge, every 60 days), classification schemes (e.g., RUGs, HHRGs, and case mix groups), and patient assessment instruments and processes used for patient classification (e.g., MDS, OASIS, and MDS-PAC). Each of these payment schemes is being phased in on different timetables, and each is being modified in different ways and at different times. How such fragmentation will affect the quality and outcomes of post-acute care is difficult to anticipate.

This project identified a mixture of both global and disease-specific measures that are important in measuring outcomes of post-acute care, based on a consensus of clinicians and researchers, and a review of the literature. The study focused on patients who, following a hospital stay, received post-acute care for conditions that required either intense medical or rehabilitation management. The conditions targeted in this study were CHF, pneumonia, stroke, and back and neck (lumbar spinal stenosis). Through discussions with expert clinicians and researchers, and a review of the literature, post-acute care outcome measures were identified that include traditional measures of physical function, utilization, and mental health, and measures emphasizing symptom relief, specific therapies and other processes of care, satisfaction, and health-related quality of life including role resumption.

Based on input from expert clinicians and researchers, and a review of the literature, the project found that existing administrative data do not contain information needed to measure important outcomes within and across post-acute care settings, and across a span of time over which important post-acute care outcomes may mature. While existing data systems include information needed for some of these measures (e.g., utilization and functional measures) many of the measures identified as important in understanding quality of post-acute care are not included in existing administrative data (e.g., mental health, quality of life, satisfaction, and role resumption). In addition, while existing data systems measure functional status (i.e., information that was considered important across all conditions), existing patient assessment instruments measure functional status in different ways and at different times across post-acute care settings. Further, the differences in patient assessment instruments and processes make it difficult to identify whether similar patients are, in fact, treated across different settings, and if so, what are their relative outcomes of care. Finally, patient assessment data is collected only as long as a patient is treated in any particular post-acute care setting. However, many outcomes that the expert clinicians and researchers identified as important may not be present until after the patient is discharged from the post-acute care setting. Thus, while existing data systems may serve a variety of purposes, they were not found to include information needed to measure post-acute care quality and outcomes.

VI. NEXT STEPS

The instruments developed under this study for each of the four tracer conditions are available to others interested in conducting research measuring the outcomes of post-acute care for patients with these conditions.

ASPE has contracted with the University of Colorado Health Sciences Center and Mathematica Policy Research, Inc., to conduct a national study that will utilize the instrument developed for stroke patients to evaluate, in a post-PPS environment, the outcomes and costs of post-acute care provided in SNFs, rehabilitation hospitals and HHAs. This national study of stroke patients is intended to address several questions about Medicare beneficiaries who are discharged from hospitals to post-acute care, including:

• What are the demographic and health-related characteristics of patients admitted to post-acute care, including persons who use multiple post-acute providers (e.g., SNF followed by HHA, or IRF followed by HHA)? What are the similarities and differences between patients admitted to the three settings or multiple settings?

• What patterns of post-acute provider use are most prevalent for these patients?

• What are the health, functional, quality of life, and other outcomes for beneficiaries treated in HHAs, SNFs, IRFs, or in multiple post-acute settings?

• Which post-acute setting, or combinations of settings, provides better outcomes and quality of care for similar patients with stroke, after controlling for case mix differences?

• How does the mix and intensity of services provided in HHAs, SNFs, IRFs, or in use of multiple post-acute settings compare?

• To what extent do Medicare expenditures and costs differ for similar patients treated in different post-acute settings, or combinations of settings?

• What core outcome and quality measures are most useful to incorporate into ongoing reporting requirements to monitor the quality of post-acute care for stroke?

This project, funded by ASPE in 1999, will be completed in January 2004.

REFERENCES

1. Liu K, Gage B, Harvell J, Stevenson D, Brennan N. Medicare's post-acute care benefits: background, trends, and issues to be faced. 1999. US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. [Full Report]

2. Gage B. The balanced budget act: implication for post-acute services. 1998. New York, NY, The Commonwealth Fund.

3. Leibson CL, Naessens JM, Campion ME, Krishan I, Ballard DJ. Trends in elderly hospitalization and readmission rates for a geographically defined population: pre- and post-prospective payment. Journal of the American Geriatrics Society 1991; 39(9):895-904.

4. Manton KG, Woodbury MA, Vertrees JC, Stallard E. Use of Medicare services before and after introduction of the prospective payment system. Health Services Research 1993; 28(3):269-292.

5. Shaughnessy PW, Kramer AM. The increased needs of patients in nursing homes and patients receiving home health care. New England Journal of Medicine 1990; 322(1):21-27.

6. Easton LS, Cogen R, Fulcomer M. Effect of Medicare prospective payment system on a home health agency: changes in patient population and services provided. Applied Nursing Research 1991; 4(3):107-112.

7. Rubenstein LV, Kahn KL, Reinisch EJ, Sherwood MJ, Rogers WH, Kamberg C et al. Changes in quality of care for five diseases measured by implicit review, 1981 to 1986. JAMA 1990; 264(15):1974-1979.

8. Office of the Inspector General, Department of Health and Human Services. Early effects of the prospective payment system on access to skilled nursing facilities. OEI-02-99-00400. 1999.

9. Office of the Inspector General, Department of Health and Human Services. Medicare beneficiary access to home health agencies: 2000. OEI-02-00-00320. 2000.

10. Prospective Payment Assessment Commission. Medicare and the American health care system: report to the Congress. 91. 1996.

11. Prospective Payment Assessment Commission. Medicare and the American health care system: report to the Congress. 110. 1996.

12. Prospective Payment Assessment Commission. Medicare and the American health care system: report to the Congress. 113. 1996.

13. Medicare Payment Advisory Commission. December 2000 meeting transcript. Medicare Payment Advisory Commission. 2000. Medicare Payment Advisory Commission.

14. Wilson IB, Cleary PD. Linking clinical variables with health-related quality of life. JAMA 1995; 273(1):59-65.

15. Kramer AM, Steiner JF, Schlenker RE, Eilertsen TB, Hrincevich CA, Tropea DA et al. Outcomes and costs after hip fracture and stroke: a comparison of rehabilitation settings. JAMA 1997; 277(5):396-404.

16. Kane RL, Chen Q, Finch M, Blewett L, Burns R, Moskowitz M. Functional outcomes of posthospital care for stroke and hip fracture patients under Medicare. Journal of the American Geriatrics Society 1998; 46:1525-1533.

17. Anderson C, Rubenach S, Mhurchu CN, Clark M, Spencer C. Home or hospital for stroke rehabilitation? Results of a randomized controlled trial: I: health outcomes at 6 months. Stroke 2000; 31(5):1024-1031.

18. Anderson C, Mhurchu CN, Rubenach S, Clark M, Spencer C. Home or hospital for stroke rehabilitation? Results of a randomized controlled trial: II: cost minimization analysis at 6 months. Stroke 2000; 31(5):1032-1037.

19. Johnson MF, Kramer AM, Lin MK, Kowalsky JC, Steiner JF. Outcomes of older persons receiving rehabilitation for medical and surgical conditions compared with hip fracture and stroke. Journal of the American Geriatrics Society 2000; 48(11):1389-1397.

20. Rogers JC, Gwinn SM, Holm MB. Comparing activities of daily living assessment instruments: FIM, MDS, OASIS, MDS-PAC. Physical and Occupational Therapy in Geriatrics 2001; 18(3):1-25.

21. Medicare Payment Advisory Commission. September 2000 meeting transcript. Medicare Payment Advisory Commission. 2000. Medicare Payment Advisory Commission.

22. Gresham GE, Duncan PW, Stason WB. Post-stroke rehabilitation: clinical practice guideline no. 16. 1995. Rockville, MD, Agency for Health Care Policy and Research.

23. Duncan PW, Jorgensen HS, Wade DT. Outcome measures in acute stroke trials: a systematic review and some recommendations to improve practice. Stroke 2000; 31(6):1429-1438.

24. Hart RG, Benavente O. Stroke: part I. A clinical update on prevention. American Family Physician 1999; 59(9):2475-2482.

25. Barnett HJ, Eliasziw M, Meldrum HE. Drugs and surgery in the prevention of ischemic stroke. New England Journal of Medicine 1995; 332(4):238-248.

26. Barker WH, Zimmer JG, Jackson Hall W, Ruff BC, Freundlich CB, Eggert GM. Rates, patterns, causes and costs of hospitalization of nursing home residents: a population-based study. American Journal of Public Health 1994; 84(10):1615-1620.

27. Kayser-Jones JS, Wiener CL, Barbaccia JC. Factors contributing to the hospitalization of nursing home residents. Gerontologist 1989; 29(4):502-510.

28. Gage B. Impact of the BBA on post-acute utilization. Health Care Financing Review 1999; 20(4):103-126.

29. Lee AJ, Huber JH, Stason WB. Poststroke rehabilitation in older Americans: the Medicare experience. Medical Care 1996; 34(8):811-825.

30. Lee AJ, Huber JH, Stason WB. Factors contributing to practice variation in post-stroke rehabilitation. Health Services Research 1997; 32(2):197-221.

31. Liu K, Gage B, Kramer A. Medicare post-acute care quality measurement: selecting and evaluating eight targeted conditions. 1998. Washington, DC, The Urban Institute.

32. Kramer A, Eilertsen T, Holthaus D, Johnson M, Gage B. Medicare post-acute care quality measurement: selecting the targeted conditions. 1998. Denver, CO, Center on Aging, University of Colorado Health Sciences Center.

33. Medicare Payment Advisory Commission. Health care spending and the Medicare program: a data book. July 1998 ed. 1998.

34. Harrington D, Summers PR, Curtis M, Maynard R. Study of the resident assessment information system. 1996. San Francisco, CA, University of California, Department of Social and Behavioral Sciences.

35. Committee on Improving Quality in Long-Term Care, Institute of Medicine, Department of Health and Human Services. Improving the quality of long-term care. Wunderlich GS, Kohler PO, editors. 2000. Washington, DC, National Academy Press.

36. Guyatt G, Cook D. Health status, quality of life, and the individual. JAMA 1994; 272(8):630-631.

37. Frank L, Kleinman L, Kline N, Legro M, Shikiar R, Revicki D. Defining and measuring quality of life in medicine. JAMA 1998; 279(6):429-430.

38. Guyatt G. Insights and limitations from health-related quality-of-life research. Journal of General Internal Medicine 1997; 12:720-721.

39. Berlowitz D, Du W, Kazis L, Lewis S. Health-related quality of life of nursing home residents: differences in patient and provider perceptions. Journal of the American Geriatrics Society 1995; 43(7):799-802.

40. Guyatt G, Feeny D, Patrick D. Measuring health-related quality of life. Annals of Internal Medicine 1993; 118(8):622-629.

41. Ware JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). Medical Care 1992; 30(6):473-481.

42. Bergner M, Bobbitt R, Carter W, Gilson B. The sickness impact profile: development and final revision of a health status measure. Medical Care 1981; 19(8):787-805.

43. Gerety M, Cornell J, Mulrow C, Tuley M, Hazuda H, Lichtenstein M et al. The sickness impact profile for nursing homes. Journals of Gerontology 1994; 49(1):M2-M8.

44. Kaplan R, Bush J, Berry C. Health status: types of validity and the index of well-being. Health Services Research 1976; 11:478-507.

45. Stadnyk K, Calder J, Rockwood K. Testing the measurement properties of the short form-36 health survey in a frail elderly population. Journal of Clinical Epidemiology 1998; 51(10):827-835.

46. Wolinsky FD, Wan GJ, Tierney WM. Changes in the SF-36 in 12 months in a clinical sample of disadvantaged older adults. Medical Care 1998; 36(11):1589-1598.

47. McHorney C. Measuring and monitoring general health status in elderly persons: practical and methodological issues in using the SF-36 health survey. Geronotologist 1996; 36(5):571-583.

48. Linacre J, Heinemann A, Wright B, Granger C, Hamilton B. The structure and stability of the functional independence measure. Archives of Physical Medicine and Rehabilitation 1994; 75:127-132.

49. Mahoney F, Barthel D. Functional evaluation: the Barthel index. Maryland State Medical Journal 1965; 14:61-65.

50. Lawton M, Brody E. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 1969; 9:179-186.

51. Katz S, Ford A, Moskowitz R, Jackson B, Jaffe M, Ford A et al. Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychosocial function. JAMA 1963; 185:914-919.

52. Finch M, Kane R, Philp I. Developing a new metric for ADLs. Journal of the American Geriatrics Society 1995; 43(8):877-884.

53. Wolinsky FD, Johnson RJ. The use of health services by older adults. Journals of Gerontology 1991; 46(6):S345-S357.

54. Fitzgerald J, Smith D, Martin D, Freedman J, Wolinsky F. Replication of the multidimensionality of activities of daily living. Journals of Gerontology 1993; 48(1):S28-S31.

55. Fitti J, Kovar M. The supplement on aging to the 1984 national health interview survey. US Government Printing Office, editor. 87-1323. 1987. Washington, DC, US Department of Health and Human Services.

56. Kramer A. Outcomes for stroke and hip fracture patients in HMO and fee-for-service systems. Presented at Beyond the Water’s Edge: Charting the Course of Managed Care for People with Disabilities. St. Michaels, MD. November 1996. [Executive Summary]

57. Wolinsky FD, Callahan CM, Fitzgerald JF, Johnson RJ. The risk of nursing home placement and subsequent death among older adults. Journals of Gerontology 1992; 47(4):S173-S182.

58. Kramer AM. Rehabilitation care and outcomes from a patient's perspective. Medical Care 1997; 35(6):JS48-JS57.

59. Radloff L. The CES-D scale: a self-report depression scale for research in the general population. Applied Psychological Measurement 1977; 1:385-401.

60. Hamilton M. A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry 1960; 23:56-62.

61. Beck A, Steer R, Garbin M. Psychometric properties of the Beck depression inventory: twenty-five years of evaluation. Clinical Psychology Review 1988; 8:77-100.

62. Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey M et al. Development and validation of a geriatric depression screening scale: a preliminary report. Journal of Psychiatric Research 1983; 17:37-49.

63. Lesher E, Berryhill J. Validation of the geriatric depression scale-short form among inpatients. Journal of Clinical Psychology 1994; 50:256-260.

64. Lyness J, Noel T, Cox C, King D, Conwell Y, Cain E. Screening for depression in elderly primary care patients: a comparison of the center for epidemiologic studies-depression scale and the geriatric depression scale. Archives of Internal Medicine 1997; 157:-449.

65. Wood-Dauphinee S, Williams JI, Opzoomer MA, Marchand B, Spitzer WO. Assessment of global function: the reintegration to normal living index. Archives of Physical Medicine and Rehabilitation 1988; 69:583-590.

66. Wood-Dauphinee S, Williams JI. Reintegration to normal living as a proxy to quality of life. Journal of Chronic Disability 1987; 40(6):491-499.

67. Pilowsky I, Bassett D, Barrett R, Petrovic L, Minniti R. The illness behavior assessment schedule: reliability and validity. International Journal of Psychiatry in Medicine 1983; 13:11-28.

68. Zung WK. A self-rating pain and distress scale. Psychosomatics 1983; 24:887-894.

69. Melzack R. The McGill pain questionnaire: major properties and scoring methods. Pain 1975; 1:277-299.

70. Sherbourne C. Pain measures. In: Stewart A, Ware Jr J, editors. Measuring functioning and well-being: the Medical Outcomes Study approach. Durham, NC, Duke University Press; 1992: 220-234.

71. Fairbank J, Couper J, Davies J, O'Brien J. The Oswestry low back pain disability questionnaire. Physiotherapy 1980; 66(8):271-273.

72. Cleary P, McNeil B. Patient satisfaction as an indicator of quality care. Inquiry 1988; 25(1):25-36.

73. Covinsky K, Rosenthal G, Chren M, Justice A, Fortinsky R, Plamer R et al. The relation between health status changes and patient satisfaction in older hospitalized medical patients. Journal of General Internal Medicine 1998; 13(4):223-229.

74. Nelson E, Hays R, Larson C, Batalden P. The patient judgment system: reliability and validity. QRB: Quality Review Bulletin 1989; 15(6):185-191.

75. Heinemann A, Bode R, Cichowski K, Kan E. Measuring patient satisfaction with medical rehabilitation. Journal of Rehabilitation Outcomes Measurement 1997; 1(4):52-65.

76. Guyatt G, Nogradi S, Halcrow S, Singer J, Sullivan M, Fallen E. Development and testing of a new measure of health status for clinical trials in heart failure. Journal of General Internal Medicine 1989; 4:101-107.

77. Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. Journal of the American Geriatrics Society 1975; 23:433-441.

78. Smyer M, Hofland B, Jonas E. Validity study of the short portable mental status questionnaire for the elderly. Journal of the American Geriatrics Society 1979; 27:263-269.

79. Lesher E, Whelihan W. Reliability of mental status instruments administered to nursing home residents. Journal of Consulting and Clinical Psychology 1986; 54:726-727.

80. Pfeiffer E, Johnson T, Chiofolo R. Functional assessment of elderly subjects in four service settings. Journal of the American Geriatrics Society 1981; 29:433-437.

81. Folstein M, Folstein S, McHugh P. Mini-mental state: a practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research 1975; 12(3):189-198.

82. Multidimensional functional assessment: the OARS methodology. Durham, NC, Duke University Center for the Study of Aging and Human Development. 1978.

83. Charlson M, Pompei P, Ales K, MacKenzie C. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. Journal of Chronic Disability 1987; 40(5):373-383.

84. Fine M, Hanusa B, Lave J, Singer D, Stone R, Weissfeld L et al. Comparison of a disease-specific and a generic severity of illness measure for patients with community-acquired pneumonia. Journal of General Internal Medicine 1995; 10:359-368.

NOTES

1. This legislation included additional changes to post-acute care payment policy that are not discussed in this report.

APPENDICES

APPENDIX A. 1998 Reports

REPORT 1: Selecting and Evaluting Eight Targeted Conditions

Korbin Liu and Barbara Gage, The Urban Institute

Andrew Kramer, University of Colorado Health Sciences Center

June 1998

This report was prepared under contract #HHS-100-97-0010 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and The Urban Institute. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/daltcp/home.htm or contact the ASPE Project Officer, Jennie Harvell, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. Her e-mail address is: Jennie.Harvell@hhs.gov.

Conclusions and opinions in this paper are solely those of the authors and do not necessarily reflect the views of the Urban Institute, University of Colorado or ASPE.

I. INTRODUCTION

The Administration has signaled its intent to move towards an integrated Medicare post-acute care financing and service delivery system. In order to integrate post-acute care services, information is needed on the cost-effectiveness of different post-acute care providers for different conditions. This project will design a set of quality of care measures for Medicare post-acute care services provided by SNFs, HHAs, rehabilitation hospitals and long-term care hospitals. The project will focus on four clinical conditions that are found in the post-acute care population. As a preliminary step to selecting the four conditions, the range of possibilities will first be narrowed to eight conditions. This report describes our analysis leading to the selection of the eight conditions.

We think that, as a general rule, the criteria used to identify the eight conditions at this stage should have policy-related implications. This orientation helps to make the findings from the eventual study more valuable to BBA prescribed and other reform initiatives directed at Medicare post-acute care services and the growth of the Medicare risk HMO program. This orientation also complements, rather than duplicates, our current plans to employ clinically-related criteria to narrow the eight conditions to the four conditions that will be the focus of the eventual outcomes study.

In light of the goal of this project to examine the relative quality outcomes of treating specific conditions across post-acute care providers, a necessary criterion for the selection of the conditions is that they are being treated in more than one post-acute care provider modality. For this study, we are examining the types of post-acute care cases that receive services from skilled nursing facilities (SNFs), home health agencies (HHAs) and rehabilitation facilities (RFs), and to a lesser extent long-term care hospitals. Although it would be particularly desirable to select conditions that are found in the caseload of all three provider types, the nature of RFs implies that only the subset of post-acute care patients that require intensive, inpatient rehabilitation will be found in this setting. A substantial proportion of post-acute care patients do not need this level of therapy services, but do need skilled nursing, medical social work and aide assistance. These services can be provided either in SNFs or by HHAs. Hence, we will not restrict the selection to only conditions that can be observed in all three settings. Rather, we will include some conditions that are treated largely in RFs or SNFs and others that are treated primarily in SNFs or by HHAs (or in some cases long-term care hospitals).

As has been noted in prior reserch (Steiner and Neu, 1993; ProPAC, 1996), post-acute care use of SNFs, HHAs and RFs is concentrated in relatively few types of cases (at least in terms of broad categorizations of patients, such as by DRGs). This situation persisted in 1995. We examined the 39 most prevalent DRGs among post-acute care users of SNFs, HHAs, and RFs, and found that those selected DRGs accounted for 53% of all SNF episodes, 36% of all HHA episodes and 68% of all RF episodes. Hence, we anticipate that selection of conditions based on some variant of those DRG categories will provide information on a sizeable proportion of Medicare’s post-acute care population.

We envisioned three steps in the process to arrive at the eight conditions that will be proposed for further analysis. The first step is to conceptualize methods for defining post-acute care conditions and identify selected conditions using this framework. The second is to establish criteria for choosing eight conditions among the unlimited number of possible conditions. The final step is to apply the criteria to narrow down the range of possibilities. The following sections address the three steps.

II. APPROACHES FOR DEFINING CONDITIONS

Various approaches are possible to define conditions for studying outcomes of post-acute care services. The commonly used approach in past studies is the selection of conditions on the basis of hospital DRGs or diagnosis (e.g. hip fracture, stroke, congestive heart failure). Two major studies of outcomes of post-acute care services across different modalities were conducted by Kramer and colleagues (1997) and Kane and colleagues (1997a, 1997b). Kramer examined the outcomes of hip fracture and stroke patients, selected on the basis of hospital diagnoses representing the two conditions. Kane selected cases based on the hospital DRGs. Along with hip fracture (DRG 210) and stroke (DRG 14) cases, Kane examined outcomes of people discharged from hospitals with congestive heart failure (DRG 127), chronic obstructive pulmonary disease (DRG 88) and hip replacement procedures (DRG 209). The selection of those hospital diagnoses or DRGs was not surprising because hip fractures and strokes are two of the most prevalent conditions treated by Medicare post-acute care providers. Moreover, the five DRGs selected by Kane accounted for almost 30 percent of Medicare-sponsored post-acute services (ProPAC, 1996).

Another approach for selecting conditions is to define them by functional measures (e.g., disability prior to the acute event, ADL disability after the acute event, changes in ADL disabilities before and after the acute event). This approach reflects the need for rehabilitation services, which is one of the major causes for people to receive post-acute care. Because many post-acute care patients require more skilled nursing care than rehabilitation services, they may be underrepresented if this approach is used. On the other hand, medical post-acute care patients may also be functionally dependent at various times during the episode of acute and post-acute care. Another potential drawback of this approach for selecting conditions is the variation in medical conditions that is associated with functional disability. Because disabled populations have such varied medical problems, it may be difficult to predict outcomes on the basis of functional status. Moreover, outcomes based on disabilities may be influenced by the accessibility and use of informal care; comparisons between post-acute care providers may be confounded if such factors are not controlled for in analyses.

A third option is to define conditions by care requirements (e.g., ventilator dependent, wound care, rehabilitation). As with the preceding approach, this strategy for selecting groups of post-acute care patients may be constrained by the diversity of underlying conditions of people requiring particular types of care. For quality measurement purposes, it is is important that study groups are relatively homogeneous so that differences in outcomes are related to site of care and not underlying medical needs. Thus, if similar quality measures can be used for all patients that are ventilator-dependent or that require wound care, it would not be critical to distinguish the exact diagnosis underlying the need for a ventilator or for wound care. On the other hand, we might have to select, for the study, subgroups of ventilator-dependent people by underlying medical conditions and levels of comorbidity (See Kramer, et al. 1990 for a further discussion of patient classification and quality measure development).

III. SELECTION CRITERIA

We reflected on various criteria that could be used to aid in the selection process and have arrived at four categories: (1) Overlap across providers of potential users of post-acute care; (2) High volume cases, either as a proportion of hospital discharges or as a high post-acute care admission group, (3) Medicare service use patterns; (4) Analytical practicality.

Overlap across post-acute care providers. This criterion, as noted above, is a requirement of the study. The aim is to develop quality measures to determine if treatment modality is responsible for differences in outcomes, all other things being equal. As a first step, it is important to be able to make comparisons between the different Medicare post-acute care providers. According to this criterion we will identify conditions that are found in substantial numbers across the different providers. Because rehabilitation facilities can only admit patients who require and can tolerate three hours of therapy per day, some conditions will be those that are treated largely in either RFs or SNFs. Conditions will also be chosen that may be treated either in SNFs or HHAs (and if possible long-term care hospitals).

High volume. Because of the policy-orientation of condition selection at this stage, we include the criterion of high Medicare volume of post-acute care services. For the eventual demonstration project to have program impact, the conditions selected will have to occur in relatively high proportions among Medicare’s post-acute care users or be a relatively high proportion of Medicare’s costs for post-acute care services. This approach is consistent with most of the prior research on post-acute care services, starting with the Rand studies in the 1980's (Neu and Harrison, 1989, Steiner and Neu, 1993).

In addition, the BBA mandated that, for selected hospital DRG’s, cases involving transfers from PPS hospitals to post-acute care providers would result in adjustments in the payment amount of those DRGs. The DRGs were chosen because they represent the highest volume of discharges to post-acute care or a disproportionate use of post-acute care services. The 10 specific DRG’s that have been selected by the Health Care Financing Administration are: strokes (DRG 14), amputations for circulatory system disorders (DRG 113), hip and limb procedures (DRGs 209-211), hip fractures (DRG 236), skin graft/debridement for skin ulcers (DRGs 263-264), organic disturbances and mental retardation (DRG 429), and tracheostomies (DRG 483). The adjustment in DRG payments could have an effect on the pattern of care for patients with those DRGs. Because of the potential change in practice patterns, it would be useful to select conditions in this group so more information will be available to determine if quality is negatively affected by the change in payment method.

Utilization patterns. This criterion covers a range of Medicare service use issues that may be important to consider in the selection of specific conditions to track across post-acute care episodes. Four issues illustrate this criterion.

First, a substantial proportion of post-acute care episodes ends with a hospital readmission. It can be shown, for example, that the rate of hospital readmission varies by DRG. Hospital readmission could reflect severity of patients’ condition and/or quality of care. Regardless, hospital readmission probably reflects higher patient costs. While hospital readmission can be used as an outcome measure, it might also be useful in selecting types of conditions to review because it provides an indication of relatively higher (lower) Medicare episode costs.

Second, some post-acute care patients receive care, in sequence, from more than one type of post-acute care provider. Selecting conditions for which patients frequently use more than one type of post-acute care provider can be useful in not only targeting relatively high cost cases, but also ones in which quality of care may be more questionable.

Third, because of the emergence of “subacute” care, which refers to treatment for patients with more complex needs, it may be important to select conditions that are characteristically viewed as requiring this level of care. Lewin-VHI (Manard, Bieg, Cameron, et al., 1995) concluded that the term subacute care tends to refer to a level of care that some nursing facilities, home care providers and others have been providing for years under a variety of different names (e.g., high end skilled care). Ventilator-dependent patients, for example, are often cited as illustrative of subacute care patients. Other “types of illnesses” treated by subacute care providers include stroke, hip fracture, spinal cord injury, pulmonary disease, and cardiovascular disease. Learning about the quality of subacute care is also motivated by the growing use of this level of care in the managed care environment, and particularly in situations where subacute care replaces inpatient hospital care.

Fourth, when the casemix-adjusted prospective payment systems for SNFs, HHAs and RFs are implemented, there may be some mismatches between payments and costs of specfic casemix categories. Conditions that are potentially subject to such mismatches would be important to consider in light of possible changes in utilization that reflect access and quality problems.

Analytical practicality. The final criterion refers to the practical aspects of selecting particular conditions for analysis. Assuming that a subset of the conditions that we select at this stage will eventually be the ones that are analyzed for the design of the demonstration, it is important to consider ways to minimize subsequent problems even at this stage of selecting the initial eight conditions. We identified two issues that fall under the criterion of analytical practicality.

First, a condition that is selected should include cases that are relatively homogeneous, thereby enhancing our ability to compare outcomes across provider modalities. Although risk adjustment strategies will be used in the eventual study, that process cannot fully compensate for potential variability of a given condition.

Second, the conditions that are chosen should be ones that are relatively recognizeable and understandable to a policy audience as well as to clinical ones. Applying this selection criterion will help to enhance the dissemination of study findings and the likelihood that results may be incorporated into future policy analyses or policies governing post-acute care services.

IV. APPLICATION OF CRITERIA IN THE SELECTION OF EIGHT CONDITIONS

We examined different approaches for defining conditions and employed the criteria discussed in the previous section to identify likely candidates for the eight conditions. This section discusses the rationale behind our selection.

A. Approach for Defining Conditions

As noted above, few studies have addressed patient outcomes when making comparisons across provider types. The conditions selected in those studies were either hospital DRGs or hospital diagnoses. We started with this strategy, partly because of the literature and partly because such DRG and diagnosis information is available from Medicare claims data. In current research using 1995 Medicare claims data, we have already constructed episodes of hospital and post-acute care use. Hence, it is posssible for us to examine expeditiously conditions based on this information source. Moreover, the claims data also allow us to examine conditions based on use of particular Medicare services (e.g., ventilators).

A major shortcoming of the Medicare claims data, for this project, is that it provides no information on functional status (e.g., ADLs, IADLs). Hence, using this data source precludes the possibility of establishing conditions based on disability. Although we considered examing other sources of information, such as the Medicare Current Beneficiary Survey, which collect information on functional status of Medicare enrollees, we focused our efforts on the claims data because of limitations in those sources. Notably, the number of cases of post-acute care use of survey samples is very small compared to the number of cases when using Medicare claims. The sample size problem of surveys means that relatively few post-acute care events can be measured. Sample size limitations are exacerbated when we focus on subgroups of beneficiaries (e.g., persons with more than 3 ADL dependencies) or when we focus on patients using particular types of post-acute care providers (e.g., rehabilitation facilities).

Episodes of post-acute care use. We employed data from the 5-percent sample of 1995 Medicare claims data to examine episodes of post-acute care use. By creating episodes, in which SNF, HHA, and RF use was linked to hospital stays and to each other, it was possible to identify nationally representative patterns of post-acute care when a single or multiple providers were involved. We could also relate the post-acute use to the DRGs or diagnoses of the qualifying hospital stay, and any other information on the hospital claims, including services used (e.g., ventilator). We could also measure the duration of the total episode of post-acute care use.

Initial selection of DRGs. Because of the importance to this study of identifying conditions that are found in multiple post-acute care settings and occur in substantial numbers, we used an initial screening process to select cases that met the two criteria. We sorted post-acute care use of SNFs, HHAs, and RFs, respectively, by the DRG of the preceding hospital stay. We selected the 20 most prevalent DRGs for each of the three provider types. Because certain DRGs (e.g., hip fracture, stroke) were found in the top 20 lists of more than one provider type, we ended up with 32 unique DRGs from the original list of 60. Finally, we created a file containing all hospital stays with those 32 DRGs, regardless of whether it was followed by use of any of the post-acute care providers. These DRGs accounted for two-thirds of all Medicare post-acute care episodes. The distribution by discharge destination (including no post-acute care use) of these high volume DRGs is presented in Table 1.

Based on the 5-percent file, we identified a total of 157,280 episodes involving the 32 DRGs. For the 32 DRGs as a whole, only 51.6 percent of the episodes did not have post-acute care. The most common type of post-acute care service was home health care (24.4 percent), followed by SNF care (12.6 percent). Rehabilitation facilities accounted for almost 2 percent of the episodes involving the DRGs, and 9.2 percent of those episodes involved the use of more than one of the three post-acute care providers.

The numbers of post-acute care episodes by DRG show that many of the DRGs from previous studies continued to be important in 1995. These include stroke (DRG 14 with 12,002 cases), chronic obstructive pulmonary disease (DRG 88 with 7,569 cases), heart failure (DRG 127 with 14,165 cases), major joint replacement procedures (DRG 209 with 12,969 cases), and hip and femur procedures (DRGs 210 and 211, with a combined 5,926 cases).

B. Application of Criteria

High volume and multiple providers. With the data from Table 1, we derived the DRG distributions of discharge locations only for cases that did use post-acute care; effectively, we excluded the cases that did not use any of the three post-acute care modalities. These distributions are presented in Table 2. From this table, we can identify specific DRGs that meet the high volume and/or multiple providers criteria.

The number of post-acute care episodes by DRG in Table 2 ranged from 10,950 for major joint procedure (DRG 209) to 337 for back and neck procedures without complications (DRG 215). As an initial step toward identifying 8 conditions for further consideration, we made a decision rule to focus on DRGs with at least 1,500 episodes in Table 2.¹ Given that we were using the 5 percent claims file, this minimum number is equivalent to 20,000 episodes in 1995. This decision rule defines 17 DRGs in Table 2 as high volume conditions: DRG 14, DRG 15, DRG 79, DRG 88, DRG 89, DRG 106, DRG 121, DRG 127, DRG 138, DRG 148, DRG 174, DRG 182, DRG 209, DRG 210, DRG 296, DRG 320, and DRG 416.

Looking at the distributions of the DRGs by provider type, it is apparent that rehabilitation facilities are not frequent providers for many of them. Some of the DRGs with the highest percentages using RFs are stroke (DRG 14; 10.6 percent), major joint procedure (DRG 209, 9.8 percent), hip procedure (DRG 210, 4.9 percent), and tracheostomy (DRG 483; 10.3 percent). It is interesting to note that, although back and neck procedures (DRGs 214 and 215) did not make the high volume cut-off, a very high proportion (11.1 percent, 10.1 percent) of their episodes involved using rehabilitation facilities The DRGs with high proportions of patients using rehabilitation facilities also tended to have lower than average proportions using HHAs. HHA use was the lowest for DRG 210, but the total number of episodes for DRG 210 is very large.

Given the decision rules that we employed, there are 17 DRGs that are high volume conditions and 3 DRGs (i.e., DRG 214, DRG 215, DRG 483) that are exceptionally interesting for this study. Of those 20 conditions, 5 are relatively well distributed across SNFs, HHAs, and RFs. Because those 5 DRGs also use RFs in relatively high proportions, the remaining 15 high volume DRGs are best suited for paired comparisons between SNFs and HHAs.

Variations in utilization patterns. For the 20 DRGs, we derived summary statistics to examine variations in the patterns of Medicare service utilization, such as hospital readmissions and lengths of stay. These statistics are presented in Table 3.

Hospital readmissions are high for most of the DRGs, ranging from 19.0 percent for back and neck procedures without complications (DRG 215) to 51.7 percent for chronic obstructive pulmonary disease (DRG 88). Most of the DRGs have approximately one-third of cases being readmitted to hospitals within the year. Other DRGs with relatively low proportions of cases readmitted to hospitals are major joint replacement (DRG 209), hip procedure (DRG 210), and back and neck procedure with complications (DRG 214). Other DRGs with relatively high hospital readmission rates include congestive heart failure (DRG 127), acute myocardial infarction (DRG 121), and heart arrythmia (DRG 138).

For all episodes, the median length of stay (LOS) was 33 days. Hip procedures (DRG 210) had a relatively long LOS of 44 days. In contrast, back and neck procedures without complications (DRG 215) had a relatively short median LOS of 23 days. It is important to note that one cause of episodes to end is a hospital readmission. Hence, for DRG 215, when a readmission occurred, it occurred relatively quickly.

Stroke (DRG 14), major joint procedure (DRG 209), hip fracture without major procedure (DRG 210), and back and neck procedure with complications (DRG 214) had among the highest post-acute care episode costs, with stroke, for example, having a median cost of $5,399. This finding is consistent with these cases being rehab DRGs which require considerable amounts of therapy services. Tracheostomy (DRG 483) also had very high costs, with a median of $5,303. In contrast, DRGs with relatively low costs included congestive heart failure (DRG 127), pneumonia (DRG 89), and chronic obstructive pulmonary disease (DRG 88).

The use of different types of post-acute care providers during an episode was highest among patients with stroke (DRG 214), hip fracture procedures (DRG 209, DRG 210), or back and neck procedures (DRG 214, DRG 215). About one-third of the episodes for those DRGs involved use of some combination of SNF, HHA and RF care. In contrast, the DRGs with the lowest proportions using multiple providers of care were arrythmia (DRG 138), esophagitis (DRG 182), and congestive heart failure (DRG 127). These DRGs also had relatively low costs.

V. RECOMMENDATIONS

A summary of characteristics of the 20 high volume or exceptional DRGs is presented in Table 4. The rehabilitation DRGs and the medical DRGs are separated and each group is ranked according to the number of episodes of post-acute care.

The two hip procedure DRGs (DRGs 209 and 210), along with stroke (DRG 14), are very high volume post-acute care cases and are among the 10 “transfer” DRGs. They are also served in relatively high proportions by all three provider types (SNFs, HHAs, and RFs). Moreover, many stroke and hip fracture episodes involve relatively high use of multiple post-acute care providers. Because many hip fractures are treated with a joint replacement (or arthroplasty), we will not define the hip fracture group exclusively by DRG assignment. Rather, we will define one group as hip fracture reflecting the emergent nature of the procedure and include patients from DRG 209, DRG 210, and DRG 211 who meet this criterion. A subgroup of the patients will have had arthroplasty. We do not plan to include elective hip replacements in the eight conditions. Thus, we will include hip fracture from DRG 209, DRG 210, DRG 211 and stroke from DRG 14 for further review. Other strokes coded under DRGs 1 and 5 (craniotomy and extravascular procedures) will also be included with those coded under DRG 14.

Back and neck procedures (DRGs 214 and 215) are interesting conditions that have not been widely studied. Our analysis indicated that people with those DRGs make substantial use of rehabilitation facilities, as well as SNFs and HHAs, so that three site comparisons are possible. In addition, utilization characteristics of back and neck procedure DRGs are somewhat similar to those of hip fracture cases (e.g., low hospital readmissions, high costs). Hence, back and neck procedures present an interesting alternative to such cases as we attempt to study “new” conditions. We recommend including back and neck procedures for further consideration.

Congestive heart failure (DRG 127) and pneumonia (DRG 89) are the highest volume conditions among the medical DRGs. CHF has a relatively high hospital readmission rate and a relatively low likelihood of being treated by multiple providers. Pneumonia is a condition that is easily recognizeable by policy makers and lay people, and while it is a relatively low cost DRG, it is treated in large numbers both in SNFs and by HHAs. More pneumonia cases are likely to be identified in other DRGs such as respiratory infections (DRG 79) and pleural effusions (DRGs 85 and 86). We recommend including these two conditions for further study.

Two other medical conditions that are treated in high volume by post-acute care providers are chronic obstructive pulmonary disease (DRG 88) and circulatory disorders with acute myocardial infarction (DRG 121). Both DRGs have very high use rates in HHAs, but are also treated in SNFs. Both are also relatively low cost and have high hospital readmission rates. Thus, we are also recommending these for further study. For both of these conditions, we anticipate that other cases can be identified by ICD9 codes included under different DRGs. For example, COPD cases may be identified under lung diseases (DRGs 92 and 93) or acute bronchitis (DRGs 96 and 97).

The tracheostomy DRG (DRG 483) appears in all three of the post-acute care settings and is relatively high cost. Moreover, it is a DRG that involves ventilator care, and ventilator care is often noted as a characteristic of “subacute care.” The increasing importance of subacute care in managed care is a significant policy-oriented criterion for supporting the study of ventilator-related conditions. We recommend including tracheostomy (and other ventilator-related conditions) for further study.

In sum, our review resulted in the recommendation of three rehab DRGs, four medical DRGs, and ventilator-related conditions for further study. Several of the recommended conditions are “transfer” DRGs and many of them can be examined in comparisons involving SNFs, HHAs, and RFs.

VI. CONCLUSION

The analysis to recommend 8 conditions for further study focused on DRGs. Although DRGs have been used to select conditions for post-acute care outcome studies, they were examined here principally to identify broad areas for more detailed consideration. In particular, we think that some of the DRGs might be heterogeneous in terms of diagnoses that are included. More precise specification of conditions for further study may involve subsetting of diagnoses in any given DRG or combining diagnoses from multiple DRGs. On the other hand, this initial screen of potential conditions for further study, based on DRG-related conditions, provides a policy-oriented group of conditions that policy and clinical experts can recognize and understand.

REFERENCES

Kane, R.L., Q. Chen, M. Finch, et al., 1997. “Functional Outcomes of Post-Hospital Care for Stroke and Hip Fracture Patients Under Medicare.” Manuscript, University of Minnesota School of Public Health.

Kane, R.L., Q. Chen, M. Finch, et al., 1997a. “The Optimal Outcomes and Costs of Post-Hospital Care Under Medicare.” Manuscript, University of Minnesota School of Public Health.

Kramer, A.M., J.F. Steiner, R.E. Schlenker, et al., 1997b. “Outcomes and Costs After Hip Fracture and Stroke.” Journal of the American Medical Association 277 (5): 396-404.

Kramer, A.M., P. W. Shaughnessy, M. K. Bauman, and K. S. Crisler, 1990. “Assessing and Assuring the Quality of Home Care: A Conceptual Framework.” The Milbank Quarterly 68 (3): 413-442.

Lewin-VHI (Manard, B., K. Bieg, R. Cameron, et al.), 1995. Subacute Care: Policy Synthesis and Market Area Analysis. Submitted to Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. [Full Report]

Neu, C.R. and S. C. Harrison, 1989. “Medicare Patients and Postacute Care.” RAND Report R-3780-MN. Santa Monica, California: The RAND Corporation.

Steiner, A. And C.R. Neu, 1993. “Monitoring the Changes in Use of Medicare Posthospital Services.” RAND Report MR-153-HCFA. Santa Monica, California: The RAND Corporation.

Prospective Payment Assessment Commission (ProPAC), 1996. Medicare and the American Health Care System: Report to the Congress. Washington, D.C.

NOTES

1. Exeptions to this general rule were DRG 15 (n = 1,477) for which almost 1,500 episodes were recorded, DRG 214 (n = 883) and DRG 215 (n=337) because they are an alternative to widely studied hip procedures, and DRG 483 (n=386) because it is likely to involve ventilator care and is a “transfer” DRG.

TABLE 1: Distributions of Hospital Discharge Destinations, by Selected DRG
DRG #	DRG Name	All Locations (Number)	Discharge Destinations (Percentage)
			No Post- Acute Care	Rehab Only	SNF Only	HHA Only	More than one PAC
Total Number/Average Percentage		157,280	51.63	1.97	12.66	24.49	9.25
001	Craniotomy age >17 except for trauma	961	46.20	8.53	12.70	16.44	16.13
005	Extracranial vascular procedures	3,132	84.29	1.15	1.56	10.89	2.11
014	Specific cerebrovascular disorders except TIA	12,002	33.82	7.05	21.08	18.68	19.37
015	Transient ischemic attack and precerebral occlusion	4,124	64.19	0.99	7.52	22.70	4.61
079	Respiratory infections and inflammations age >1	5,231	52.76	0.19	22.14	20.59	4.32
088	Chronic obstructive pulmonary disease (COPD)	7,569	57.68	0.30	6.72	32.05	3.24
089	Simple pneumonia and pleurisy age >17 with cc	11,445	57.52	0.12	14.40	24.50	3.46
104	Cardiac valve procedures w/ cardiac cath	759	44.14	3.16	5.01	39.53	8.17
106	Coronary bypass with cardiac cath	3,410	45.54	1.52	3.99	42.17	6.77
107	Coronary bypass w/o cardiac cath	2,018	47.87	1.49	3.07	42.96	4.61
112	Percutaneous cardiovascular procedures	5,130	85.32	0.19	0.82	12.83	0.84
113	Amputation for circulatory system disorders except UP	798	24.44	5.14	33.33	17.04	20.05
121	Circulatory disorders w AMI	3,476	46.63	0.29	12.43	35.39	5.26
124	Circulatory disorders except AMI	2,822	81.11	0.32	0.67	17.04	0.85
127	Heart failure and shock (CHF)	14,165	51.82	0.17	8.96	35.69	3.36
132	Atherosclerosis with cc	2,698	75.02	0.15	2.63	20.87	1.33
138	Cardiac arrhythmia and conduction disorders with	5,214	71.12	0.15	4.83	22.06	1.84
140	Angina pectoris	3,116	76.89	0.00	2.18	20.12	0.80
143	Chest pain	3,389	88.05	0.09	1.56	9.94	0.35
148	Major small and large bowel procedures with cc	4,766	48.41	0.46	10.41	33.17	7.55
174	G.I. hemorrhage with cc	5,966	69.29	0.12	8.28	19.78	2.53
182	Esophagitis gastroent and miscellaneous digestive disorders	5,537	71.90	0.09	5.20	20.90	1.91
209	Major joint and limb reattachment procedures	12,969	15.57	8.31	16.39	26.42	33.30
210	Hip and femur procedures except major joint age	5,031	12.70	4.33	39.30	11.65	32.02
211	Hip and femur procedures except major joint age	895	12.85	6.93	33.30	13.97	32.96
214	Back and neck procedures with cc	1,740	49.25	5.63	5.63	22.07	17.41
215	Back and neck procedures without cc	1,293	73.94	2.63	3.17	13.92	6.34
236	Fractures of hip and pelvis	1,283	22.14	3.66	31.57	17.61	25.02
239	Pathological fractures and musculoskeletal and con	1,769	31.83	1.47	20.69	28.15	17.86
243	Medical back problems	2,168	42.90	1.94	16.10	25.78	13.28
294	Diabetes age > 35	2,022	46.04	0.20	9.59	40.36	3.81
296	Nutritional and miscellaneous metabolic disorders >1	5,353	48.70	0.32	17.65	28.08	5.25
320	Kidney and urinary tract infections age >17 wit	4,124	50.87	0.12	20.59	24.30	4.12
416	Septicemia age > 17	4,694	57.56	0.23	18.60	19.26	4.35
429	Organic disturbances and mental retardation	1,207	38.19	0.17	35.13	21.29	5.22
468	Extensive o.r. procedure unrelated to principa	1,447	45.06	1.87	16.45	25.36	11.26
471	Bilateral or multiple major joint procs of low	397	13.60	16.62	10.58	16.62	42.57
478	Other vascular procedures with cc	2,188	47.35	1.23	9.00	35.47	6.95
483	Tracheostomy except for mouth larynx or pharyn	972	60.29	4.12	17.59	9.77	8.23

TABLE 2: Discharge Destinations of Post-Acute Care Users, by Selected DRG
DRG #	DRG Name	All Locations (Number)	Discharge Destinations (Percentage)
			Rehab Only	SNF Only	HHA Only	More than one PAC
Total Number/Average Percentage		76,081	4.08	26.16	50.62	19.13
001	Craniotomy age >17 except for trauma	517	15.86	23.60	30.56	29.98
005	Extracranial vascular procedures	492	7.32	9.96	69.31	13.41
014	Specific cerebrovascular disorders except TIA	7,943	10.65	31.85	28.23	29.27
015	Transient ischemic attack and precerebral occlusion	1,477	2.78	20.99	63.37	12.86
079	Respiratory infections and inflammations age >1	2,471	0.40	46.86	43.59	9.15
088	Chronic obstructive pulmonary disease (COPD)	3,203	0.72	15.89	75.74	7.65
089	Simple pneumonia and pleurisy age >17 with cc	4,862	0.29	33.90	57.67	8.14
104	Cardiac valve procedures w/ cardiac cath	424	5.66	8.96	70.75	14.62
106	Coronary bypass with cardiac cath	1,857	2.80	7.32	77.44	12.44
107	Coronary bypass w/o cardiac cath	1,052	2.85	5.89	82.41	8.84
112	Percutaneous cardiovascular procedures	753	1.33	5.58	87.38	5.71
113	Amputation for circulatory system disorders except UP	603	6.80	44.11	22.55	26.53
121	Circulatory disorders w AMI	1,855	0.54	23.29	66.31	9.87
124	Circulatory disorders except AMI	533	1.69	3.56	90.24	4.50
127	Heart failure and shock (CHF)	6,825	0.35	18.59	74.08	6.97
132	Atherosclerosis with cc	674	0.59	10.53	83.53	5.34
138	Cardiac arrhythmia and conduction disorders with	1,506	0.53	16.73	76.36	6.37
140	Angina pectoris	720	0.00	9.44	87.08	3.47
143	Chest pain	405	0.74	13.09	83.21	2.96
148	Major small and large bowel procedures with cc	2,459	0.89	20.17	64.29	14.64
174	G.I. hemorrhage with cc	1,832	0.38	26.97	64.41	8.24
182	Esophagitis gastroent and miscellaneous digestive disorders	1,556	0.32	18.51	74.36	6.81
209	Major joint and limb reattachment procedures	10,950	9.84	19.42	31.30	39.44
210	Hip and femur procedures except major joint age	4,392	4.96	45.01	13.34	36.68
211	Hip and femur procedures except major joint age	780	7.95	38.21	16.03	37.82
214	Back and neck procedures with cc	883	11.10	11.10	43.49	34.31
215	Back and neck procedures without cc	337	10.09	12.17	53.41	24.33
236	Fractures of hip and pelvis	999	4.70	40.54	22.62	32.13
239	Pathological fractures and musculoskeletal and con	1,206	2.16	30.35	41.29	26.20
243	Medical back problems	1,238	3.39	28.19	45.15	23.26
294	Diabetes age > 35	1,091	0.37	17.78	74.79	7.06
296	Nutritional and miscellaneous metabolic disorders >1	2,746	0.62	34.41	54.73	10.23
320	Kidney and urinary tract infections age >17 wit	2,026	0.25	41.91	49.46	8.39
416	Septicemia age > 17	1,992	0.55	43.83	45.38	10.24
429	Organic disturbances and mental retardation	746	0.27	56.84	34.45	8.45
468	Extensive o.r. procedure unrelated to principa	795	3.40	29.94	46.16	20.50
471	Bilateral or multiple major joint procs of low	343	19.24	12.24	19.24	49.27
478	Other vascular procedures with cc	1,152	2.34	17.10	67.36	13.19
483	Tracheostomy except for mouth larynx or pharyn	386	10.36	44.30	24.61	20.73

TABLE 3: Utilization and Cost Statistics on High Post-Acute Care (PAC) Use, by Selected DRG
DRG #	DRG Name	Readmission Rate (%)	Median LOS (days)	Median PAC Costs ($)	Multiple PAC Users (%)
All Episodes		36.3	33	$2,327	19.1
014	Specific cerebrovascular disorders except TIA	32.6	40	5,399	29.3
015	Transient ischemic attack and precerebral occlusion	36.8	39	2,420	12.9
079	Respiratory infections and inflammations age >1	41.5	30	2,607	9.2
088	Chronic obstructive pulmonary disease (COPD)	51.7	36	1,507	7.7
089	Simple pneumonia and pleurisy age >17 with cc	40.4	30	1,830	8.1
106	Coronary bypass with cardiac cath	33.0	27	1,099	12.4
121	Circulatory disorders w AMI	45.4	31	1,539	9.9
127	Heart failure and shock (CHF)	49.4	36	1,600	7.0
138	Cardiac arrhythmia and conduction disorders with	43.7	36	1,573	6.4
148	Major small and large bowel procedures with cc	37.7	31	1,846	14.6
174	G.I. hemorrhage with cc	38.7	32	1,793	8.2
182	Esophagitis gastroent and miscellaneous digestive disorders	47.0	38	1,689	6.8
209	Major joint and limb reattachment procedures	19.7	32	3,621	39.4
210	Hip and femur procedures except major joint age	26.8	44	6,146	36.7
214	Back and neck procedures with cc	24.1	28	3,226	34.3
215	Back and neck procedures without cc	19.0	23	2,070	24.3
296	Nutritional and miscellaneous metabolic disorders >1	39.8	35	2,488	10.2
320	Kidney and urinary tract infections age >17 wit	39.3	37	2,669	8.4
416	Septicemia age > 17	39.1	30	2,745	10.2
483	Tracheostomy except for mouth larynx or pharyn	45.9	33	5,303	20.7

TABLE 4: Distributions of Hospital Discharge Destinations, by Selected DRG
DRG #	DRG Name	Volume	All Sites	Hospital Readmit	LOS	Cost	More than one PAC	Practical Issues
Rehabilitation
014	Specific cerebrovascular disorders except TIA	7,943	X		Hi	Hi	Hi	Res
015	Transient ischemic attack and precerebral occlusion	1,477			Hi
209	Major joint and limb reattachment procedures	10,950	X	Lo		Hi	Hi	Res
210	Hip and femur procedures except major joint age	4,392	X	Lo	Hi	Hi	Hi	Res
214 215	Back and neck procedures	1,220	X	Lo	Lo		Hi
Medical
079	Respiratory infections and inflammations age >1	2,471					Lo
088	Chronic obstructive pulmonary disease (COPD)	3,203		Hi		Lo	Lo	Res
089	Simple pneumonia and pleurisy age >17 with cc	4,862					Lo
106	Coronary bypass with cardiac cath	1,857				Lo
127	Heart failure and shock (CHF)	6,825		Hi		Lo	Lo	Res
148	Major small and large bowel procedures with cc	2,459
121	Circulatory disorders w AMI	1,855		Hi		Lo	Lo
138	Cardiac arrhythmia and conduction disorders with	1,506				Lo	Lo
174	G.I. hemorrhage with cc	1,832				Lo	Lo
182	Esophagitis gastroent and miscellaneous digestive disorders	1,556		Hi	Hi	Lo	Lo
296	Nutritional and miscellaneous metabolic disorders >1	2,746
320	Kidney and urinary tract infections age >17 wit	2,026					Lo
416	Septicemia age > 17	1,992
Procedure
483	Tracheostomy except for mouth larynx or pharyn	386	X	Hi		Hi

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REPORT 2: Selecting the Targeted Conditions

Andrew Kramer, Theresa Eilertsen, Danielle Holthaus, Marie Johnson
University of Colorado Health Sciences Center

Barbara Gage
The Urban Institute

July 22, 1998

This report was prepared under contract #HHS-100-97-0010 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and The Urban Institute. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/daltcp/home.htm or contact the ASPE Project Officer, Jennie Harvell, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. Her e-mail address is: Jennie.Harvell@hhs.gov.

Conclusions and opinions in this paper are solely those of the authors and do not necessarily reflect the views of the Urban Institute, University of Colorado or ASPE.

I. INTRODUCTION

A. Purpose of the Project

In this project, we will develop a set of quality of care measures for Medicare post-acute care (PAC) services provided by SNFs, HHAs, rehabilitation hospitals or units (referred to as rehabilitation hospitals) and long-term hospitals. To the extent that ambulatory care is provided for these conditions during the post-acute period, services such as outpatient physician care will also be considered part of PAC. The measures will be designed for evaluating the quality of PAC services in both fee-for-service and HMO settings.

The project will focus on four clinical conditions for which PAC is frequently provided. For each of the four targeted conditions, outcome measures reflecting quality of PAC will be identified. For each outcome measure, the necessary data items, the data sources, approaches to applying the measures across episodes of care, and risk factors will be specified. In addition, we will develop methods to stratify patients within a condition for the purpose of comparing similar patients across settings, and also approaches to testing the validity and reliability of the outcome measures that are proposed.

B. Framework for Selecting Tracer Conditions

The possible clinical conditions for further study were narrowed down to eight based on policy considerations (Liu, Gage, and Kramer, 1998). The selection criteria to choose eight conditions included: 1) conditions for which PAC is provided in different PAC settings; 2) high volume conditions for PAC either as a proportion of hospital discharges or in terms of the number of PAC admissions; 3) Medicare utilization criteria such as readmission rates to the hospital, conditions where more than one PAC setting is used in an episode, or where prospective payment systems for PAC providers are likely to have their greatest impact; and 4) DRGs that include a homogeneous group of clinical conditions from the perspective of outcome measurement.

Using Medicare claims analyses of hospitalizations occurring in the thirty days prior to PAC episodes, eight DRGs were chosen meeting these eligibility criteria. These included: (1) hip fracture/replacement, (2) stroke, (3) pneumonia, (4) congestive heart failure, (5) acute myocardial infarction, (6) chronic obstructive pulmonary disease, (7) back and neck procedures, and (8) ventilator-dependent patients. In this report, we discuss the framework for further evaluating these eight conditions, and then review the conditions using this framework. Finally, we recommend four conditions for inclusion in the project based on this framework.

The framework for selecting four conditions from these eight emphasizes representativeness of the conditions as a group as much as the characteristics of the individual conditions. We want the conditions included in the project to represent different types of illnesses (chronic versus acute); different PAC settings; different PAC services; and different domains of outcome measures (e.g., functional status, utilization, quality of life). Recognizing that all eight of these conditions meet the criteria of policy relevance, the criteria applied in this paper relate more to clinical issues.

We evaluated each of the conditions based on the literature and further analysis of Medicare claims data. We were interested in the PAC settings in which patients with each condition are treated and the types of PAC services that patients receive in these settings (e.g., physical therapy, IV care). We also classified the conditions in terms of whether PAC is provided following a single acute event or an exacerbation of an underlying chronic disease. With respect to outcomes, we were interested in the types of outcome measures used for the different conditions (e.g., functional status, mortality, quality of life, symptoms). Finally, we were interested in whether there was evidence that outcomes for the condition differed between in PAC settings, to the extent that such information was available.

The results of our literature review and claims analysis are synthesized in two tables. However, a more extensive presentation of selected literature for each condition is provided in the Appendix. The literature included in this paper is intentionally not exhaustive -- our goal was to describe PAC services and the types of outcomes measured. However, after selecting the four tracer conditions, a more comprehensive literature summary will be provided in a subsequent paper with more detail on specific outcome measures.

II. METHODS

A. Literature Search

We conducted a systematic review of published studies describing outcomes in skilled nursing facilities, rehabilitation hospitals, home health agencies and long term hospital settings for each of the eight conditions. Because published literature evaluating outcomes in PAC was extremely limited for six of the eight conditions, we broadened our search to include studies describing outcomes in acute care hospitals and outpatient programs using home health or rehabilitation services that may be in the continuum of PAC. We searched the MEDLINE database for articles published in English between January 1990 and March 1998. We supplemented this literature with papers published in the 1980s when limited assessment studies were available. We used each of the eight conditions as a title word or key word combined with the following title and key words: aftercare, PAC, hospital discharge, skilled nursing facility, rehabilitation hospitals, rehabilitation, home health care, and outcomes. To identify additional articles, we searched the reference lists of the selected articles.

B. Definition of the Criteria

Our criteria for selecting targeted conditions included the following service-related criteria: variation in PAC settings, and variation in type of services provided. PAC settings that we included are rehabilitation hospitals (RH), skilled nursing facilities (SNF), home health agencies (HHA), and long term care hospitals (LTH). Of secondary interest were outpatient-based programs and specialized hospital units (SHU). The latter include extended hospital stays in acute hospitals in a specialized program for which PAC may substitute. Type of services referred to the specific services provided within the PAC setting. From claims and the literature, we were only able to obtain meaningful data corresponding to: physical therapy, occupational therapy, respiratory therapy, speech therapy, skilled nursing, and IV care.

One criterion for selecting targeted conditions pertained to the domains of outcome measures used for assessing quality of care. We collapsed individual measures into domains (general categories of measures) that represented similar constructs. However, this taxonomy of measures is preliminary and will be refined in the subsequent paper and throughout the project. Currently, we have identified the following 11 outcome domains: function, mortality, return to community, psychological, physiologic, symptom resolution, quality of life, patient satisfaction, utilization, weaning from mechanical ventilation, and disease-specific outcomes (endurance, re-infarct rate, and motor assessments).

Another criterion related to the chronicity of the condition. This referred to whether the condition occurs acutely without the prior active diagnosis, or as an acute exacerbation of a chronic disease, or as an acute episode that may become a chronic problem. The final criterion referred to whether there was evidence that differences in PAC settings and services actually impact outcomes for the condition. While information on outcomes of PAC was not available for all conditions, we wanted to include conditions for which available evidence suggests that outcomes are influenced by the PAC services. If PAC services do not alter outcomes significantly for a condition, the condition will not be a useful tracer for comparing treatment options.

C. Analysis of Medicare Claims Data

Service utilization was determined using HCFA’s 1995 5% sample Standard Analytical Files for Inpatient, SNF and HHA Medicare claims. Only the Medicare Part A files were available for this analysis. Patients were selected from these files if all the following conditions were met:

• age >65,
• enrolled in Medicare Part A and Part B,
• not ESRD patient,
• not HMO enrollee, and
• received PAC in a RH, SNF, or HHA following an acute episode (data were not available for LTH).

The majority of these patients’ admissions occurred in 1995, though there were some 1994 admissions. The claims records indicate what services were provided during the post-acute stay; we compiled statistics for physical therapy, occupational therapy, speech therapy, respiratory therapy, skilled nursing, and IV care. Because skilled nursing is not a separate cost center for SNFs and RHs, we could not determine the percent of patients in these settings receiving skilled nursing.

It is important to note that the file contains claims for services billed under Medicare Part A only; services provided through Part B are not included. This affects SNFs more than RHs or HHAs because some therapy services are billed under Part B for SNFs. This may somewhat underestimate the percent of patients receiving therapy services in SNFs. We have some concern that the claims data are not 100% accurate, as facilities are ultimately reimbursed based on year-end cost report data rather than interim claims data. Because these claims are not used for payment, all services may be somewhat underreported. However, we believe that any error in reporting services is likely to be approximately equivalent across facility types and across services, and thus should not introduce large biases in any particular direction.

D. Application of Criteria

The evaluation of the conditions involved applying the above criteria, synthesizing the information, and considering different combinations of conditions. To apply our criteria, we rated each condition based on setting, chronicity, services, and outcomes. The purpose was to identify similarities and differences among conditions such that four conditions could be chosen that would represent a broad spectrum of PAC. If two or three conditions were found to have similar profiles, only one of them was included in the final set of four conditions.

For each of the eight conditions, the predominant settings in which PAC occurs was determined, based on Medicare billing data. For most conditions, this was two settings (e.g. PAC for pneumonia is received largely in skilled nursing facilities and home health agencies).

Using Medicare claims data, the eight conditions were ranked based on the percentage of patients with that condition receiving each of the following five services: physical therapy, occupational therapy, speech therapy, respiratory therapy and the use of intravenous medications. We did not rank facilities on provision of any skilled nursing care because we only had HHA data for this service. Because the percentage of patients receiving services were very similar for some conditions, the conditions were ranked in quartiles from highest to lowest percentage of patients receiving each service. When the same percentage of patients received a service for more than two conditions, they were all assigned to the same quartile.

Each condition was labeled as either acute or chronic based on the predominant clinical presentation of such conditions. In the case of ventilator-associated conditions, both acute and chronic conditions are included.

Outcome measurement criteria were applied by identifying the outcome domains with some supporting literature and for which validated measures exist. The predominant outcome domains studied for each condition was determined from the literature review. We also identified conditions where outcomes are known to be sensitive to PAC setting, when such information was available.

For each of the four criteria, conditions with a similar profile were assigned to the same group (A, B, C, etc.). A final overall grouping was then determined based on similarities in the individual criteria groups. We then considered various combinations of the conditions to select the final four conditions.

III. RESULTS

A. Service Utilization

The proportion of patients receiving six services in different types of PAC facilities is presented in Table 1. The data presented indicate the percent of patients who received any amount of each service during their PAC stay. The PAC stay was defined by the period after hospital discharge until death, hospitalization or no PAC services for at least 30 days. For example, 83% of hip fracture patients in rehabilitation hospitals (RHs) received physical therapy during their stay, and 46% of pneumonia patients in skilled nursing facilities (SNFs) received physical therapy during their stay. The percentages listed for RH, SNF, and HHA include patients who received PAC only in the specified setting during an episode that involved PAC. Data for patients admitted to more than one type of care (for example, RH followed by SNF, or SNF followed by home health) are combined under >1 PAC.

For some conditions, very few patients (less than 1% of discharges) were admitted to RHs, making utilization statistics unreliable. The RH row is therefore not presented for pneumonia, CHF, AMI, or COPD. In addition, skilled nursing is not discernable for patients in RHs and SNFs, all of whom presumably receive skilled nursing care. Therefore, skilled nursing figures are presented only for patients receiving home health care. However, the percent of patients receiving IV care (a type of skilled care) is listed separately for all provider types. Service intensity figures in parentheses for hip fracture and stroke patients were obtained from previous national research conducted by Kramer, et al., 1997. No other studies for other conditions provided intensity figures.

For all eight conditions, it is apparent that the predominant services provided in PAC facilities are therapies, particularly physical and occupational therapy. That there is relatively little IV care provided for conditions such as pneumonia suggests that most patients with these conditions who are discharged to PAC may have completed the acute phase of their illness. Recognizing that the claims may underestimate the percent of patients receiving IV care as well as other services, the important point is that relatively more therapy services were provided for these patients. Thus, the focus of PAC services even for most patients with medical conditions appears to be functional recovery designed to help patients return home, rather than management of extremely ill, medically complex patients.

Across conditions, there is variation in the amount of each therapy provided. For example, the condition with the most patients receiving physical therapy (hip fracture) is also the condition with the fewest patients receiving respiratory therapy. This variation in service mix will enable us to divide the eight conditions into groups with similar patterns of service utilization.

B. Outcomes

The availability of literature on outcomes for the eight conditions varied substantially by condition. With respect to PAC outcomes, only hip fracture and stroke have been studied in some depth. Congestive heart failure and chronic obstructive pulmonary disease have been studied to a lesser extent after hospitalization; while pneumonia, back and neck procedures, and ventilator care have been studied largely with respect to the acute care outcomes. Acute MI has been studied in outpatient treatment and cardiac rehabilitation occurring in the home, but not generally involving home health nurses. The availability of extant research is summarized in the second column of Table 2a. The specific studies that were most relevant to outcomes of these conditions in PAC settings are summarized in the Appendix by condition.

From the studies reviewed, we identified outcomes and classified them into the domains shown in Table 2a. While this is only a preliminary taxonomy of outcomes that will be refined both in the subsequent paper to the clinical panel and clinical panel reviews, it provides a simple way of classifying the various types of outcome measures that we found in the literature. The relative use of measures from the different domains across conditions is rated from +++, denoting that an outcome measure was used in almost all the studies reviewed, to a blank in the table representing that no outcome measure from that domain was found in the literature for that condition. The types of measures that we included in each domain are listed in Table 2b. However, for comparative purposes at this stage of the study we are focusing on outcome domains and not specific measures.

Function was the most widely studied outcome domain for the eight conditions. However, different outcome measures were used depending upon the condition and study. While our intent is not to review the specific measures in this paper, illustrative measures that we identified from the literature are listed in Table 2b. For example, ambulation and walking distance were emphasized for hip fracture, measures of neurological functioning was emphasized for stroke, the New York Heart Association (NYHA) functional classes were used for congestive heart failure, exercise capacity was used for acute MI and independence from mechanical ventilation was used for ventilator-dependent patients. Activity of daily living (ADL) and instrumental activity of daily living (IADL) measures were used for multiple conditions, with substantial variation in the scales used (e.g., RUGS III, FIM).

Mortality was the next most frequent outcome domain for these post-acute conditions, in part because so many of the outcome studies to date examined the hospital stay where keeping patients alive is often the focus of care.

For some conditions, disease-specific measures of physiology and symptom-specific measures were often found. Various quality of life measures were used in studying outcomes for many conditions, but not in the context of PAC. While re-hospitalization is a PAC issue, many studies examined re-hospitalization for chronic conditions over extended periods of time. In the Other category, we included condition-specific outcome measures that were not applied across conditions.

C. Profiling the Eight Conditions

Table 3 classifies each condition based on the settings in which PAC was frequently received following the acute stay, the chronicity of the disease, major outcome domains which are supported in the published literature, and the percentage of patients receiving selected services.

Using the information from Table 3, we grouped the eight conditions into categories according to their similarities with respect to each of the four criteria. Table 4 depicts these categories. Under the Setting criterion, we assigned hip fracture and stroke to the same category because both are primarily treated in rehabilitation hospitals, skilled nursing facilities and home health agencies, and secondarily in long term hospitals. Back and neck procedures differed only slightly because treatment occurs largely in home health agencies but secondarily in rehabilitation hospitals and skilled nursing facilities. Pneumonia, CHF, acute MI, and COPD were all in the same group for setting. Ventilator was in its own category due to the large proportion of patients on ventilators who are treated in long term care hospitals, making this a unique condition.

All conditions were either acute or chronic, with the exception of ventilator, which can be an acute and/or chronic condition. This does not refer to disease severity, rather the difference between a rapid onset event or illness without prior existence of the specific diagnosis (acute) versus an ongoing disease that becomes worse requiring immediate attention (chronic). We recognize that those diseases that we classified as acute often occur in patients at higher risk due to underlying disease processes (e.g., osteoporosis and balance impairment for hip fracture), but the person does not have the diagnosis of hip fracture until the actual fracture occurs, which is not the case for CHF or COPD. These classifications were carried over directly from Table 3 to Table 4.

The conditions were divided into five groups for outcome domains, with hip fracture and stroke grouped together -- having similar outcome domains except that stroke includes additional outcome domains. CHF, Acute MI, and COPD were grouped together because they all included five similar domains (function, mortality, physiology, quality of life, and utilization) and selected other domains (e.g., return to community, symptom resolution). The remaining three conditions had unique combinations of outcome domains based on the literature, and therefore were assigned individual categories.

For the Services criterion, we matched conditions to one another by the overall patterns of quartile designations across five services. We did not include the skilled nursing service for selecting conditions because data for skilled nursing was only available for home health patients. Hip fracture and back and neck procedures are grouped together because a high proportion of patients with these conditions received physical therapy and occupational therapy, and a low proportion of these patients receive respiratory therapy and IV services. Stroke is also similar, but differs slightly by the high proportion of stroke patients who receive speech therapy as well. Ventilator constitutes its own category due to the high proportion of ventilator patients who receive all five services. Among the remaining four conditions, pneumonia and COPD have similar patterns across services -- low proportions of patients receiving physical therapy and occupational therapy, but a high proportion of patients receiving respiratory therapy -- and are therefore grouped together. Finally, low proportions of CHF and AMI patients receive physical therapy, occupational therapy, and respiratory therapy, creating a separate category.

Overall, Table 4 illustrates several points. First, hip fracture, and stroke patients receive similar types of PAC services, both in rehabilitation hospitals and skilled nursing facilities. Both conditions are acute and studied outcome domains are largely functional, return to community living and mortality, with some additions for stroke (i.e., psychological and quality of life).

Second, pneumonia, CHF, COPD and AMI patients all receive PAC largely in skilled nursing facilities and home health agencies, but vary mostly in chronicity of the conditions, the types of outcome domains studied, and in use of respiratory therapy. COPD and CHF are both chronic conditions and share many outcome domains. Pneumonia and AMI are both acute. COPD and pneumonia use more respiratory therapy.

Third, back and neck patients receive similar services to hip fracture and stroke patients, and many similar outcome domains are studied. While the chronicity of illness is different, setting and services are not.

Finally, ventilator patients are different from all other conditions in setting of care, services received (particularly respiratory therapy), combination of both chronic and acute illnesses, and outcome measures related to ventilator weaning.

IV. DISCUSSION/CONCLUSION

While there is no scientific method for selecting tracer conditions, we have tried to follow an unbiased and systematic approach to evaluate the eight conditions. Our overall objective is to identify conditions that represent the range of patients, settings, services, and outcomes that constitute PAC. We used explicit criteria, collecting data pertinent to each criterion.

The final step is to examine the profiles of the different conditions to choose a combination of conditions that exhibits the greatest variation in these criteria. This final step involves making selections based on the profiles in Table 4, that summarizes the results from all the previous tables. While all eight of these conditions would be interesting to study for one reason or another, we are restricted to four due to project limitations. Thus, our proposed four tracer conditions are contained below, including the rationale.

Either hip fracture or stroke should be included in the study because they are the major conditions treated in both rehabilitation hospitals and skilled nursing facilities. However, we see little benefit in including both of these conditions because they are both acute, require similar services, and can be studied with similar outcome measures. If our sole criterion were number of PAC admissions or PAC cost, then both of these conditions would probably be chosen for this project. However, for developing quality measures, we are interested in a range of conditions so that we address different clinical situations, different settings, different services, and different outcomes during the developmental process.

We recommend choosing stroke over hip fracture for two reasons. First, with the frequency of speech therapy as a service and the multiple types of neurologic and mobility impairments that result from stroke, to measure outcomes will require a wider range of measures for stroke than hip fracture. This is supported in part by the additional outcome domains that have been studied for stroke. Second, stroke outcomes have been shown repeatedly to be influenced by PAC setting (Kramer et al., 1997, Kane et al., 1996). For hip fracture patients, evidence is mixed at best that the PAC setting influences outcomes (Koval et al., 1998, Kramer et al., 1997, Kane et al., 1996). If this is the case, then hip fracture will not be a very sensitive tracer for comparing care in HMO and fee-for-service settings or examining the impacts of prospective payment on quality.

The four medical conditions -- pneumonia, CHF, Acute MI, and COPD -- exhibit similarities and differences. While they are all treated frequently in both SNFs and home health agencies, two of them are acute (pneumonia and acute MI) and the other two are chronic. PAC services are similar for the two cardiac conditions (acute MI and CHF), while the pulmonary conditions have more respiratory therapy (pneumonia and COPD). By selecting two of these four conditions, we can choose one that is an acute medical problem (either pneumonia or acute MI) and one chronic medical problem (CHF or COPD). We can also choose one that is a cardiac problem and one that is a pulmonary problem. Thus, to maximize variability we should select either pneumonia and CHF, or acute MI and COPD.

In view of the extremely high PAC utilization and cost of both CHF and pneumonia, we recommend including these two in the study. By choosing COPD instead of pneumonia, we would be selecting a second chronic medical condition -- an acute condition such as pneumonia introduces different outcome measurement issues (e.g., measurement time points). Furthermore, pneumonia has more patients treated in SNFs than COPD (Liu et al., 1998), while both have substantial numbers of home health patients. Because there is significant clinical overlap among these conditions, however, we will not be entirely eliminating any of the four. Pneumonia patients receiving PAC often have underlying COPD, while CHF patients receiving PAC often have underlying coronary artery disease and/or a previous acute MI.

Both back and neck procedures and ventilator-dependent patients have unique profiles. However, patients with back and neck procedures use fairly similar settings and services to hip fracture and stroke patients. While it is a chronic condition, often the treatment for which someone is receiving PAC will be in response to an acute repair of a back or neck injury. While an interesting condition, we do not find it as compelling for studying rehabilitation as either hip fracture or stroke. The latter have so many more PAC cases.

Ventilator care offers the addition of long-term hospitals as a major setting, a unique mix of services with very intense respiratory care, unique outcomes, and patients who may in some cases be acute while in others will go on to become chronically dependent on the ventilator. This type of care can be extremely expensive and the choice among post-acute settings will be driven substantially by new payment policies. Controversy exists regarding the use of long-term hospitals, and subacute care reimbursement for treating very complex patients such as those who are dependent upon ventilators.

Thus, the four conditions we recommend for development of quality measures include stroke, pneumonia, congestive heart failure, and ventilator-dependent patients. As a group, they represent both acute and chronic conditions, cover all PAC settings, and the range of post-acute services in these settings. Most importantly for this project, these conditions will require a range of quality measures to assess quality of care across PAC settings.

REFERENCES

Atlas SJ, Deyo RA, Keller RB, Chapin AM, Patrick DL, Long JM, Singer DE. The Maine lumbar spine study, part II: 1-year outcome of surgical and nonsurgical management of sciatia. Spine 1996;21(5):1777-86.

Atlas SJ, Deyo RA, Keller RB, Chapin AM, Patrick DL, Long JM, Singer DE. The Maine lumbar spine study, part III: 1-year outcomes of surgical and nonsurgical management of lumbar spinal stenosis. Spine 1996;21(15):1787-95.

Ciol MA, Deyo RA, Howell E, Kreif S. An assessment of surgery for spinal stenosis: time trends, geographic variations, complications, and reoperations. JAGS 1996;44:285-90.

DeBusk RF, Haskell WL, Miller NH, Berra K, Taylor CB, Burger WE III, Lew H. Medically directed at home rehabilitation soon after clinically uncomplicated acute myocardial infarction: A new model for patient care. American Journal of Cardiology 1985;55(4):251-7.

Dennis LI, Blue CL, Stahl SM, Benge ME, Shaw CJ. The relationship between hospital readmissions of Medicare beneficiaries with chronic illness and home care nursing interventions. Home Healthcare Nurse 1996;14:303-8.

Deyo RA, Ciol MA, Cherkin DC, Loeser JD, Bigos SJ. Lumbar spinal fusion: a cohort of complications, reoperations, and resource use in the Medicare population. Spine 1993;18(11):1463-70.

Deyo RA, Cherkin DC, Loeser JD, Bigos SJ, Ciol MA. Morbidity and mortality in sssociation with operations on the lumbar spine. Journal of Bone & Joint Surgery 1992;74A(4):536-43.

Dressendorfer RH, Franklin, Cameron JL, Trahan KJ, Gordon S, Timmis GC. Exercise training frequency in early post-infarction cardiac rehabilitation. Journal of Cardiopulmonary Rehabilitation 1995;15(4):269-76.

Dubach P, Myers J, Dziekan G, Goebbels U, Reinhart W, Vogt P, Ratti R, Muller P, Miettunen R, Buser P. Effect of exercise training on myocardial remodeling in patients with reduced left ventricular function after myocardial infarction. Circulation 1997. 95(8):2060-7.

Elpern EH, Lurson R, Douglass P, Rosen RL, Bone RC. Long-term outcomes for elderly survivors of prolonged ventilator assistance. Chest 1989;96(5):1120-4.

Fine MJ, Smith MA, Carson CA, Mutha SS, Sankey SS, Weissfeld LA, Kapoor WN. Prognosis and outcomes of patients with community-acquired pneumonia. JAMA 1996;274:134-141.

Gracey DR, Naessens JM, Viggiano RW, Koenig GE, Silverstein MD, Hubmayr RD. Outcome of patients cared for in a ventilator-dependent unit in a general hospital. Chest 1995;107(2): 494-9.

Gracey DR, Viggiano RW, Naessens JM, Hubmayr RD, Silverstein, MD, Koenig, GE. Outcomes of patients admitted to a chronic ventilator-dependent unit in an acute-care hospital. Mayo Clinic Proceedings 1992;67(2):131-6.

Gulanick, M. Is phase 2 cardiac rehabilitation necessary for early recovery of patients with cardiac disease? A randomized, controlled study. Heart & Lung 1991;20(1):9-15.

Hamalainen H, Luurila OJ, Kallio V, Knuts L-R. Reduction in sudden deaths and coronary mortality in myocardial infarction patients after rehabilitation. European Heart Journal 1995;16(12):1839-44.

Hanumanthus S, Butler J, Chonsky D, Davis S, Wilson JR. Effect of a heart failure program on hospitalization frequency and exercise tolerance. Circulation 1997;96:2842-48.

Harjai KJ, Mehra MR, Ventura HO, Lapeyre YM, Miugo JP, Stapleton DD, Smart FW. Home inotropic therapy in advanced heart failure. Chest 1997;112:1298-1303.

Hood SA, Weigl K. Lumbar spinal stenosis: surgical intervention for the older person. Israel Journal of Medical Sciences 1983;19:169-72.

Kane RL, Chen Q, Blewett LA, Sangl J. Do rehabilitative nursing homes improve the outcomes of care. JAGS 1996;44:545-554.

Kane RL. A study of post-acute care. 1994. Institute for Health Services Research.

Katz JN, Lipson SJ, Lew RA, Grobler LJ, Weinstein JN, Brick GW, Fossel AH, Lean MH. Lumbar laminectomy alone or with instrumented or noninstrumented arthrodesis in degenerative lumbar spinal stenosis. Spine 1997;22(10):1123-31.

Keith RA, Wilson DB, Gutierrez P. Acute and subacute rehabilitation for stroke: a comparison. Arch Phys Med & Rehab 1995;76:495-500.

Kennie DC, Reid J, Richardson IR, Kiamari AA, Kelt C. Effectiveness of geriatric rehabilitative care after fractures of the proximal femur in elderly women. BMJ 1998; 297:1083.

Ketelaars CAJ, Abu-Saad HH, Schlosser MAG, Mostert R, Wouters EFM. Long-term outcome of pulmonary rehabilitation in patients with COPD. Chest 1997;112(2):363-9.

Kopacz MA, Moriarty-Wright R. Multidisciplinary approach for the patient on a home ventilator. Heart & Lung 1984;13(3):255-62.

Kornowski R, Zeeli D, Averbuch M, Finkelstein A, Schwartz D, Moshkovitz M, Weinrieb B, Hershkovitz R, Eyal D, Miller M. Intensive home-care surveillance prevents hospitalization and improves morbidity rates among elderly patients with severe congestive heart failure. Am Heart J 1995;129:762-6.

Koval KJ, Aharonoff GB, Su ET, Zuckerman JD. Effect of acute inpatient rehabilitation on outcome after fracture of the femoral neck or intertrochanteric fracture. Journal of Bone and Joint Surgery 1998;80-A(3):357-64.

Kramer AM, Steiner JF, Schlenker RE, Eilertsen TB, Hrincevich CA, Tropea DA, Ahmad LA, Eckoff DG. Outcomes and costs after hip fracture and stroke. JAMA 1997;277:5:396-404.

Leitch JW, Newling RP, Basta M, Inder K, Dear K, Fletcher PJ. Randomized trial of a hospital-based exercise training program after acute myocardial infarction: Cardiac autonomic effects. Journal of the American College of Cardiology 1997;29(6):1263-8.

Make B, Gilmartin M, Brody JS, Snider GL. Rehabilitation of ventilator-dependent subjects with lung diseases: the concept and the initial experience. Chest 1984;86(3):358-65.

McLean RF, McIntosh JD, Kung GY, Leung DMW, Byrick RJ. Outcome of respiratory intensive care for the elderly. Critical Care Medicine 1985;13(8):625-9.

Meehan TP, Fine MJ, Krumholz HM, Scinto JD, Galushi DH, Mockalis JT, Weber GF, Petullo MK, Hauch PM, Fine JM. Quality of care process, and outcomes in elderly patients with pneumonia. JAMA 1997;278:2080-2084.

Metlay JP, Fine MJ, Schulz R, Marrie TJ, Coley CM, Kapoor WN, Singer DE. Measuring symptomatic and functional recovery in patients with community acquired pneumonia. JGIM 1997;12:423-430.

Miller NH, Haskell WL, Berra K, DeBusk RF. Home versus group exercise training for increasing functional capacity after myocardial infarction. Circulation 1984;70(4):645-9.

Muir J, Girault C, Cardinaud J, Polu J. French Cooperative Study Group. Survival and long-term follow-up of tracheostomized patients with COPD treated by home mechanical ventilation: a multicenter French study. Chest 1994;106(1):201-9.

Munin MC, Rudy TE, Glynn NW, Crossett LS, Rubash HE. Early inpatient rehabilitation after elective hip and knee arthroplasty. JAMA 1998;279(11):847-52.

Niederman MS, Henerson Clemente P, Fein AM, Feinsilver SH, Robinson DA, Ilowite JS, Bernstein MG. Benefits of a multidisciplinary pulmonary rehabilitation program. Chest 1991;99(4):798-804.

North RB, Kidd DH, Campbell JN, Long DM. Dorsal root ganglionectomy for failed back surgery syndrome: A 5-year Follow-Up Study. J Neurosurg 1991;74:236-42.

North RB, Campbell JN, James CS, Conover-Walker MK, Wong H, Piantadosi S, Rybock JD, Long DM. Failed back surgery syndrome: 5 year follow-up in 102 patients undergoing repeated operation. Neurosurgery 1991;28:685-91.

Oldridge N, Guyatt G, Jones N, Crowe J, Singer J, Feeney D, McKelvie R, Runions J, Steiner D, Torrance G. Effects on quality of life with comprehensive rehabilitation after acute myocardial infarction. American Journal of Cardiology 1991;67(13):1084-9.

Ortqvist A, Hedlund J, Gilner L, Jalonen E, Kallings I, Leinonen M, Kalin M. Aetiology, outcome and prognostic factors in community-acquired pneumonia requiring hospitalization. Eur Resp J 1990;3:1105-1113.

Pehrsson K, Olofson J, Larsson S, Sullivan M. Quality of life of patients treated by home mechanical ventilation due to restrictive ventilatory disorders. Respiratory Medicine 1994;88:21-26.

Reardon J, Awad E, Normandin E, Vale F, Clark B, ZuWallack RL. The effect of comprehensive outpatient pulmonary rehabilitation on dyspnea. Chest 1994;195(4):1046-52.

Retchin SM, Brown, RS, Yeh SJ, Chu D, Moreno L.Outcomes of stroke patients in Medicare fee for service and managed care. JAMA 1997;278(2):119-24.

Rich MW, Beekham V, Wittenberg C, Leven CL, Freedland KE, Carney RM. A multidisciplinary intervention to prevent readmission of elderly patients with congestive heart failure. N Engl J Med 1995;333(18):1213-4.

Rich MW, Vinson JM, Sperry JC, Shah AS, Spinner LR, Chung MK, Davila-Roman V. Prevention of readmission in elderly patients with congestive heart failure. JGIM 1993;8:585-590.

Smith EB, Hanigan WC. Surgical results and complications in elderly patients with benign lesions of the spinal canal. JAGS 1992;40(9):867-70.

Stapleton DC, Kaplan SJ, Manard, B. Ventilator dependent unit demonstration: outcome evaluation and assessment of post acute care. 1996. Report prepared for Office of Research and Demonstrations, Health Care Financing Administration.

Steiner T, Mendoza G, DeGeorgia M, Schellinger P, Holle R, Hache W. Prognosis of stroke patients requiring mechanical ventilation in a neurological critical care unit. Stroke 1997;28(4):711-15.

Strijbos JH, Postma DS, van Atena R, Gimeno F, Koeter GH. A comparison between an outpatient hospital-based pulmonary rehabilitation program and a home-care pulmonary rehabilitation program in patients with COPD. Chest 1996;109(2):366-72.

Stineman MG, Fiedler RC, Granger CV, Maislin G. Functional task benchmarks for stroke rehabilitation. Archives of Physical Medicine and Rehabilitation 1998;79(5):497-504.

Swinburne A, Fedullo AJ, Bixby K, Lee DK, Wahl GW. Respiratory failure in the elderly: analysis of outcome after treatment with mechanical ventilation. Arch Inter Med 1993;153:1657-62.

Trzcieniecka-Green A, Steptoe A. Stress management in cardiac patients: a preliminary study of the predictors of improvement in quality of life. Journal of Psychosomatic Research 1994;38(4):267-80.

Vale F, Reardon JZ, ZuWallack RL. The long-term benefits of outpatient pulmonary rehabilitation on exercise endurance and quality of life. Chest 1993. 103(1):42-5.

Votto J, Bowen J, Scalise P, Wollschlager C, ZuWallack R. Short-stay comprehensive inpatient pulmonary rehabilitation for advanced chronic obstructive pulmonary disease. Archives of Physical Medicine & Rehabilitation 1996;77(11):1115-8.

Wijkstra PJ, van der Mark Th. W, Kraan J, van Atena R, Koeter GH, Postma DS. Effects of home rehabilitation on physical performance in patients with chronic obstructive pulmonary disease (COPD). European Respiratory Journal 1996;9(1):104-10.

Wijkstra PJ, Van Atena R, Kraan J, Otten V, Postma DS, Koeter GH, Postma DS. Quality of life in patients with chronic obstructive pulmonary disease improves after rehabilitation at home. European Respiratory Journal 1994;7:269-73.

Williams DN. Reducing costs and hospital stay for pneumonia with intravenous cefotaxime treatment: results with a computerized ambulatory drug delivery system. Amer J Med 1994;97:50-55.

Young, JB, Forster A. The Bradford community stroke trial: results at 6 months. BMJ 1992;304:1085-9.

Zuckerman JD, Sakales SR, Fabian DR, Frankel VH. Hip fractures in geriatric patients: results of an interdisciplinary hospital care program. Clinical Orthopeadics 1992; 274:213.

TECHNICAL ADVISORY GROUP RECOMMENDATIONS

At the conclusion of this phase of the study, we distributed this report and the report entitled "Selecting and Evaluating Eight Targeted Conditions" to our Technical Advisory Group (TAG) for review. Feedback from members of the TAG revealed a high level of concern over the inclusion of ventilator-dependent patients as one of our four selected conditions. Although many TAG members agreed that ventilator-dependent patients represent a unique and interesting condition for study, they expressed concerns about whether such a group is representative of post-acute care patients. The low prevalence of ventilator-dependent patients in post-acute care, as well as a lack of homogeneity among these patients, were among the specific concerns expressed. Furthermore, the large majority of ventilator-dependent patients are treated in long-term care hospitals, while relatively few are treated in more traditional types of post-acute settings.

In light of these concerns, we decided to include back and neck medical and surgical conditions instead of ventilator dependency as our fourth condition for study. Back and neck patients are similar to ventilator-dependent patients in that they both have somewhat unique profiles across treatment settings, chronicity, outcome domains, and services required (see Table 4). Back and neck patients are also relatively prevalent in the post-acute care population, are treated in multiple settings, and represent a population that has not been well studied.

TABLE 1: Percentage of Post Acute Patients with Each Condition Receiving Selected Services by Setting
	Setting1	Frequent Settings2	Specific Services3
			PT	OT	RT	ST	RN4	IV
Hip Fracture	RH LTH SHU SNF HHA OUTPT >1 PAC	X X X X X X	83% (1.5 h/d)2 (2 h/d) 81% (.6-.8 h/d) 89% 98%	82% (1.25 h/d) 56% (.2-.4 h/d) 7% 79%	16% 10% 0% 12%	8% 12% 0% 8%	81% 77%	1% 1% 0% 1%
Stroke	RH LTH SHU SNF SSNF5 HHA OUTPT >1 PAC	X X X X X X X	79% (1.3 h/d) 68% (.3-.5 h/d) (.9 h/d) 62% (.35 h/v) (.5 h/v) 97%	78% (1.4 h/d) 58% (.2-.4 h/d) (.9 h/d) 26% (.65 h/v) (.5 h/v) 90%	20% 14% 0% 20%	71% (.75 h/d) 49% (.1-.25 h/d) .9 hr/day 23% 76%	93% 76%	3% 2% 0% 2%
Pneumonia	RH LTH SHU SNF HHA OUTPT >1 PAC	X X X	46% 21% 83%	31% 3% 57%	27% 0% 40%	17% 1% 18%	99% 98%	3% 0% 4%
CHF	RH LTH SHU SNF HHA OUTPT >1 PAC	X X X X	55% 17% 82%	40% 3% 60%	19% 0% 30%	14% 0% 11%	100% 97%	2% 0% 3%
Acute MI	RH LTH SHU SNF HHA OUTPT >1 PAC	X X X X	59% 20% 83%	43% 3% 59%	17% 0% 23%	18% 1% 21%	100% 90%	1% 0% 2%
COPD	RH LTH SHU SNF HHA OUTPT >1 PAC	X X X X	52% 15% 80%	40% 3% 58%	35% 0% 34%	10% 1% 10%	99% 98%	1% 0% 4%
Back & Neck Procedures	RH LTH SHU SNF HHA OUTPT >1 PAC	X X X X	85% 81% 63% 97%	84% 60% 10% 81%	20% 9% 0% 16%	13% 9% 0% 14%	91% 79%	3% 1% 0% 2%
Ventilator	RH LTH SHU SNF HHA OUTPT >1 PAC	X X X X X X	75% 58% 28% 87%	75% 47% 8% 71%	46% 34% 0% 55%	54% 35% 7% 42%	99% 89%	5% 4% 0% 4%
Settings are rehabilitation hospital (RH), long term hospital (LTH), specialized hospital unit (SHU), skilled nursing facility (SNF), home health agency (HHA), outpatient (OUTPT), and more than one PAC setting (>1 PAC). Frequent settings include those that admit at least 1% of PAC discharges for that condition. Source Liu et al., (1998). Although long term hospitals account for a relatively small percentage of Medicare PAC admissions, patients admitted with hip fracture, stroke, and ventilators represent the largest percentage of long term hospitals’ admissions. Outpatient and specialized hospital units are marked when the literature frequently references PAC in these settings. Services include physical therapy (PT), occupational therapy (OT), respiratory therapy (RT), speech therapy (ST), skilled nursing (RN), and IV care (IV). Percentages represent patients receiving each service based on Part A Medicare claims cost center data for the PAC episode. These may underestimate actual percentage receiving each service because facilities are reimbursed on year-end cost report data rather than interim claims. These service percentages were only computed for RHs, SNFs, and HHAs and only when a large enough number of cases were available. Actual hours per day for services provided in parentheses are based on literature. Source for stroke and hip fracture is Kramer et al., 1997. Skilled nursing care is not a separate cost center for SNFs and rehabilitation facilities, so it could not be assessed at the patient level. For stroke patients, actual hours of therapy were found to differ between traditional SNFs and those providing a high volume of Medicare PAC: 5000 or more Medicare days or >90% Medicare days. These are separated in the table for stroke only.

TABLE 2a: Availability of Outcome Research and Outcome Domains Based on Review of Literature Pertaining to the Eight Conditions
Condition	Availability of Extant Research by Setting1	Outcome Domains3
		Function	Mortality	Return to Community	Indep. from Mech. Vent	Physiology	Symptom Resolution	Psychological	Quality of Life	Satisfaction	Utilization Outcomes	Other
Hip Fracture	--  Acute hospitals: High --  Rehabilitation hospitals: Moderate --  SNFs: High --  Home health: Low --  Long term hospitals: Low	+++	++	++							+	+ (Home assistance)
Stroke	--  Acute hospitals: High --  Rehabilitation hospitals: Moderate --  SNFs: High --  Home health: Low --  Long term hospitals: Low	+++	+++	++				+	+		+	+ (Motor assessments)
Pneumonia	--  Acute hospitals: High --  Home health: Low	+	+++			+	+
CHF	--  Acute hospitals: High --  SNFs: Low --  Home health: Low --  Multidisc. In/outpt prog: High	+	++	+		+			++		+++	+ (Endurance)
Acute MI	--  Acute hospitals: High --  Outpatient rehab.: High	++	+++			+++	+	++	++		++	++ (Re-infarct, endurance)
COPD	--  Acute hospitals: High --  Rehabilitation hospitals: Low --  SNFs: Low --  Home health: Low --  Outpatient & in-home rehab.: High	++	+	+		+++	+	++	++	+	+	+++ (Endurance)
Back & Neck Procedures	--  Acute hospitals: High	+++				++	+++		+	++	++	+ (Medication intake, re-operation)
Ventilator	--  Hospital units: High --  Home health: Low --  Long term hospitals: Low	+++	++		+++	+		++			++	++ (Home oxygen, vent. Type, d/c status, post d/c caregiver)
Only settings for which outcomes research was available are listed. We found no outcomes studies in unlisted settings. +++ Outcome domain included in almost all studies; ++ Outcome domain included in several studies; + Outcome domain included in one or two studies; Blank - Outcome domain never included in studies.

TABLE 2b: Specific Measures Included in Each Outcome Domain

Function Ambulation Walking distance Neurological function Employment status Sickness Impact Profile Roland Score SF-36 score Barthel index Rankin scores Return to usual activities NYHA functional class Exercise capacity Self-rated functional independence Self-rated activity compared to premorbid Lumbar movement Tendon reflex Limp Straight leg raising Return to work Recovery of function in ADL/IADL RUGS III dependence index Functional Independence Measure (FIM) Mortality Mortality rate 90 day survival rate without re-hospitalization Length of survival after hospital admission Length of survival after hospital discharge Return to Community Independence from mechanical ventilation Length of ventilator episode Physiology Blood gas Pulmonary function tests Morbid complications X-ray resolution Cardiac function measures In-hospital complications Post-operative complications Other Endurance Re-infarct rate Motor assessments Re-operation Medication intake Home oxygen Ventilator type Discharge status Post-discharge caregiver Need for home assistance

Symptom Resolution Pain Pain relief Pulmonary distress/dyspnea Sciatia/stenosis Frequency Index Neurological symptoms (pain, sensation, weakness) Psychological Anxiety Stress Caregiver stress Depression Beck Depression Inventory Mood Adjective Check List Hospital Anxiety and Depression Scale SF-36 Social support Caregiver burden Quality of Life Chronic Heart Failure Questionnaire Minnesota Living with Heart Failure Questionnaire Rosser QOL Index Time trade-off Chronic Respiratory Disease Questionnaire Satisfaction Patient satisfaction with care Rating of whether surgery was worthwhile Utilization Outcomes Cumulative hospital days Cost Re-hospitalization Mean length of stay Subsequent hospital days Discharge to nursing home Extended care facility days Home nursing services Length of stay (LOS) in hospital LOS in VDU Expenditure measures Discharge destination

TABLE 3: Application of the Four Major Selection Criteria to the Eight Conditions
	Setting	Chronic vs. Acute	Outcome Domains	Service Quartiles
				PT	OT	ST	RT	IV
Hip Fracture	R, S, H, L	A	F/C/M/U	Q1	Q1	Q3	Q4	Q4
Stroke	R, S, H, L	A	F/M/C/Ps/QL/U	Q2	Q1	Q1	Q3	Q3
Pneumonia	S, H	A	M/Ph/F/S	Q3	Q3	Q3	Q2	Q1
CHF	S, H	C	UM/QL/F/C/Ph	Q3	Q3	Q3	Q3	Q2
Acute MI	S, H	A	M/Ph/U/F/Ps/QL/S	Q3	Q3	Q3	Q3	Q4
COPD	S, H	C	Ph/F/QL/Ps/M/C/S/Sa/U	Q3	Q3	Q3	Q2	Q2
Back & Neck Procedures	R, S, H	C	F/S/U/Sa/Ph/QL	Q1	Q1	Q3	Q4	Q3
Ventilator	S, H, L	AC	F/W/M/Ps/U/Ph	Q2	Q2	Q1	Q1	Q1

TABLE 4: Classification of the Eight Conditions Based on the Four Major Selection Criteria
	Setting	Chronic vs. Acute	Outcome Domains	Services
Hip Fracture	A	A	A	A
Stroke	A	A	A	A+
Pneumonia	B	A	B	B
CHF	B	C	C	C
Acute MI	B	A	C	C
COPD	B	C	C	B
Back & Neck Procedures	A+	C	D	A
Ventilator	C	AC	E	D
A+ = Similar to Category A, with one anomaly.

APPENDIX

HIP FRACTURE
Source	Treatment Settings	Services Received	Outcome Measures
Kramer et al. Outcomes and costs after hip fracture and stroke. JAMA 1997;277:5:396-404.	Inpt. rehab. hosp. Skilled nursing facility (subacute and traditional)	Physical therapy Occupational therapy Recreational therapy Social work Physician	Return to community at 3 and 6 months Functional recovery in bathing, dressing, toileting, transferring and walking 20 feet Mortality
Kane et al. Do rehabilitative nursing homes improve the outcomes of care. JAGS 1996;44:545-554.	Rehab. facilities Rehab. NHS NHS		ADL/IADL dependency scale at discharge, 6 weeks, 6 months and 12 months
Kennie et al. Effectiveness of geriatric rehabilitative care after fFractures of the proximal femur in elderly Women. BMJ 1988; 297:1083.	Acute hospital ward Rehab. ward	PT/OT Geriatrician as well in rehab. ward	Katz ADL Index Discharge to nursing home
Zuckerman et al. hip fractures in geriatric patients: results of an interdisciplinary hospital care program. Clinical Orthopeadics 1992; 274:213.	Interdisciplinary unit Acute orthopedic unit	Geriatrician PT 2x/day OT Nutrition Social work Case manager f/u	Discharge home Ambulatory status 4 levels Ambulatory distance
Koval KJ, et al. Effect of acute inpatient rehabilitation on outcome after fracture of the femoral neck or intertrochanteric fracture. Journal of Bone and Joint Surgery 1998;80-A(3):357-64.	Inpt. rehab. program	Physical therapy Occupational therapy Education	Hospital discharge status Mortality rate Place of residence Walking ability Need for home assistance Independence in ADL/IADL
Munin, MC et al. Early inpatient rehabilitation after elective hip and knee arthorplasty. JAMA 1998;279(11):847-52	Inpt. rehab program		Length of stay Functional Independence Measure SF-36 Cost

STROKE
Source	Treatment Settings	Services Received	Outcome Measures
Kramer et al. Outcomes and costs after hip fracture and stroke. JAMA 1997;277:5:396-404.	Inpt. rehab. hosp. Skilled nursing facility (subacute and traditional)	Physical therapy Occupational therapy Recreational therapy Social work Physician	Return to community at 3 and 6 months Functional recovery in bathing, dressing, toileting, transferring and walking 20 feet Mortality
Kane et al. Do rehabilitative nursing homes improve the outcomes of care. JAGS 1996;44:545-554.	Rehab. facilities Rehab. NHS NHS		ADL/IADL dependency scale at discharge, 6 weeks, 6 months and 12 months
Young & Forster. The Bradford community stroke trial: results at 6 months. BMJ 1992;304:1085-9.	Home care Day hospital	15 visits total: 6.5 hrs PT, 10.0 hrs OT 31 visits total: 15.0 hrs PT, 15.0 hrs OT	Barthel Index Motor Club Assessment Frechay Activities Index Ambulation Nottingham Health Profile -- extended activity Caregiver stress: General Health Questionnaire All at 6 months
Keith et al. Acute and subacute rehabilitation for stroke: a comparison. Arch Phys Med & Rehab 1995;76:495-500.	Rehab. facility Subacute SNF	4.2 hrs billed/day: 1.7 PT, 1.6 OT, .95 2.7 hrs billed/day: .9 PT, .9 OT, .95	FIM change during stay Community discharge
Retchin et al. Outcomes for stroke patients in Medicare fee for service and managed care. JAMA 1997;278(2):119-24.	Acute hospital		Survival rates Discharge destination
Stineman, MG et al. Functional task benchmarks for stroke rehabilitation. Arch Phys Med & Rehab 1998;79(5):497-504.	Rehab. facility		Functional Independence Measure (FIM)

PNEUMONIA
Source	Treatment Settings	Services Received	Outcome Measures
Fine, MJ, et al. Prognosis and outcomes of patients with community-acquired pneumonia. JAMA 1996;274:134-141.	Hospital		Mortality Morbid complications Symptom resolution 6 mon-5yr Return to work/usual activities Functional status
Metlay et al. Measuring symptomatic and functional recovery in patients with community acquired pneumonia. JGIM 1997;12:423-430.	Outpatient		Symptom resolution 7, 30, 90 days after onset MOS SF-36 Pneumonia related outpatient visits in first 90 days
Williams et al. Reducing costs and hospital stay for pneumonia with intravenous cefotaxime treatment: results with a computerized ambulatory drug delivery system. Amer J Med 1994;97:50-55.	Home care		Length of hospital stay Cost Adverse events
Meehan TP, et al. Quality of care process, and outcomes in elderly patients with pneumonia. JAMA 1997;278:2080-2084.	Hospital		Mortality associated with care processes: O2 saturation measurement, blood cultures, time to antibiotics
Ortqvist, A, et al. Aetiology, Outcome and prognostic factors in community-acquired pneumonia requiring hospitalization. Eur Resp J 1990;3:1105-1113.	Hospital Outpatient follow-up		Mortality Morbid complications LOS Return to normal activities 8 weeks after onset Radiographic resolution

CHF
Source	Treatment Settings	Services Received	Outcome Measures
Rich, MW, et al. Prevention of readmission in elderly patients with congestive heart failure. JGIM 1993;8:585-590.	Acute care hospital Home care Outpatient clinic	Education Medication review Diet assessment Outpatient follow-up	Rehospitalization in 90 days Cumulative hospital days in 90 days
Kornowski, R, et al. Intensive home-care surveillance prevents hospitalization and improves morbidity rates among elderly patients with severe congestive heart failure. Am Heart J 1995;129:762-6.	Home care (RN and MD)	Weekly visit PE Medication review IV drugs as needed Lab tests PT as needed O2 as needed	Hospitalizations/year Hospitalizations (cardiac) Hospital days/year “Global functional status” (1-4 rating scale: 1=confined to bed, 2=assist with daily activities, 3=housebound but no assist, 4=independent with daily activities)
Rich, MW, et al. A multidisciplinary intervention to prevent readmission of elderly patients with congestive heart failure. N Engl J Med 1995;333(18):1213-4.	Acute care hospital Home care Outpatient clinic	Education Dietary instruction Social service evaluation Medication evaluation	Quality of life (Chronic Heart Failure Questionnaire) Cost Rehospitalization in 90 days Cumulative hospital days
Dennis, LI, et al. The relationship between hospital readmissions of Medicare beneficiaries with chronic illness and home care nursing interventions. Home Healthcare Nurse 1996;14:303-8.	Home care services	Assess symptoms and PE Education	Hospital readmissions/# of home care nurse visits
Harjai, KJ, et al. Home inotropic therapy in advanced heart failure. Chest 1997;112:1298-1303.	Home care	Home IV dobutamine, milrinone, dopamine, or combination	Cost Hospital readmission Hospital days NYHA functional class
Kane et al. A study of Post-Acute Care. 1994. Institute for Health Services Research.	Home health Skilled nursing facility		Mortality Function (weighted ADL/IADL score) Rehospitalization Cost Symptoms Caregiver burden Return to community
Hanumanthus, S, et al. Effect of a heart failure program on hospitalization frequency and exercise tolerance. Circulation 1997;96:2842-48.	Heart failure clinic Home care (10% of patients)		Use of CHF medications (ACE inhibitors, loop diuretics, Digoxin) Hospitalization frequency Exercise capacity (treadmill) Quality of life (Minnesota Living with Heart Failure Questionnaire)

ACUTE MI
Source	Treatment Settings	Services Received	Outcome Measures
Leitch, JW, et al. Randomized trial of a hospital-based exercise training program after acute myocardial infarction: Cardiac autonomic effects. Journal of the American College of Cardiology 1997;29(6):1263-8.	Hospital-based outpatient cardiac rehab vs. Home walking program	6 week exercise program. Both groups told to follow unsupervised home walking program. Outpatient: To hospital 3-4x/wk for exercise lasting 30-60 mins & supervised by clinical nurse specialist and physiotherapist. Home: 5 to 30 mins walking 2x/day unsupervised.	Change in begin to end of rehab: Baroreflex sensitivity Heart rate variability Oxygen consumption Endurance capacity
Dressendorfer, RH, et al. Exercise training frequency in early post-infarction cardiac rehabilitation. Journal of Cardiopulmonary Rehabilitation 1995;15(4):269-76.	Hospital-based outpatient cardiac rehab	5 week monitored exercise program, beginning 4 weeks after MI. Moderate intensity phase II exercise sessions 1 vs 2 vs 3 x/wk.	Change in begin to end of rehab: Treadmill duration VO2 max HR, BP Perceived exertion
Dubach, P et al. Effect of exercise training on myocardial remodeling in patients with reduced left ventricular function after myocardial infarction. Circulation 1997. 95(8):2060-7.	Residential rehab center (Switzerland)	8 week residential program of patient education, exercise, low-fat meals. Two 1hr walking sessions daily, accompanied by a physician with emergency equipment. Monitored cycling exercise 4x/wk.	Change in begin to end of rehab: HR, BP Oxygen consumption Perceived exertion Exercise duration Ventricular mass, volume Ejection fraction Myocardial wall thickness
Gulanick, M. Is phase 2 cardiac rehabilitation necessary for early recovery of patients with cardiac disease? A randomized, controlled study. Heart & Lung 1991;20(1):9-15.	Hospital-based outpatient cardiac rehab (exercise+ teaching , teaching only) vs Home walking program	5 week program, beginning 4 weeks after MI. All patients had already participated in inpatient cardiac rehab. Exercise: 15 supervised exercise sessions 30 mins each. Teaching: 2 30 min sessions + video re exercise techniques.	Change in begin to end of rehab in self-efficacy and performance scales for: Walking Climbing stairs Lifting objects Household chores Social visits Sexual activity Driving/Transportation
DeBusk, RF, et al. Medically directed at home rehabilitation soon after clinically uncomplicated acute myocardial infarction: A new model for patient care. American Journal of Cardiology 1985;55(4):251-7.        - AND - Miller, NH, et al. Home versus group exercise training for increasing functional capacity after myocardial infarction. Circulation 1984;70(4):645-9.	Outpatient vs Home cardiac rehab	Begin 3 weeks after MI. Rehab program lasts 8 weeks or 23 weeks, in home or as outpatient (4 groups total). Home: 30 mins 5 days/wk. Nurse-monitored 1-minute EKG via phone line 2x/wk. Outpatient: Supervised by nurse or nurse and physician. 1hr training 3x/wk.	Change baseline to 8 wks, and 8 wks to 23 wks: Functional capacity (peak treadmill workload, in METs) Re-infarction rate Mortality
Trzcieniecka-Green, A, et al. Stress management in cardiac patients; A preliminary study of the predictors of improvement in quality of life. Journal of Psychosomatic Research 1994;38(4):267-80.	Outpatient and Home	12 week stress management program. 12 sessions with clinical research psychologist covering relaxation training, education of effect of stress on health, counseling re uncertainties of recovery. Also home relaxation tape 2x/day.	Change in begin rehab vs end rehab (12 wks) vs 6mo followup: Hospital Anxiety & Depression Scale Psychological General Well-Being Schedule Social Support Questionnaire Functional Status Questionnaire (ADL, social, sexual, satisfaction) Spouse’s rating of pt’s psych state Chest pain 16 Personality Factor Questionnaire
Oldridge, N, et al. Effects on quality of life with comprehensive rehabilitation after acute myocardial infarction. American Journal of Cardiology 1991;67(13):1084-9.	Outpatient cardiac rehab	8 week cardiac rehab program. Exercise: 1hr 2x/wk supervised by cardiologist and exercise specialist. Psych: 1½ hrs 1x/wk group counseling + ½ hr relaxation training.	Change in baseline to 8 wks, 4 mos, 8 mos, and 12 mos: Quality of Life After AMI Questionnaire (symptoms, restrictions, emotional function, confidence, self-esteem) Time trade-off Quality of Well-Being Questionnaire (symptoms, mobility, physical activity, social activity) Exercise tolerance Anxiety Depression Return to work
Hamalainen, H, et al. Reduction in sudden deaths and coronary mortality in myocardial infarction patients after rehabilitation. European Heart Journal 1995;16(12):1839-44.	Outpatient and Home cardiac rehab	3 year rehab program, run by multidisciplinary team of physicians, social worker, psychologist, dietitian, physiotherapist. Exercise, anti-smoking and dietary counseling, psycho-social counseling. Visit to physician 1x/mo for 18mos, 3x/yr after that.	3, 6, 10, 15 year followup of: Total mortality Coronary mortality Cancer mortality

COPD
Source	Treatment Settings	Services Received	Outcome Measures
Strijbos, JH, et al. A comparison between an outpatient hospital-based pulmonary rehabilitation program and a home-care pulmonary rehabilitation program in patients with COPD. Chest 1996;109(2):366-72.	Hospital-based outpatient rehab vs Home rehab program	12 week program of patient education, breathing & relaxation exercises, bronchial hygiene, exercise reconditioning. Both groups told to continue exercise at home unsupervised. Outpatient rehab: To hospital 2x/wk for 1hr therapy, 3 hrs total education, 3 physician visits. Home rehab: Exercise led by physiotherapist 24x for 30 mins each. Pts told to exercise 30 mins on their own at home. 3 home health nurse visits, 3 physician visits.	Change in admit to 18mo followup: Lung function Cycle ergometer test 4 minute walking test General well-being
Wijkstra, PJ, et al. Effects of home rehabilitation on physical performance in patients with chronic obstructive pulmonary disease (COPD). European Respiratory Journal 1996;9(1):104-10.        - AND - Wijkstra, PJ, et al. Quality of life in patients with chronic obstructive pulmonary disease improves after rehabilitation at home. European Respiratory Journal 1994;7:269-73.	Home rehab program	12 week home rehab program managed by multidisciplinary team (MDT): pulmonologist, physiotherapist, nurse, general practitioner. Patient performed in-home daily inspiratory muscle training, upper limb training, exercise training, and every other day relaxation exercises, breathing retraining. Visit to physiotherapist 2x/wk. Monthly education visit from nurse; monthly clinical visit to general practitioner.	Change in baseline to 12 weeks : Spirometry Cycle ergometer test 6 minute walking distance Quality of life as measured by Chronic Respiratory Questionnaire(dyspnea, fatigue, emotion, mastery)
Votto, J, et al. Short-stay comprehensive inpatient pulmonary rehabilitation for advanced chronic obstructive pulmonary disease. Archives of Physical Medicine & Rehabilitation 1996;77(11):1115-8.	Inpatient rehab hospital	8 to 12 day inpatient rehab program managed by MDT: pulmonary physician, physiatrist, respiratory therapist, physical therapist, occupational therapist, nutritionist, rehab nurse, social worker, and therapeutic recreation specialist, with psych eval and therapy as needed. Instruction in compensatory breathing techniques. PT and OT 2 to 3 hours a day (gait & balance training, exercise, stair climbing). Supervised community outings. Instruction in ADLs wrt energy conservation. Home visit to assess safety. Medication adjustment.	Discharge status (O2 reqs and home vs ECF) Change in admit to discharge: 12 minute walking distance Pulmonary Functional Status Scale (function, dyspnea, and psychosocial status)
Niederman, MS, et al. Benefits of a multidisciplinary pulmonary rehabilitation program. Chest 1991;99(4):798-804.	Outpatient rehab	9 week outpatient rehab program. Sessions 3x/wk for 2½ hours of education and exercise. Education: support group, medications, diet, relaxation, stress management, breathing retraining. Exercise: Treadmill, weights, cycle ergometer, upper body.	Change in baseline to 9 weeks: Maximal exercise performance Exercise endurance Beck Depression Inventory COPD disability scale
Reardon, J, et al. The effect of comprehensive outpatient pulmonary rehabilitation on dyspnea. Chest 1994;195(4):1046-52.        - AND - Vale, F, et al. The long-term benefits of outpatient pulmonary rehabilitation on exercise endurance and quality of life. Chest 1993. 103(1):42-5.	Outpatient rehab	6 week outpatient rehab program of 12 3-hr sessions of education and exercise. Education: breathing retraining, work simplification, nutrition, medication, relaxation, stress management. Physical conditioning: light weights, treadmill, bicycle, stairs, upper extremity training.	Change in baseline to 6 weeks: Dyspnea Spirometry Exercise endurance Heart rate Change in baseline vs 6 weeks vs approx 12mo followup: 12 minute walking distance Quality of life as measured by Chronic Respiratory Questionnaire(dyspnea, fatigue, emotion, mastery
Kane et al. A study of post-acute care. 1994. Institute for Health Services Research.	Home health Skilled nursing facility		Mortality Function (weighted ADL/IADL score) Rehospitalization Cost Symptoms (pulmonary distress scale) Caregiver burden Return to community
Ketelaars, CAJ, et al. Long-term outcome of pulmonary rehabilitation in patients with COPD. Chest 1997;112(2):363-9.	Inpatient rehab hospital	10 to 12 week inpatient rehab program managed by MDT: chest physician, nurse, physical therapist, occupational therapist, dietitian, social worker, psychologist. Respiratory techniques, PT, exercise conditioning, psychosocial rehab, OT, pt/family education.	Change in admit to discharge, and discharge to 9mo followup: Health-related quality of life, as measured by the St. George’s Respiratory Questionnaire (symptoms, activities, impact), and well-being component of the Medical Psychological Questionnaire for Lung Diseases (psychological) COPD Coping Questionnaire Lung function measures 12 minute walking test

BACK & NECK PROCEDURES
Source	Treatment Settings	Services Received	Outcome Measures
Deyo, RA, et al. Lumbar spinal fusion: a cohort of complications, reoperations, and resource use in the medicare population. Spine 1993;18(11):1463-70.	Hospital unit		6 week postoperative mortality In-hospital complications Blood transfusion Discharged to nursing home Mean length of stay Mean hospital charges 4-yr. follow-up - Reoperation, Rehospitalization
Smith, EB, et al. Surgical results and complications in elderly patients with benign lesions of the spinal canal. JAGS 1992;40(9):867-70.	Hospital unit		"Long-term follow-up" - no time specified: Changes in neurological symptoms (pain, sensation, weakness) Changes in ADL Standardized scale obtained from consecutive outpatient visits, telephone interviews, or written responses Complications associated with spinal surgery Associated illness and postoperative complications
Hood, SA, et al. Lumbar spinal stenosis: surgical intervention for the older person. Israel Journal of Medical Sciences 1983;19:169-72.	Hospital unit		1.5-5 yr. follow-up (at 3 mo. intervals in yr. 1, 6 mo. intervals thereafter): Improved walking distance Partial pain relief Complete pain relief Rating of whether surgery was worthwhile Other measures (objective): Straight leg raising Limp Tendon reflex Lumbar movement Valleix & Valsava signs
Ciol, MA, et al. An assessment of surgery for spinal stenosis: time trends, geographic variations, complications, and reoperations. JAGS 1996;44:285-90.	Hospital unit		Postoperative mortality Postoperative complications Reoperation rate (one cohort at 7 years, another at 3 years)
North, RB, et al. Dorsal root ganglionectomy for failed back surgery syndrome: A 5-year follow-up study. J Neurosurg 1991;74:236-42.	Hospital unit		Follow-up at 6 wks, 6 mos, 2 yrs, 5.5 yr mean Pain relief Satisfaction with treatment "Success" = aggregate of 1 & 2 Secondary Measures Ability to perform everyday activities (ADLs) Medication intake Patients' subjective impressions of changes in neurological function (touch sensation, muscle strength, bladder/bowel control).
North, RB, et al. Failed back surgery syndrom: 5 year follow-up in 102 patients undergoing repeated operation. Neurosurgery 1991;28:685-91.	Hospital unit		Pain relief Satisfaction with treatment outcome "Success" = aggregate of pain relief and satis. Secondary Measures Ability to perform ADLs Neurological function (strength, sensation, bowel/bladder control) Medication intake Return to work
Deyo, RA, et al. Morbidity and mortality in association with operations on the lumbar spine. Journal of Bone & Joint Surgery 1992;74A(4):536-43.	Hospital unit		In hospital mortality Postoperative complications Rate of discharge to a nursing home Prolonged hospitalization (>10 days) Mean hospital charges
Katz, JN, et al. Lumbar laminectomy alone or with instrumented or noninstrumented arthrodesis in degenerative lumbar spinal stenosis. Spine 1997;22(10):1123-31.	Hospital unit		Follow-up at 6 months and 24 months: Global sickness impact profile (SIP) Walking capacity Back pain Leg Pain Satisfaction with surgery Rpeat operation within 24 months Resource use - costs, mean length of stay
Atlas, SJ, et al. The Maine lumbar spine study, part II: 1-year outcome of surgical and nonsurgical management of sciatica. Spine 1996;21(5):1777-86.	Hospital unit		1 Year follow-up: Symptoms: Low back pain Leg pain Change in predominant symptom Sciatica Frequency Index (symptom freq.) Functional status: Roland score, mean change (3,6,12 mos) SF-36 score, mean change (3,6,12 mos) Disability days in past month, mean change Improved quality of life Satisfaction: Overall results of treatment Spend rest of life like now, satisfied If surgery, still choose back operation, yes Employment & WC status: Employed after 1 year Receiving WC after 1 year
Atlas, SJ, et al. The Maine lumbar spine study, Part III: 1-year outcomes of surgical and nonsurgical managment of lumbar spinal stenosis. Spine 1996;21(15):1787-95.	Hospital unit		Same asPart II above, except: Stenosis Frequency Index (rather than sciatica) Does not include employment or WC info

VENTILATOR
Source	Treatment Settings	Services Received	Outcome Measures
Elpern, EH, et al. Long-term outcomes for elderly survivors of prolonged ventilator assistance. Chest 1989;96(5):1120-4.	Hospital unit		Postdischarge survival (0-12 mos, 13-24 mos, 25-36 mos, >36 mos) Subsequent hospital days Extended care facility days Home nursing services 3 year follow-up (self-rated functional independence)
McLean, RF, et al. Outcome of respiratory intensive care for the elderly. Critical Care Medicine 1985;13(8):625-9.	Hospital unit		12-24 month follow-up: Living at home Living in nursing home Inpatient in acute care hospital Self-rated activity compared to premorbid state Self-rating of quality of life
Gracey, DR, et al. Outcome of patients cared for in a ventilator-dependent unit in a general hospital. Chest 1995;107(2): 494-9.	Hospital unit		Discharge Location: Home - Directly home - Physicial medicine and rehabilitation then home - Other hospital unit then home Nursing home (off ventilator) Hospital near home then home Hospital near home then nursing home (off ventilator) Liberation from ventilator Post-discharge survival
Gracey, DR, et al. Outcomes of patients admitted to a chronic ventilator-dependent unit in an acute-care hospital. Mayo Clinic Proceedings 1992;67(2):131-6.	Hospital unit		No mechanical ventilation Home mechanical ventilation (nocturnal) Home oxygen Died in hospital
Make, B, et al. Rehabilitation of ventilator-dependent subjects with lung diseases: the concept and the initial experience. Chest 1984;86(3):358-65.	Hospital unit	Rehabilitation care Physical therapy Occupational therapy Respiratory therapy Discharge planning, including assistance with arranging home health aids, visiting nurses, etc.	Number of hours of free time from mechanical assistance (upon discharge from resp. care ctr.) Independence in ADL (upon discharge) Location after discharge from Respiratory Care Center Mortality
Swinburne, A, et al. Respiratory failure in the elderly: analysis of outcome after treatment with mechanical ventilation. Arch Inter Med 1993;153:1657-62.	Hospital unit		Survival to discharge Survival after discharge
Pehrsson, K, et al. Quality of life of patients treated by home mechanical ventilation due to restrictive ventilatory disorders. Respiratory Medicine 1994;88:21-26.	Home mechanical ventilation		Sickness Impact Profile (SIP) - overall health status Mood Adjective Check List (MACL) - emotional status and mental well-being Hospital Anxiety and Depression Scale - psych. morbidity Study-specific questionnaire - effects of HMV and "on-treatment" problems (problems with vent., sleep problems, social life) Blood gas values
Muir, J, et al. Survival and long-term follow-up of tracheostomized patients with COPD treated by home mechanical ventilation: A multicenter French study. Chest 1994;106(1):201-9.	Home mechanical ventilation		ABG - Arterial Blood Gas PFT - Pulmonary Functional Test Survival - 18 months-2 years, 3 years, 5 years, 7 years, 10 years
Kopacz, MA, et al. Multidisciplinary approach for the patient on a home ventilator. Heart & Lung 1984;13(3):255-62.	Home mechanical ventilation		1-41 month follow-up Number of repeat hospitalizations Length of stay (of repeat hosp.) Complications
Steiner, T, et al. Prognosis of stroke patients requiring mechanical ventilation in a neurological critical care unit. Stroke 1997;28(4):711-15.	Hospital unit		Survival at one year Barthel Index (at least 12-month follow-up, up to 3 years) Rankin Scores (at least 12-month follow-up, up to 3 years)
Stapleton, DC, et al. Ventilator dependent unit demonstration: outcome evaluation and assessment of post acute care. 1996. Report prepared for Office of Research and Demonstrations, Health Care Financing Administration.	Ventilator dependent unit (VDU)		Length of stay (LOS) in hospital LOS in VDU Length of ventilator episode Length of survival after hospital admission Length of survival after hospital discharge Discharge status Ventilator type Discharge destination Post-discharge caregiver ADLs RUGS III dependence index Expenditure measures

APPENDIX B. Members of First Expert Panel

Members of First Expert Panel
Steven J. Atlas, MD, MPH (Back & neck panel only) Instructor in Medicine Massachusetts General Hospital Boston, Massachusetts	Carole Lewis, PT, GCS, MSG, MPH, PhD President, Physical Therapy Services of Washington, D.C. Adjunct Professor George Washington University Bethesda, Maryland
Joanne Cassidy, MEd, OTR/L National Director of Product Development NovaCare, Inc. Contract Rehabilitation Division King of Prussia, Pennsylvania	Wayne McCormick, MD, MPH Associate Professor of Medicine Medical Director Visiting Nurses of King County Director, University of Washington Long Term Care Service Seattle, Washington
Leora Cherney, PhD, MA, CCC-SLP, BC-NCD (Stroke panel only) Clinical Educator/Researcher Center for Clinical Excellence Rehabilitation Institute of Chicago Associate Professor Physical Medicine and Rehabilitation Northwestern University Medical School Chicago, Illinois	Deborah McCoy, RN, BS Charge Nurse, Subacute Unit Lifecare Center of Evergreen Evergreen, Colorado
Lisa Farrell-Roberts, RN, MN Assessor and Clinician Rehabilitation Without Walls Mountlake Terrace, Washington	Michael W. Rich, MD (CHF panel only) Director, Geriatric Cardiology Director, Cardiac Rapid Evaluation Unit Barnes-Jewish Hospital St. Louis, Missouri
Michael J. Fine, MD (Pneumonia panel only) Associate Professor of Medicine University of Pittsburgh Montefiore University Hospital Pittsburgh, Pennsylvania	Hilary Siebens, MD Associate Director Physical Medicine and Rehabilitation Service Massachusetts General Hospital Spalding Rehabilitation Hospital Boston, Massachusetts
Silvia M. Koerner, MS, BS Director of Quality Management Services Visiting Nursing Service of New York Glendale, New York	Mark Snowden, MD Assistant Professor of Psychiatry Harborview Medical Center Seattle, Washington

APPENDIX C. Sample Rating Form (Back & Neck Condition)

Table of Contents

Physical Function Outcomes

Mental Health Outcomes

Quality of Life Outcomes

Utilization Outcomes

Physiology Outcomes

Satisfaction Outcomes

Process

Notes

Outcome indicators refer to change (e.g., decline, improvement, recovery) in the item listed.

Indicator Rating Scale:
     0 = negligible value
     1 = definite value
     2 = extremely important for measuring quality of care

Measure Rating:
     R = recommend
     NR = not recommend
     Blank = not familiar

Physical Function Outcomes
Rating	Indicator	Rating	Measure
	General/Global Function
			Patient Questionnaire for Lumbar Spinal Stenosis
			Oswestry Low Back Pain Disability Questionnaire
			Functional Rating Scale (FRS)
			Low Back Pain Rating Scale (RS)
			Roland and Morris Disability Questionnaire
			Quebec Back Pain Disability Scale
			SF-36
			Sickness Impact Profile
			Functional Independence Measure (FIM)
			Restricted Activity Days
			Bed Days
			Nottingham Health Profile
			Duke Health Profile
			Million Instrument
	Self Care
			Oswestry Low Back Pain Disability Questionnaire
			Neck Disability Index (revised form of Oswestry)
			Dallas Pain Questionnaire (DPQ)
			Functional Rating Scale (FRS)
			Revised Oswestry Disability Index
			Revised Oswestry Pain Questionnaire
			Northwick Park Neck Pain Questionnaire
			Million Instrument
			Functional Status Questionnaire (Jette)
			6 Item Activities of Daily Living (ADL) (Katz)
			Weighted 7 Item ADL (Kane)
			5 Item ADL Recovery (Kramer)
			Bristol ADL (for persons with dementia) Barthel Index
			Lawton Instrumental Activities of Daily Living (IADLs)
			OARS (Older American Resources and Services) Multidemensional
			Physical Performance Test (Reuben)
	Ambulation/Mobility
			Limp
			Walking
			Discharge with assistive devices for ambulation
			Oswestry Low Back Pain Disability Questionnaire
			Gait speed
			Walking distance
			Tinetti Gait and Balance

Mental Health Outcomes
Rating	Indicator	Rating	Measure
	Anxiety-Depression		Dallas Pain Questionnaire (DPQ)
	Depression
			Geriatric Depression Scale (GDS)
			DSM IV
			CES-D
			HAM-D
			Life Satisfaction Index K
			Zung Self-Rating Depression Scale
	Cognition
			MMSE
			Short Portable (Pfiefer)
			Blessed Dementia Scale
			Abbreviated Mental Test
			Clock Drawing Test
			Neuropsychological Testing
	Delirium
	Anxiety
			DSM IV
	Patient Motivation

Quality of Life Outcomes
Rating	Indicator	Rating	Measure
	Social Life		Oswestry Low Back Pain Disability Questionnaire
	Social Interest		Dallas Pain Questionnaire (DPQ)
	Travel		Oswestry Low Back Pain Disability Questionnaire
	Work Activities		Dallas Pain Questionnaire (DPQ), Functional Rating Scale (FRS)
	Leisure Activities		Dallas Pain Questionnaire (DPQ)
	Time Spent in Bed		Functional Rating Scale (FRS)
	Health-Related Quality of Life
			SF-36 (mental health score)
			Sickness Impact Profile (SIP)
			Quality of Well-Being Scale (QWB)
			Reintegration to Normal Living Scale
	Self-Perceived Ability to Participate in Social/Recreational Activities
			Activity Pattern Indicator
	Subjective Well-Being
	Days of Work Absenteeism
			Health Interview Survey Items
	Days in Bed
			Health Interview Survey Items
	Days of Limited Activity
			Health Interview Survey Items
	Work Status
			NASS Questionnaire
	Compensation Status
			NASS Questionnaire
	Job Description
			NASS Questionnaire
	Vocational Outcomes
	Social Function
			Sickness Impact Profile (SIP)
			Oswestry Disability Questionnaire
			Nottingham Health Profile
	Household Activities
			Sickness Impact Profile (SIP)
	Recreation
			Sickness Impact Profile (SIP)
	Living Situation

Utilization Outcomes
Rating	Indicator	Rating	Measure
	Repeat Spinal Surgery
	Hospitalization
			Hospitalized in Fixed Time Period
			Number of Hospitalizations in Fixed Time Period
			Total Hospital Days in Fixed Time Period
			Average Length of Stay of Hospitalizations Occurring within Fixed Time Period
			Length of Stay >10 days
			Total Hospital Cost/Charges in Fixed Time Period
			Days Until Hospitalized
			Hospitalized for Same Condition
			Hospitalized for New Condition
	Admission to ICU
	Emergency Room Admission
			ER Admission in Fixed Time Period
			Total ER Admissions in Fixed Time Period
			Total ER Cost/Charges in Fixed Time Period
			Days Until ER Admission
	Rehabilitation Facility Admission
			Admission to RF in Fixed Time Period
			Number of RF Admissions in Fixed Time Period
			Total RF Days in Fixed Time Period
			Average Length of Stay of RF Admissions Occurring within Fixed Time Period
			Total RF Cost/Charges in Fixed Time Period
			Days Until RF Admission
	Skilled Nursing Facility Admission
			Admission to SNF in Fixed Time Period
			Number of SNF Admissions in Fixed Time Period
			Total SNF Days in Fixed Time Period
			Average Length of Stay of SNF Admissions Occurring within Fixed Time Period
			Total SNF Cost/Charges in Fixed Time Period
			Days Until SNF Admission
	Home Health Care Use
			Use of Home Health Aide
			Use of Home Health Nurse
			Number of Home Health Aide Visits in Fixed Time Period
			Number of Home Health Nurse Visits in Fixed Time Period
			Total Home Health Aide+Nurse Cost/ Charges in Fixed Time Period
	Total Combined PAC
			Total Days in PAC in Fixed Time Period
			Number of PAC Settings in Fixed Time Period
			Number of PAC Admissions in Fixed Time Period
			Average Length of Stay of PAC Admissions in Fixed Time Period
			Total PAC Cost/Charges in Fixed Time Period
	Level of Care Provided
			Admission to Long Term Care (NH)
			Days Until NH Placement
			Transferred from RF to SNF
			Transferred from RF to HH
			Transferred from SNF to HH
			Transferred from HH to SNF
	Use of Home-Delivered Meals (Meals-on-Wheels)
	Amount and Intensity of Care Provided		TISS (Therapeutic Intervention Scoring System)

Physiology Outcomes
Rating	Indicator	Rating	Measure
			Blood Transfusion Rate
			Straight Leg Raising
			Tendon Reflex
			Lumbar Movement
	Symptom Severity		Patient Questionnaire for Lumbar Spinal Stenosis
	Pain Intensity
			Oswestry Low Back Pain Disability Questionnaire
			Low Back Pain Rating Scale (RS)
			Revised Oswestry Pain Questionnaire
			Revised Oswestry Disability Index
			NASS Questionnaire
	Pain
			Patient Pain Scale 1-10
			Dallas Pain Score
			Chronic Pain Grade (VonKorff)
			Visual Analog Scale
			Hospice QI
			Pain and Impairment Relationship Scale (PAIRS)
			Pain Disability Index
			Functional Interference Estimate
			McGill Pain Questionnaire
			The Modified Somatic Perception Questionnaire (MSPQ)
	Fatigue
	Nausea
	Vomiting
	Dyspnea
	Cough
	Sensory Changes
	Urinary Incontinence
	Fecal Incontinence
	Anorexia, Diminished Appetite
	Sleep Disorder
	Chest Pain
	Sputum Production
	Heart Rate
	Respiratory Rate
	Blood Pressure
	Oxygenation
	Deep Venous Thrombosis
	Pulmonary Embolism
	Aspiration Pneumonia
	Pressure Sores
	Flexion Contractures
	Dehydration
	Falls
	Falls with Injury
	Constipation
	Fecal Impaction
	Electrolyte Complications
	Adverse Drug Reactions
	Wound Infections
	Nosocomial Infections
	Rash
	Renal Failure
	Hepatic Function Abnormalities
	Pleural Effusion
	Urinary Retention
	Clostridium Difficile Infection
	Malnutrition
	Mortality

Satisfaction Outcomes
Rating	Indicator	Rating	Measure
	Patient Satisfaction		Patient Questionnaire for Lumbar Spinal Stenosis
			Satisfaction with Results of Surgery
			Satisfaction with Treatment Outcome
			Would Go Through Operation Again for the Same Result
			Would Still Choose Back Operation
			Surgery was Worthwhile
			Would be Satisfied to Spend Rest of Life Like Now
	Patient Satisfaction
			MOS Items
			Nursing Home Resident Satisfaction Scale
	Caregiver Satisfaction
			Family Assessment Device

Process
Rating	Indicator	Rating	Measure
	Use of Prescription Analgesic Medications		Functional Rating Scale (FRS)
	Transcutaneous Electrical Nerve Stimulator (TNS) Usage		Functional Rating Scale (FRS)
	Neurological Checks
	Depression Treatment
			Anti-Depressants
			Psychotherapy
	Patient Education
	Family Education
	Caregiver Education
	Integrated, Multidisciplinary Care Program
	Time to Nurse or Physician Follow-up After Hospital Discharge
	Discussion of Advance Care Directives
	Persistence of Urinary Catheter
	Immunization Status
	Monitoring Drug Therapy
	Dietician Evaluation
	Sedative Hypnotic Use
	Antipsychotic Drug Use

APPENDIX D. Notes From First Expert Panel Meeting

Table of Contents

Clinical Panel Meeting Notes for Congestive Heart Failure

Clinical Panel Meeting Notes for Pneumonia

Clinical Panel Meeting Notes for Stroke

Clinical Panel Meeting Notes for Back & Neck

CLINICAL PANEL MEETING NOTES FOR CONGESTIVE HEART FAILURE

December 9, 1998

Indicators discussed:

• Physiology - Mortality
• Quality of life - Well-being
• Physical function - Exercise tolerance
• Utilization - Skilled nursing facility utilization
• Process - Medication compliance
• Mental health - Anxiety
• Additional indicators suggested by panelists

Measures were discussed for:

• Depression
• Patient satisfaction

A. Indicators

1. Physiology

Mortality
As an indicator, it is measurable and believed to be sensitive to quality of care processes (e.g., ACEI use). ACEI use alone is not a good indicator because its utility in diastolic heart failure, common in the elderly, is unclear. Death may not be an undesirable outcome in all circumstances, CHF may be a condition for which profound disability is rare such that patients might welcome death (compared with more disabling conditions or those causing greater suffering). However, assessment of patient goals, advance directives, will be necessary.

2. Quality of Life

Well-being
As an entity in itself, it’s difficult to measure. Validated measures of health related quality of life may be better. Unclear that a single question about subjective well-being is valid or responsive while health related quality of life measures have already been developed.

The indicator “well-being” was re-defined as “disease-specific quality of life” versus general health related quality of life.

3. Physical Function

Exercise Tolerance
As in indicator itself, it crosses over with many other physical function indicators. Since it other physical function measures really assess what people are able to do in their daily lives, exercise tolerance seems a narrow proxy for more important measures. Ambulation, for example, is probably a more meaningful indicator.

4. Utilization

Skilled Nursing Facility Utilization
This may be more a measure of severity of illness as well as lack of social supports, etc. rather than quality of care. However, number of admissions to SNF may be an important indicator, suggesting inadequate care in another setting (e.g., home health). For general utilization measures, hospitalization days was considered a very important indicator of quality in CHF -- and since some CHF acute care occurs in SNFs alone, a combined acute care utilization measure using total number of inpatient days may be useful. ER visits is unlikely to be a good utilization indicator, adding little to hospitalizations since the vast majority of patients visiting an ER with CHF are admitted. All in all, though, it is difficult to know if SNF admission is a good or bad outcome in CHF, so by itself it is not a very good quality indicator. If it is used as a measure, point of origin prior to admission would be important (e.g., home health to SNF).

A new indicator of utilization, total combined inpatient days in hospital and SNF, was added. The measures for SNF days were moved to the indicator list to represent individual quality indicators.

5. Process

Evaluation of Medication Compliance
Several panel members supported this indicator because medication compliance is known to directly affect outcomes like re-hospitalizations and long-term mortality. Several panel members felt it was important in the spectrum of patient education and self-efficacy. Some felt it was too process oriented and that functional outcomes were good enough -- patients who feel well and are functioning well is what matters, not whether they are taking their medications. All agreed that actual patient compliance is difficult to measure, but that measuring a PAC provider’s assessment of patient compliance may be possible, as well as measuring the provider’s provision of medication education. As part of this discussion, members felt that assessment of patients’ knowledge following provider education may be important. The cardiologist on the panel noted that his research group has developed a tool for assessing patient knowledge in CHF.

The indicator was redefined as evaluation of medication compliance: patient education and intervention to assist compliance. A new indicator, patient knowledge, was added.

6. Mental Health

Anxiety
Ambiguous indicator. Formal anxiety disorder, by DSM criteria, is probably rare and not an important indicator in this population. Less severe anxiety may be more common -- but the proper assessment of it and, more importantly, management of it are unknown. Such an indicator might suggest that more individuals should be treated for it, and that’s not at all clear. There is the Hamilton Anxiety scale, though it’s utility in this setting would be uncertain. Some members noted that good medical care of CHF and management of functional disabilities should lead to decreased patient anxiety.

B. Additional Indicators Suggested by Panelists

1. Quality of Life

Role Resumption
Many panelists commented that role resumption, with respect to social interactions, previous responsibilities e.g. as a caregiver, were very important to patients and may not be reflected by health related quality of life of physical function indicators. The Canadian Occupational Performance Measure was suggested as a possible tool to measure role resumption.

2. Process

Assessment of LV Function
Clinically important in CHF. An important care process in some settings, particularly outpatient management of CHF by primary care MDs. Unclear importance in PAC settings -- like vaccinations, PAC providers should assure that such assessment has occurred at some point and if not, provide assessment themselves.

Non-use of Calcium Channel Blockers
Easily measured. Inappropriate to use CaCh blockers in CHF across many studies yet still widely used.

Hypertension Control
Was not discussed by the panel but Michael Rich commented on the important of this as a quality indicator.

C. Measures

Depression
Widely considered a very important indicator by the panel, both the assessment for depression and appropriate treatment when identified -- although whether CHF outcomes improve with treatment of depression is unknown. Measures which can be used by non-mental health professionals are very appealing e.g. the GDS, also specifically developed for an elderly population. A mental health specialist must administer the HAM-D. The CES-D was developed for a younger, healthier population. The BECK counts physical symptoms, is longer than the GDS but would not be unreasonable. The DSM criteria may be too insensitive for depressive symptoms, which are also important in this population. The SKID, from the Diagnostic Interview Schedule is also a possibility and can be administered by telephone for potential follow-up after PAC or for home health patients.

Patient Satisfaction
Panel was unsure about how to measure it. The cardiologist was aware of two patient satisfaction questionnaires that have been used in CHF that we can consider -- though most panel members felt satisfaction was an area in which a general, non-condition specific measure would be appealing. Satisfaction may be difficult to measure because it’s difficult to assign the period/episode during which satisfaction is assessed. Does the episode include the hospitalization? Would different tools be necessary in different settings? A recent JAMA article assessing satisfaction following rehabilitation may be pertinent.

Patient satisfaction, as an indicator, was redefined as “satisfaction with care.”

CLINICAL PANEL MEETING NOTES FOR PNEUMONIA

December 10, 1998

The following indicators were discussed:

• Utilization - Physician visits for pneumonia
• Utilization- Home health care use
• Process - Immunization status
• Quality of life - Days in bed
• Mental health - Delirium
• Physiology - Duration of fever
• Physiology - Duration of fever and chest pain
• Physiology - Pleural exudate, abcess/empyema, pleural effusion
• Additional indicators suggested by panelists

Measures were discussed for:

• Health-related quality of life
• Symptoms

A. Indicators

1. Utilization

Physician Visits for Pneumonia
In and of itself, physician visits may not be a quality measure. Variation in physician visits may be due to practice patterns and differing facility requirements, rather than reflecting real differences in quality. It is also difficult to determine from a record review whether the physician visit was for pneumonia or for some other condition. Assuming that some physician contact is desirable, one may be able to define certain minimum standards of care that would vary by setting. Although there is currently no hard data to support any specific figures, one might propose the following:

Setting	Minimum Frequency of Physician Visits
Acute hospital	Once daily
SNF	Once weekly
Home	1 visit within 30 days of discharge home

We refined the definition of the indicator to be a process measure instead of a utilization measure.

Nursing Home Acquired Pneumonia
If we are measuring quality of care for all pneumonia patients, we can't exclude patients who develop pneumonia while being treated in a SNF. Since the diagnosis and treatment of NH-acquired pneumonia (NHAP) is different from community-acquired pneumonia (CAP), we will need to develop two sets of quality indicators for the two groups. For example, blood cultures, time to antibiotics, and oxygenation are important quality indicators for long-term NH patients, but not for more transient SNF or home health care patients. The same issue will have to be considered for patients who develop CHF or who suffer a stroke while in a SNF. Since an increasing number of patients with CAP are being treated in a SNF without a prior acute admission, we will actually need three sets of quality indicators: (1) for CAP patients with an acute hospitalization and SNF admission, (2) for CAP patients treated in a SNF without hospitalization, (3) for NHAP patients with an acute transfer and return. There may be some difficulty determining exactly when the pneumonia began. The standard measure is the detection of an acute pulmonary radiographic infiltrate, with an incubation period of 10 days during which symptoms (fever, etc.) may occur.

Home Health Care Use
Home health care use is usually seen as a resource outcome, and not a quality measure. For patients for whom home health care is appropriate, then receiving home health is an indicator of quality. If a patient is not a good candidate for home health care, then not receiving home health is an indicator of quality. If we assume that the distinction between the two types of patients is definable, then we can use the item as a quality measure.

We refined the definition of the indicator to be more of a process marker of "appropriate home health care use".

2. Process

Immunization Status
All agreed that pneumonia patients should receive a flu shot and a pneumo-vax. The discussion revolved around who should be responsible for providing it, and how to handle patients who had already received them prior to their pneumonia.

We refined the definition of the indicator to be a measure of "immunization status evaluation", where status is assessed and shots are given when appropriate.

3. Quality of Life

Days in Bed
Using retrospective recall during a patient interview ("In the last x days, how many days did you spend most of the day in bed?") may be difficult if the time period is too long. Experience has shown that the answers tend to cluster at 0-1-2, 7, 14, 21, etc. which results in the item being collapsed into categories. Days of limited activity may be a better measure because it includes days in bed. Perhaps a better measure would be to ask "When did you return to your usual household activities?" The COPM measure of role resumption gets at this, as well as an assessment of the patient's satisfaction with their level of ability. It has been validated in older individuals and takes about 30 minutes to administer.

We added a new quality of life indicator for return to usual activity, with a measure "days until".

4. Mental Health

Delirium
As a quality indicator, delirium itself may not be an appropriate measure. One could imagine a process indicator that rewards facilities for at least checking for delirium, though since the MDS requires an assessment there will be 100% compliance (even if the accuracy of the MDS assessment is in question). The MDS delirium item is considered inaccurate, though the MDS cognitive performance scale has been found to correlate well with the Folstein MMSE. Although an estimated 35% of older patients present with delirium upon acute admission, there are a number of issues with trying to measure it. It may be preferable to move away from delirium specifically and look at a more general cognitive assessment process measure. Since cognitive assessment is required, no one will admit that one has not been performed, and so we could consider testing the patients ourselves and comparing our results to the facility's results (i.e., if we find a cognitive problem but the facility says they did a cognitive assessment and found no problem, then there is a quality issue).

We added a new process indicator for cognitive assessment, and refined the definition of the delirium indicator to reflect change in delirium over time.

5. Physiology

Duration of Symptoms
Since symptoms will have differing times until resolutions and differing severities, each will have to be asked separately, and we will ask duration separately from severity. The key symptoms are cough, SOB, fatigue, and possibly sputum production. Chest pain is seen only in about 50% of pneumonia patients, and the prevalence and severity of chest pain decreases with increasing age. Again, it may be hard to tie symptoms and symptom severity to quality of care, or even to changes in treatment. For now, let's assume that being symptom-free is a preferable outcome regardless of whether or not the treatment itself alleviated the symptoms. An alternative measure could be "symptom-free at time x".

B. Additional Indicators Suggested by Panelists

1. Process

Time Until Begin Antibiotics
Some patients with advance directives may have specified that they do not want antibiotics. We will need to account for this when using this measure. The same will be true for mortality and hospitalization measures for patients with advance directives.

Advance Directive Discussion with Doctor
We want the indicator "advance directive discussion" to mean more than a simple box checked off at admission, and more than a simple DNR note.

We refined the definition of the indicator such that it must require a doctor's note in the chart that advance directives were discussed with patient.

Appropriate Antibiotic Use
This may be difficult to measure, particularly if the antibiotics for NHAP are different than those for CAP. There are published guidelines for these, however, and would not require determining etiology of infection.

Blood Cultures
JAMA article from last November showed that receiving a blood culture in 24 hrs prior to antibiotics was among 4 quality indicators that improved mortality at 30 days. Blood cultures aren't usually done in the SNF/NH setting because they are expensive (equivalent to one day of care), but if SNFs are substituting for hospital care, then they have to be held to the same standard. This indicator does not apply to home health care, however.

2. Physiology

Time to Reach Stability
For this indicator we really mean "stable at discharge" as a way to find problems with patients discharged too early to a non-institutional setting. We could define stable using JAMA article (Holm and others) criteria: systolic BP >100, pulse rate <100, respiratory rate <24, oxygenation >90%, return to baseline mental status. The criteria could be modified to better reflect an aged population. The probability of a patient being unstable at discharge is low because most pneumonia patients getting post-acute care are there because they are deconditioned. It may be more appropriate to measure "deconditioned at discharged".

We refined the definition of the indicator to reflect stability at discharge from SNF.

C. Measures

Health-Related Quality of Life
The SF-36 while common, does not apply to institutionalized patients very well (questions regarding vacuuming, golf), and some patients are offended by it. There is a shorter version, the SF-12. The SIP is a very good instrument, but is very long (136 questions). There is also a shorter version (68 questions). The QWB is 50 questions, self-report, and takes 12 minutes to administer. Other measures are the Life Satisfaction Index, and the Re-Integration with Normal Living Scale. The big problem with all these measures will be their applicability to a frail population.

Symptoms
Generally, these take the form "Do you have x - Yes/No", and if yes then apply a 5-point Likert scale for severity. There is usually a good distribution of responses on the scale. For patients who are cognitively impaired, a proxy report for yes/no is still OK but we might have to develop specific criteria to assess severity (e.g., SOB at rest, SOB while walking, SOB while going up stairs).

CLINICAL PANEL MEETING NOTES FOR STROKE

December 10, 1998

The following indicators were discussed:

• Quality of Life - Self perceived ability to participate in social/recreational activities
• Utilization - Level of care provided
• Physical Function - Gait and balance
• Mental Health - Patient motivation
• Process - PT/OT/ST evaluation
• Process - Stroke prevention
• Process - Driving evaluation
• Physical Function - Communication

Measures were discussed for:

• Self perceived ability to participate in social/recreational activities
• Level of care provided
• Gait and balance
• Communication

A. Indicators

1. Quality of Life

Self Perceived Ability to Participate in Social/Recreational Activities
Please also refer to the closely related discussion of role resumption under congestive heart failure. In general, the panel as a whole placed a moderate-to-high level of importance on this indicator, yet struggled initially to understand how it was similar to role resumption.

The panel identified the importance of further dissecting quality of life into social function, recreation/leisure and role resumption.

With regard to the latter, the main emphasis was on household tasks and caregiving roles rather than productive roles (i.e. employment), although it was recognized that many older adults continue to maintain a role in the workforce. Further, several members pointed out that there may be considerable overlap between household tasks and IADL indicators (such that household tasks should be grouped with function).

Self care was divided into ADLs and IADL/Household. Caregiver stress was added as a separate indicator. Self-perceived ability to participate in social/recreational activities was subsequently dropped as an indicator as its main construct was incorporated in other indicators.

There was strong support for patient-identified quality of life goals (and using such instruments as the Canadian Occupational Performance Measure). Yet for patients with stroke in particular, aphasia or neglect may influence self-perception and ability to formulate personalized goals. Additional measurement points concerned the limitations of using a proxy to measure personalized goals.

2. Utilization

Level of Care Provided
The discussion began with an overall recognition that the ability to determine that the level of care needed matched the level of care received is very important. However, it was also widely recognized that such algorithms do not exist. Practically, some delivery systems arbitrarily use a two-week time interval to evaluate response to therapy. The panel conveyed concern over the use of such time windows, particularly when the variation in individual recovery in stroke is often wide. Cost containment seems to pervade the decisions determining level of care. The panel seemed comfortable recommending that for any level of care, therapy should continue as long as the patient demonstrates improvement.

Nursing home residence was added as an indicator.

3. Physical Function

Gait and Balance
This discussion began attempting to disentangle Gait and Balance from mobility measures encompassed in the more global function and self-care measures (i.e., is this a separate construct from ambulation/mobility?). Some degree of redundancy was identified. In addition, several of the panel members pointed out that the ability to perform safe transfers was the most important factor determining return to home. Gait speed has also been correlated with safety.

As the conversation moved to focus more on mobility, there was some interest in dividing mobility into bed mobility, transfer mobility (sit to stand) and gait. Additional distinctions were made between home mobility and community ability (longer distances, use of bus or escalator).

The panel supported separate indicators: (1) Gait and Balance, (2) Mobility to include bed transfers and walking, and (3) Mobility to include community mobility.

4. Mental Health

Patient Motivation
This indicator was rated fairly highly as many of the panel members recognized its central role. Additional related constructs were discussed, including sense of self-efficacy, work ethic, and sense of optimism. Next there was interest on the perspective from which this indicator would be assessed -- patient, nurse or therapist. The role cognitive function, patient expectation and family support were identified as key factors that may influence motivation. In the particular case of stroke, neglect syndromes may also influence motivation and the deficit may not be perceived.

Concern was raised, however as to whether this would fit the criteria of a quality indicator. Namely, can external quality agencies hold institutions accountable for patient motivation? Patient rights would dictate that they have the right to refuse therapy.

The discussion shifted towards a related and more operational question: What should the evaluation of a patient not participating in therapy consist of? Initially, this might involve starting by talking with the patient to determine their reason(s) (and documenting the reasons). During this conversation, depression and neglect could be assessed. The second stage of the evaluation would consist of physician evaluation of the patient, not only to further elucidate the first stage but also to evaluate whether there were medical or psychiatric contributing factors. The third stage would involve convening a multidisciplinary team to formulate a customized plan that may or may not necessitate the involvement of a mental health professional.

5. Process

PT/OT/ST Evaluation
There was strong support for the addition of separate indicators for: (1) Physical Therapy Evaluation; (2) Occupational Therapy Evaluation; (3) Speech Therapy Evaluation.

In addition, the indicator for integrated, multidisciplinary care was changed to interdisciplinary conference.

Stroke Prevention
The Anticoagulation process measure was modified to encompass stroke prevention more broadly.

Driving Evaluation
The discussion for adding a process measure on driving evaluation was brief. This was categorized as a higher level of function -- community ability -- and would be targeted towards those who were ready for reintegration into the community (and who were driving prior to their stroke). There was support for including driving evaluation as a component of community mobility (see discussion above). It was recognized that this process measure would apply to a minority of patients (estimated at 10-15%).

6. Physical Function

Communication
The discussion of communication assessment quickly proceeded to measurement assessment as there was little disagreement as to the importance of the indicator and the time remaining was short.

B. Measures

Self Perceived Ability to Participate in Social/Recreational Activities
With regard to measures, the Nottingham Health Profile was not rated highly initially, yet this instrument has been used extensively in Britain and has been compared directly with the SF-36 in the setting of Stroke. It contains 45 questions and takes approximately 10 minutes to complete. There was interest in learning more about this instrument as it contains a number of the domains listed above. One identified limitation was that it places a large emphasis on distress, moreso than SIP or SF-36. The SIP has also been used in the setting of stroke and has been modified as such.

Level of Care Provided
With regard to measurement, one suggestion was made to measure days until long-stay nursing home placement. Alternatively, another measure might be number of days in an inpatient setting (hospital, SNF, rehabilitation facility) (where fewer is better). The measure would need to be designed to capture individual patients who were “bouncing back” or experiencing repeat admissions to SNF.

Yet another suggested measure was the number of days until the person returns home (which would include total number of days in rehab, and SNF). Such a measure might be problematic unless individuals who resided in a nursing home prior to their stroke could be readily accounted for.

A similar measure might be designed looking at total number of Medicare days (SNF, rehabilitation) or total number of inpatient days (Medicare days plus non-Medicare days to capture the long stay nursing home group).

Gait and Balance
In terms of measurement, there was a brief discussion of the use of self-report versus performance measures. Several members voiced that the Berg balance test was too lengthy, requiring 20 minutes whereas the Tinetti measure could be done in under 10 minutes. Apparently the Rivermead instrument has not been shown to be predictive of falls.

Communication
The CADL (Communication Abilities of Daily Living) has been validated on both left and right sided stroke. Administration time varies from 30-60 minutes. A short form has not been designed but it may be possible to abstract 1-2 subtests.

The Functional Communication Profile is an older measure that requires advanced training for scoring.

The ASHA Functional Communication Measure is new and validity and reliability studies have been conducted. It looks more closely at daily tasks and breaks down the communicative skills (e.g., going to a movie theater). At present there is only data for patients with aphasia and there is ongoing work on right hemisphere communication. Administration time is approximately 30 minutes.

The Communicative Effectiveness Index (CEI) is a self-report instrument used only in aphasia and has not been used in right hemisphere communication.

The Edinburgh Functional Communication Profile is quick but was not familiar to the panel.

The FIM does include two relevant measures -- comprehension (includes both hearing and understanding) and expression.

The RIC-FAS (Rehabilitation Institute of Chicago) has expanded the FIM communication measure to include reading and writing; speech production and community function. The measure has been used by other centers. Reliability and Validity are only known for the first version -- the measure is now in its 5th version.

CLINICAL PANEL MEETING NOTES FOR BACK & NECK

December 9, 1998

The following indicators were discussed:

• Physiology - Pain, pain intensity, symptom severity
• Physiology - Numbness
• Quality of Life - Social function
• Quality of Life - Days of limited activity
• Process - Neurological checks
• Mental Health - Depression
• Mental Health - Somatization
• Satisfaction - Patient satisfaction

Measures were discussed for:

• Pain
• Physical function

A. Indicators

1. Physiology

Pain, Pain Intensity, Symptom Severity
Symptom severity and pain refer to the same construct; therefore, it is necessary to combine the two into one indicator, called pain. In addition to pain intensity, we should also consider the impact of pain on life functions/activities.

We refined the definition of the indicator such that symptom severity and pain intensity would be replaced by two new indicators: (1) back and neck pain intensity and frequency and (2) leg and arm pain intensity and frequency.

Numbness
Numbness and tingling can be as significant as pain in evaluating symptoms of patients with back and neck conditions such as spinal stenosis. When asked about symptoms, patients often will respond that they are not experiencing pain, but rather a numbness, tingling, or "discomfort." However, numbness is most likely not as sensitive to differences in quality of care (as is pain).

2. Quality of Life

Social Function
Social function seems to overlap a great deal with role resumption (see CHF discussion). However, social function and role resumption do not necessarily refer to the same construct. For example, social function might include such activities as participating in a weekly card game, but this activity would not be considered a "role." A valuable quality indicator with respect to social function would be "return to previous social function" or "perception of self returning to prior situation." However, this may be a difficult indicator to measure because change in social function may or may not be the result of the care that is provided.

Days of Limited Activity
Days of limited activity is a very common, well-regarded quality indicator for PAC. It has high face validity and is frequently cited in the literature. However, there are several issues with using this indicator as a measure of PAC quality. It is most commonly measured with the following item, "During how many of the past 30 days was your activity limited due to your illness?" with responses being 0, 14, 28. Because this measure is not continuous, it is less informative. Furthermore, the term "limited" can be difficult to define. One person's experience of a "limited activity day" may not be the same as another's. Yet another issue of concern is that the days of limited activity might be due to physician's order, rather than the patient's actual status/ability. Measuring limited activity days does have the advantage of picking up clinically meaningful change over time, but generally does not provide any additional information over and above function or social function.

A new indicator, role resumption, was added to the rating sheet. (See discussion of indicators for CHF.)

3. Process

Neurological Checks
Neurological checks in a post-acute setting do not necessarily reflect quality of post-acute care; this is something that should be done in the acute setting. However, ongoing sensory/motor checks are more indicative of quality in the PAC setting. These checks are generally done during the process of other evaluations, such as physical therapy.

A new indicator, physical therapy evaluation, replaced physical therapy use. A new indicator, occupational therapy evaluation, was added to the rating sheet.

4. Mental Health

Depression
It is generally believed that a measure of depression must exist for a condition such as back and neck. However, the incidence of major depression in patients with chronic back pain is much lower than in patients with CHF. Of more consequence than major depression is less severe depression or a general feeling of sadness. This level of depression may be more sensitive to changes in quality of PAC for back and neck patients.

Somatization
For back and neck patients, somatization is of special importance. This is a disorder which can significantly affect (exaggerate) health care resource utilization. However, recognizing and diagnosing these patients can be especially difficult.

5. Satisfaction

Patient Satisfaction
Patient satisfaction is an indicator that is frequently used and well liked. A differentiation must be made between whether we examine patient satisfaction with care or patient satisfaction with where they are currently (or current status).

We refined the definition of the indicator such that patient satisfaction would refer to patient satisfaction with care, rather than patient satisfaction with current status.

6. Utilization

A new indicator, total inpatient days, was added to the rating sheet.

B. Measures

Pain
SF-36 -- Has only two items that measure pain severity. Visual Analogue Scale (VAS) -- Good, but non-specific.

Physical Function
Recommended measures of physical function in back and neck patients are: Oswestry, FIM, SF-36, and self-reported walking distance.

APPENDIX E. Final Ratings and Dropped Quality Indicators

Table of Contents

CHF -- Final Ratings

Pneumonia -- Final Ratings

Stroke -- Final Ratings

Back & Neck -- Final Ratings

Discussion of Dropped Quality Indicators

CHF -- FINAL RATINGS
Rank	Count	Domain	Indicator
1	9	Physical Function	General/Global Function
2	9	Physical Function	Self Care
3	9	Physical Function	Ambulation/Mobility
4	9	Mental Health	Depression
5	9	Quality of Life	Well-being
6	9	Quality of Life	Health-related quality of life
7	9	Utilization	Hospitalization
8	9	Satisfaction	Patient satisfaction
9	8	Quality of Life	Role resumption
10	8	Utilization	Total inpatient days
11	8	Process	Evaluation of medication compliance
12	7	Satisfaction	*Caregiver satisfaction
13	6	Utilization	*Home health care use
14	6	Physiology	Mortality
15	5	Quality of Life	Social function
16	5	Utilization	*Skilled Nursing Facility admission
17	5	Physiology	Weight Change
18	5	Process	*Patient education
19	4	Utilization	Emergency room admission
20	4	Utilization	*Rehabilitation facility admission
21	4	Process	*Medication review
22	4	Process	ACE Inhibitor use (or alternative where appropriate e.g. nitrates or hydralazine)
23	3	Quality of Life	Self-perceived ability to participate in social/recreational activities
24	3	Quality of Life	Subjective well-being
25	3	Quality of Life	Days in bed
26	3	Quality of Life	Days of limited activity
27	3	Quality of Life	Household activities
28	3	Utilization	Total combined PAC
29	3	Utilization	Level of care provided
30	3	Process	Non use of calcium channel blockers in systolic heart failure
31	2	Mental Health	Cognition
32	2	Mental Health	Patient Motivation
33	2	Quality of Life	Recreation
34	2	Quality of Life	Living situation
35	2	Utilization	Admission to ICU
36	2	Physiology	Edema
37	2	Physiology	Pain
38	2	Physiology	Dyspnea
39	2	Process	Daily Weights
40	2	Process	Appropriate response to change in status e.g. increase diuretics
41	2	Process	Prescription of exercise
42	2	Process	Caregiver education
43	2	Process	Discussion of advance care directives
44	1	Physical Function	Exercise tolerance
45	1	Mental Health	Sedative hypnotic use
46	1	Mental Health	Anxiety
47	1	Utilization	Amount and intensity of care provided
48	1	Physiology	Electrolyte abnormalities
49	1	Physiology	Fatigue
50	1	Physiology	Chest Pain
51	1	Physiology	Oxygenation
52	1	Physiology	Pressure sores
53	1	Process	Sodium restriction
54	1	Process	Treatment/control of hypertension
55	1	Process	Depression Treatment
56	1	Process	Family education
57	1	Process	Integrated, multidisciplinary care program
58	1	Process	Monitoring drug therapy
59	1	Process	Patient knowledge
60	0	Mental Health	Antipsychotic drug use
61	0	Mental Health	Delirium
62	0	Quality of Life	Days of work absenteeism
63	0	Quality of Life	Work status
64	0	Quality of Life	Compensation status
65	0	Quality of Life	Job description
66	0	Quality of Life	Vocational outcomes
67	0	Utilization	Use of home-delivered meals (Meals-on-Wheels)
68	0	Physiology	Rales
69	0	Physiology	S3 gallop
70	0	Physiology	Chest Xray abnormalities
71	0	Physiology	Nausea
72	0	Physiology	Vomiting
73	0	Physiology	Cough
74	0	Physiology	Sensory Changes
75	0	Physiology	Urinary Incontinence
76	0	Physiology	Fecal Incontinence
77	0	Physiology	Anorexia, diminished appetite
78	0	Physiology	Sleep Disorder
79	0	Physiology	Sputum production
80	0	Physiology	Heart Rate
81	0	Physiology	Respiratory Rate
82	0	Physiology	Blood Pressure
83	0	Physiology	Deep Venous Thrombosis
84	0	Physiology	Pulmonary Embolism
85	0	Physiology	Aspiration pneumonia
86	0	Physiology	Flexion contractures
87	0	Physiology	Dehydration
88	0	Physiology	Falls
89	0	Physiology	Falls with injury
90	0	Physiology	Constipation
91	0	Physiology	Fecal impaction
92	0	Physiology	Electrolyte complications
93	0	Physiology	Adverse drug reactions
94	0	Physiology	Wound infections
95	0	Physiology	Nosocomial infections
96	0	Physiology	Rash
97	0	Physiology	Renal Failure
98	0	Physiology	Hepatic function abnormalities
99	0	Physiology	Pleural effusion
100	0	Physiology	Urinary retention
101	0	Physiology	Clostridium difficile infection
102	0	Physiology	Malnutrition
103	0	Process	Evaluation of dietary compliance
104	0	Process	Evaluation for ischemia
105	0	Process	Evaluation for chronic hypoxemia
106	0	Process	Evaluation for exercise-induced hypoxemia
107	0	Process	Referral to cardiologist
108	0	Process	Prescription of oxygen
109	0	Process	Anticoagulation for severe left ventricular dysfunction
110	0	Process	Time to nurse or physician follow-up after hospital discharge
111	0	Process	Persistence of urinary catheter
112	0	Process	Immunization status
113	0	Process	Dietician evaluation
114	0	Process	Sedative hypnotic use
115	0	Process	Antipsychotic use
116	0	Process	Assessment of LV function
* Dropped indicators. Indicators that were discussed at the panel meetings are in bold.

PNEUMONIA -- FINAL RATINGS
Rank	Count	Domain	Indicator
1	9	Satisfaction	Patient satisfaction
2	8	Physical Function	General/Global Function
3	8	Physical Function	Self Care
4	8	Quality of Life	Health-related quality of life
5	8	Utilization	Hospitalization
6	8	Physiology	Fatigue
7	8	Physiology	Dyspnea
8	8	Physiology	Cough
9	8	Satisfaction	*Caregiver satisfaction
10	7	Physical Function	Ambulation/Mobility
11	7	Mental Health	*Cognition
12	7	Quality of Life	Role resumption
13	7	Utilization	Physician visits for pneumonia
14	7	Utilization	*Home health care use
15	7	Utilization	Total inpatient days
16	7	Physiology	*Time to reach stability
17	7	Process	Discussion of advance care directives
18	6	Quality of Life	Return to usual activities
19	6	Process	Immunization status
20	6	Process	Cognition evaluation
21	6	Process	PT evaluation
22	5	Physiology	Mortality
23	5	Process	Blood cultures, etc.
24	5	Process	OT evaluation
25	4	Quality of Life	*Days of limited activity
26	4	Utilization	Emergency room admission
27	4	Utilization	*Skilled Nursing Facility admission
28	4	Process	*Patient education
29	4	Process	Appropriate antibiotic use
30	3	Mental Health	Depression
31	3	Quality of Life	Social function
32	3	Physiology	Follow-up x-ray findings
33	3	Process	Time until begin antibiotics
34	2	Mental Health	Delirium
35	2	Quality of Life	Self-perceived ability to participate in social/recreational activities
36	2	Utilization	Admission to ICU
37	2	Utilization	Rehabilitation facility admission
38	2	Utilization	Total combined PAC
39	2	Utilization	Level of care provided
40	2	Physiology	Duration of respiratory symptoms
41	2	Physiology	Oxygenation
42	2	Physiology	Dehydration
43	1	Quality of Life	Subjective well-being
44	1	Quality of Life	Days in bed
45	1	Quality of Life	Household activities
46	1	Quality of Life	Recreation
47	1	Physiology	Duration of fever
48	1	Physiology	Sputum production
49	1	Physiology	Falls with injury
50	1	Physiology	Pleural effusion
51	1	Physiology	Clostridium difficile infection
52	1	Physiology	Respiratory symptoms
53	1	Process	Caregiver education
54	0	Mental Health	Anxiety
55	0	Mental Health	Patient Motivation
56	0	Quality of Life	Days of work absenteeism
57	0	Quality of Life	Work status
58	0	Quality of Life	Compensation status
59	0	Quality of Life	Job description
60	0	Quality of Life	Vocational outcomes
61	0	Quality of Life	Living situation
62	0	Utilization	Use of home-delivered meals (Meals-on-Wheels)
63	0	Utilization	Amount and intensity of care provided
64	0	Physiology	Morbid complications:
65	0	Physiology	Pleural exudate
66	0	Physiology	Abcess/empyema
67	0	Physiology	Meningitis
68	0	Physiology	Otitis media/sinusitis
69	0	Physiology	Myocarditis/aseptic arthritis
70	0	Physiology	Cardiovascular
71	0	Physiology	Asthma
72	0	Physiology	Duration of fever and chest pain
73	0	Physiology	Pain
74	0	Physiology	Nausea
75	0	Physiology	Vomiting
76	0	Physiology	Sensory Changes
77	0	Physiology	Urinary Incontinence
78	0	Physiology	Fecal Incontinence
79	0	Physiology	Anorexia, diminished appetite
80	0	Physiology	Sleep Disorder
81	0	Physiology	Chest Pain
82	0	Physiology	Heart Rate
83	0	Physiology	Respiratory Rate
84	0	Physiology	Blood Pressure
85	0	Physiology	Deep Venous Thrombosis
86	0	Physiology	Pulmonary Embolism
87	0	Physiology	Aspiration pneumonia
88	0	Physiology	Pressure sores
89	0	Physiology	Flexion contractures
90	0	Physiology	Falls
91	0	Physiology	Constipation
92	0	Physiology	Fecal impaction
93	0	Physiology	Electrolyte complications
94	0	Physiology	Adverse drug reactions
95	0	Physiology	Wound infections
96	0	Physiology	Nosocomial infections
97	0	Physiology	Rash
98	0	Physiology	Renal Failure
99	0	Physiology	Hepatic function abnormalities
100	0	Physiology	Urinary retention
101	0	Physiology	Malnutrition
102	0	Process	Depression treatment
103	0	Process	Family education
104	0	Process	Integrated, multidisciplinary care program
105	0	Process	Time to nurse or physician follow-up after hospital discharge
106	0	Process	Persistence of urinary catheter
107	0	Process	Monitoring drug therapy
108	0	Process	Dietician evaluation
109	0	Process	Sedative hypnotic use
110	0	Process	Antipsychotic drug use
* Dropped indicators. Indicators that were discussed at the panel meetings are in bold.

STROKE -- FINAL RATINGS
Rank	Count	Domain	Indicator
1	9	Physical Function	Self Care
2	9	Physical Function	IADLs
3	9	Physical Function	Ambulation/Mobility
4	9	Physical Function	Communication
5	9	Quality of Life	Health-related quality of life
6	9	Quality of Life	Role resumption
7	9	Satisfaction	Patient satisfaction
8	9	Satisfaction	*Caregiver satisfaction
9	8	Physical Function	General/Global Function
10	8	Mental Health	Depression
11	8	Process	Speech evaluation
12	8	Process	Family/caregiver education and support
13	8	Process	Anticoagulation therapy (stroke prevention)
14	7	Mental Health	*Cognition
15	7	Quality of Life	Social function
16	6	Physical Function	*Gait and Balance
17	6	Quality of Life	*Recreation/Leisure
18	6	Utilization	Nursing home resident at some time x
19	6	Process	Integrated, multidisciplinary care program
20	6	Process	PT evaluation
21	6	Process	OT evaluation
22	5	Utilization	Hospitalization
23	5	Utilization	*Level of care provided
24	5	Physiology	Mortality
25	4	Physical Function	Community Mobility
26	4	Utilization	*Medicare-covered inpatient days
27	4	Process	Swallow evaluation
28	4	Process	*Motivation evaluation
29	3	Utilization	Home health care use
30	3	Utilization	Total inpatient days
31	3	Physiology	Pressure sores
32	3	Process	Receipt of appropriate therapy as long as functional recovery taking place
33	2	Quality of Life	Days of limited activity
34	2	Quality of Life	Caregiver stress
35	2	Utilization	Emergency room admission
36	2	Utilization	Rehabilitation facility admission
37	2	Physiology	Flexion contractures
38	2	Physiology	Falls with injury
39	2	Process	Patient education
40	1	Physical Function	Motor Function
41	1	Physiology	Feeding tube
42	1	Physiology	Pain
43	1	Physiology	Oxygenation
44	1	Physiology	Dehydration
45	1	Physiology	Falls
46	1	Process	Depression Treatment
47	1	Process	Intensity and duration of therapy services (PT, OT, ST)
48	0	Physical Function	Stroke Deficit Scales
49	0	Mental Health	Delirium
50	0	Mental Health	Anxiety
51	0	Mental Health	Patient Motivation
52	0	Quality of Life	Self-perceived ability to participate in social/recreational activities
53	0	Quality of Life	Subjective well-being
54	0	Quality of Life	Days of work absenteeism
55	0	Quality of Life	Days in bed
56	0	Quality of Life	Work status
57	0	Quality of Life	Compensation status
58	0	Quality of Life	Job description
59	0	Quality of Life	Vocational outcomes
60	0	Quality of Life	Household activities
61	0	Quality of Life	Living situation
62	0	Utilization	Admission to ICU
63	0	Utilization	Skilled Nursing Facility admission
64	0	Utilization	Total combined PAC
65	0	Utilization	Use of home-delivered meals (Meals-on-Wheels)
66	0	Utilization	Amount and intensity of care provided
67	0	Physiology	Fatigue
68	0	Physiology	Nausea
69	0	Physiology	Vomiting
70	0	Physiology	Dyspnea
71	0	Physiology	Cough
72	0	Physiology	Sensory Changes
73	0	Physiology	Urinary Incontinence
74	0	Physiology	Fecal Incontinence
75	0	Physiology	Anorexia, diminished appetite
76	0	Physiology	Sleep Disorder
77	0	Physiology	Chest Pain
78	0	Physiology	Sputum production
79	0	Physiology	Heart Rate
80	0	Physiology	Respiratory Rate
81	0	Physiology	Blood Pressure
82	0	Physiology	Deep Venous Thrombosis
83	0	Physiology	Pulmonary Embolism
84	0	Physiology	Aspiration pneumonia
85	0	Physiology	Constipation
86	0	Physiology	Fecal impaction
87	0	Physiology	Electrolyte complications
88	0	Physiology	Adverse drug reactions
89	0	Physiology	Wound infections
90	0	Physiology	Nosocomial infections
91	0	Physiology	Rash
92	0	Physiology	Renal Failure
93	0	Physiology	Hepatic function abnormalities
94	0	Physiology	Pleural effusion
95	0	Physiology	Urinary retention
96	0	Physiology	Clostridium difficile infection
97	0	Physiology	Malnutrition
98	0	Process	Days until receipt of therapy (PT,OT)
99	0	Process	Receipt of minimum intensity of therapy (PT, OT)
100	0	Process	Neuro checks
101	0	Process	Corrective action for sensory problems
102	0	Process	High risk for pressure ulcers with no skin care program
103	0	Process	Corrective action for communicative problems
104	0	Process	Patient participation in care decision making
105	0	Process	Family education
106	0	Process	Caregiver education
107	0	Process	Time to nurse or physician follow-up after hospital discharge
108	0	Process	Discussion of advance care directives
109	0	Process	Persistence of urinary catheter
110	0	Process	Immunization status
111	0	Process	Monitoring drug therapy
112	0	Process	Dietician evaluation
113	0	Process	Anxiety Treatment
114	0	Process	Sedative hypnotic use
115	0	Process	Antipsychotic use
* Dropped indicators. Indicators that were discussed at the panel meetings are in bold.

BACK & NECK -- FINAL RATINGS
Rank	Count	Domain	Indicator
1	9	Physical Function	General/Global Function
2	9	Physical Function	Self Care
3	9	Quality of Life	Health-related quality of life
4	9	Quality of Life	Role resumption
5	9	Utilization	Hospitalization
6	9	Physiology	Back/Neck pain
7	9	Physiology	Leg/Arm pain/numbness/weakness
8	9	Satisfaction	Patient satisfaction
9	9	Process	PT evaluation
10	8	Physical Function	Ambulation/Mobility
11	8	Quality of Life	Social function
12	8	Process	OT evaluation
13	7	Mental Health	Depression
14	7	Quality of Life	*Days of limited activity
15	7	Process	*Patient education
16	6	Quality of Life	*Days in bed
17	6	Utilization	Emergency room admission
18	6	Satisfaction	*Caregiver satisfaction
19	5	Utilization	*Rehabilitation facility admission
20	5	Utilization	*Skilled Nursing Facility admission
21	5	Utilization	*Home health care use
22	5	Utilization	Total inpatient days
23	5	Process	Use of prescription analgesic medications
24	4	Utilization	*Repeat spinal surgery
25	4	Utilization	*Total combined PAC
26	4	Quality of Life	*Recreation/leisure
27	3	Process	Caregiver education
28	2	Mental Health	Patient Motivation
29	2	Quality of Life	Social life
30	2	Quality of Life	Self-perceived ability to participate in social/recreational activities
31	2	Quality of Life	Subjective well-being
32	2	Quality of Life	Living situation
33	2	Utilization	Level of care provided
34	2	Physiology	Symptom severity
35	2	Physiology	Mortality
36	2	Process	Depression Treatment
37	2	Process	Family education
38	1	Quality of Life	Work status
39	1	Quality of Life	Household activities
40	1	Utilization	Admission to ICU
41	1	Utilization	Amount and intensity of care provided
42	1	Physiology	Sensory Changes
43	1	Physiology	Urinary Incontinence
44	1	Physiology	Fecal Incontinence
45	1	Physiology	Pressure sores
46	1	Physiology	Falls
47	1	Physiology	Falls with injury
48	1	Physiology	Adverse drug reactions
49	1	Physiology	Muscle atrophy
50	1	Process	Time to nurse or physician follow-up after hospital discharge
51	0	Mental Health	Anxiety-depression
52	0	Mental Health	Cognition
53	0	Mental Health	Delirium
54	0	Mental Health	Anxiety
55	0	Quality of Life	Social interest
56	0	Quality of Life	Travel
57	0	Quality of Life	Work activities
58	0	Quality of Life	Time spent in bed
59	0	Quality of Life	Days of work absenteeism
60	0	Quality of Life	Compensation status
61	0	Quality of Life	Job description
62	0	Quality of Life	Vocational outcomes
63	0	Utilization	Use of home-delivered meals (Meals-on-Wheels)
64	0	Physiology	Pain intensity
65	0	Physiology	Fatigue
66	0	Physiology	Nausea
67	0	Physiology	Vomiting
68	0	Physiology	Dyspnea
69	0	Physiology	Cough
70	0	Physiology	Anorexia, diminished appetite
71	0	Physiology	Sleep Disorder
72	0	Physiology	Chest Pain
73	0	Physiology	Sputum production
74	0	Physiology	Heart Rate
75	0	Physiology	Respiratory Rate
76	0	Physiology	Blood Pressure
77	0	Physiology	Oxygenation
78	0	Physiology	Deep Venous Thrombosis
79	0	Physiology	Pulmonary Embolism
80	0	Physiology	Aspiration pneumonia
81	0	Physiology	Flexion contractures
82	0	Physiology	Dehydration
83	0	Physiology	Constipation
84	0	Physiology	Fecal impaction
85	0	Physiology	Electrolyte complications
86	0	Physiology	Wound infections
87	0	Physiology	Nosocomial infections
88	0	Physiology	Rash
89	0	Physiology	Renal Failure
90	0	Physiology	Hepatic function abnormalities
91	0	Physiology	Pleural effusion
92	0	Physiology	Urinary retention
93	0	Physiology	Clostridium difficile infection
94	0	Physiology	Malnutrition
95	0	Process	Transcutaneous electrical nerve stimulator (TNS) usage
96	0	Process	Neurological checks
97	0	Process	Integrated, multidisciplinary care program
98	0	Process	Discussion of advance care directives
99	0	Process	Persistence of urinary catheter
100	0	Process	Immunization status
101	0	Process	Monitoring drug therapy
102	0	Process	Dietician evaluation
103	0	Process	Sedative hypnotic use
104	0	Process	Antipsychotic drug use
105	0	Process	Somatization evaluation
* Dropped indicators. Indicators that were discussed at the panel meetings are in bold.

DISCUSSION OF DROPPED QUALITY INDICATORS

As noted in Chapter III, several quality indicators were rated highly by the clinical panel (selected by four or more panel members) but subsequently dropped for various reasons. Following is a list of the indicators that were dropped, including the rationale for dropping them.

A. Global

• Cognition (Mental Health): Although cognition was rated highly by the panels for both pneumonia and stroke, it is more appropriately regarded as a risk adjuster than a measure of post-acute care quality. In all four of our instruments, the Pfieffer Short Portable Mental Status Questionnaire is included for risk adjustment rather than a quality indicator.

• Days of limited activity (Quality of Life): Days of limited activity, rated highly by both the pneumonia and back and neck panels, is encompassed within the broader "role resumption" and "social function" quality of life indicators. Further review of this measure also revealed that it may not be a highly sensitive or accurate measure of limitation because of the tendency of respondents to round the number of days up or down to a figure approximating weeks.

• Recreation/Leisure (Quality of Life): Recreation/Leisure is encompassed within the broader "social/role function" quality of life indicator, measured using the Resumption of Normal Activities questions.

• Home health care use (Utilization): The interpretation of home health care utilization, as a measure of the quality of care, is uncertain. In some cases, high utilization rates may reflect good quality of care with very close follow-up of patients, while in other circumstances it may reflect persistence of patient illness and thus poor quality of care. As such, we did not believe that it clearly and accurately reflects the quality of post-acute care, despite being highly ranked by our panel.

• Skilled nursing facility admission (Utilization): Similar to home health use, SNF admission could be a reflection of appropriate or inadequate post-acute care. Admission to SNF alone does not indicate quality of post-acute care.

• Rehabilitation facility admission (Utilization): See discussion of skilled nursing facility and home health care admission above.

• Caregiver satisfaction (Satisfaction): Caregiver satisfaction was rated highly by the panels for all four conditions. Due to the added data collection burden associated with a caregiver assessment, we dropped this indicator. Recognizing the importance of satisfaction overall, however, we assess patient satisfaction in the patient report components of the instruments (and therefore proxy respondents when a proxy is necessary who are arguably the most burdened caregivers).

• Patient education (Process): Documentation of patient education is unlikely to be reliably documented in medical records. Additionally, the components of adequate or good patient education are extremely difficult to define to develop a meaningful measure. We therefore dropped this as a quality indicator.

B. CHF

• Medication review (Process): Similar to patient education, documentation of medication review will most likely not be consistently available in the medical record. The panel ranked both medication review and assessment of patient compliance with medication very highly. Because of similarities between these two measures, and the implicit review of medications that would occur in an assessment of medication compliance, we left the latter indicator in as a process measure. However, we are uncertain to what degree such information will be documented in the medical record.

C. Back & Neck

• Days in bed (Quality of Life): Similar to days of limited activity, days in bed is encompassed within the broader "role resumption" and "social function" quality of life indicators.

• Total combined PAC (Utilization): This indicator is similar to another indicator, total inpatient days, which is included in the final indicator list.

• Repeat spinal surgery (Utilization): For some patients, repeat spinal surgery may be an appropriate and necessary treatment; while for others, repeat surgery might indicate poor quality of post-acute care. Furthermore, the need for additional surgery is more likely to reflect quality issues related to earlier surgery than quality problems in the post-acute care received.

D. Pneumonia

• Time to reach stability (Physiology): Stability is more sensitive to hospital care than to post-acute care; the majority of patients are stable before transfer to a post-acute facility. This measure was chosen by the panel following a discussion about how Medicare HMOs may bypass acute hospitalization and treat pneumonia patients directly in subacute care units. Such subacute care should therefore scrutinize processes and outcomes of care that are more traditionally hospital-based. However, other measures were chosen for this same purpose (e.g., obtaining blood cultures, appropriate antibiotic use) and should suffice. Such subacute care that bypasses acute hospitalization is likely to affect only a small minority of all pneumonia patients receiving post-acute care.

• Cognition evaluation (Process): While evaluation of cognition in general and delirium in particular were viewed as important for post-acute care of persons with dementia, this indicator was dropped due to concerns that it could not be uniformly assessed from providers' entries to medical records.

E. Stroke

• Gait and balance (Physical Function): No validated self-report measures specifically designed to assess gait and balance exist.

• Level of care provided (Utilization): As with home health care utilization, SNF and rehabilitation hospital utilization, the panel was concerned that transfers to higher levels of care may be a reflection of post-acute care quality. Again, this is an ambiguous measure because transfers to higher levels of care may be necessary and reflect good care in some circumstances while representing poor care in others. Given this ambiguity, this indicator was also dropped.

• Medicare-covered inpatient days (Utilization): This indicator is similar to another indicator, total inpatient days, which is included in the final quality indicator list.

• Motivation evaluation (Process): Motivation, though selected by four of the stroke panel members, is not measurable using a standardized instrument and therefore post-acute care providers cannot be expected to reliably measure and record it.

APPENDIX F. Final Quality Indicator Ratings Across All Conditions

Final Quality Indicator Ratings Across All Conditions
Domain	Indicator	CHF	Back/Neck	Pneumonia	Stroke
GLOBAL
Physical Function	Self care	9	9	8	9
Physical Function	General/Global function	9	9	8	8
Physical Function	Ambulation/Mobility	9	8	7	9
Mental Health	Depression	9	7	3	8
Quality of Life	Health-related quality of life	9	9	8	9
Quality of Life	Role resumption	8	9	7	9
Quality of Life	Social function	5	8	3	7
Utilization	Hospitalization	9	9	8	5
Utilization	Total inpatient days	8	5	7	3
Utilization	Emergency room admission	4	6	4	2
Physiology	Mortality	6	2	5	5
Satisfaction	Patient satisfaction	9	9	9	9
Process	PT evaluation	-	9	6	6
Process	OT evaluation	-	8	5	6
CHF
Quality of Life	Disease-specific measure of well-being (Minnesota Living with Heart Failure, and Chronic CHF questionnaires)	9	-	-	-
Physiology	Weight change	5	-	-	-
Process	Medication compliance evaluation	8	-	-	-
Process	Use of ACE inhibitor for systolic HF	4	-	-	-
BACK/NECK
Physiology	Back/Neck pain	-	9	-	-
Physiology	Leg/Arm pain/numbness/weakness	-	9	-	-
Process	Use of prescription analgesic medications	-	5	-	-
PNEUMONIA
Quality of Life	Return to usual activities	-	-	6	-
Physiology	Dyspnea	2	0	8	0
Physiology	Fatigue	1	0	8	0
Physiology	Cough	0	0	8	0
Process	Discussion of advance care directives	2	0	7	0
Process	Physician visits for pneumonia	-	-	7	-
Process	Immunization status	0	0	6	0
Process	Blood cultures	-	-	5	-
Process	Appropriate antibiotic use	-	-	4	-
STROKE
Physical Function	Communication	-	-	-	9
Physical Function	IADLs	-	-	-	9
Physical Function	Community mobility	-	-	-	4
Utilization	Nursing home residents at some time x	-	-	-	6
Process	Speech evaluation	-	-	-	8
Process	Anticoagulation therapy	-	-	-	8
Process	Family/Caregiver education and support	-	-	-	8
Process	Integrated, multidisciplinary care program	1	0	0	6
Process	Swallow evaluation	-	-	-	4

APPENDIX G. Barthel Conversion Codes

Table of Contents

Barthel Index Replicated Using the MDS 2.0 (10/94n)

Barthel Index Replicated Using the MDS PAC (Draft 8)

Barthel Index Replicated Using the OASIS (Draft B1)

Barthel Index Replicated Using the MDS 2.0 (10/94n)
ADL	Barthel Item	Barthel Score	MDS 2.0 Variable	MDS 2.0
Feeding	#1	10 - independent 5 - some help 0 - dependent	G1HA	0 1,2 3,4
Transfer	#2	15 - independent 10 - minimal assist or SBA 5 - moderate/maximum assist 0 - dependent	G1BA	0,1 2 3 4
Grooming	#3	5 - independent 0 - assist	G1JA	0,1 2,3,4
Toileting	#4	10 - independent 5 - some help 0 - assist	G1IA	0,1 2 3,4
Bathing	#5	5 - independent 0 - assist	G2A	0,1 2,3,4
Walking	#6	15 - independent for 50 yards 10 - min assist for 50 yards 5 - independent in wheelchair 0 - dependent	G1DA	0 1,2 3,4,8 and G5b=1 3,4,8 and G5b=0
Stairs	#7	10 - independent 5 - help or supervision 0 - dependent	NOT ASSESSED NOT ASSESSED NOT ASSESSED
Dressing	#8	10 - independent 5 - some help 0 - dependent	G1GA	0,1 2 3,4
Bowel Continence	#9	10 - independent 5 - help w/suppository 0 - dependent	H1A	0 1,2 3,4
Bladder Continence	#10	10 - independent 5 - occastional incontinence/some assistance 0 - dependent	H1B	0 1,2 3,4

NOTES

ADL Self-Performance (#1 Feeding, #2 Transfer, #3 Grooming, #4 Toileting, #6 Walking, #7 Stairs, #8 Dressing)

0 - independent
1 - supervision
2 - limited assistance
3 - extensive assistance
4 - total dependence
8 - activity did not occur

Bathing Self-Performance (#5 Bathing)

0 - independent
1 - supervision oversight help only
2 - physical help limited to transfer only
3 - physical help in part of bathing activity
4 - total dependence
8 - activity did not occur

Continence Self-Performance (#9 Bowel Continence, #10 Bladder Continence)

0 - continent
1 - usually continent
2 - occasionally incontinent
3 - frequently incontinent
4 - incontinent

Barthel Index Replicated Using the MDS PAC (Draft 8)
ADL	Barthel Item	Barthel Score	MDS PAC Variable	MDS PAC
Feeding	#1	10 - independent 5 - some help 0 - dependent	E1h	0,1 2,3 4,5,6
Transfer	#2	15 - independent 10 - minimal assist or SBA 5 - moderate/maximum assist 0 - dependent	E1b	0 1,2,3 4,5 6
Grooming	#3	5 - independent 0 - assist	E1k	0 1,2,3,4,5,6
Toileting	#4	10 - independent 5 - some help 0 - assist	E1i/E1j	0 1,2,3 4,5,6
Bathing	#5	5 - independent 0 - assist	E1l	0 1,2,3,4,5,6
Walking	#6	15 - independent for 50 yards 10 - min assist for 50 yards 5 - independent in wheelchair 0 - dependent	E1d	0 1,2,3 NA 4,5,6
Stairs	#7	10 - independent 5 - help or supervision 0 - dependent	E3d	0 1,2,3,4 5,6
Dressing	#8	10 - independent 5 - some help 0 - dependent	E1e	0 1,2,3 4,5,6
Bowel Continence	#9	10 - independent 5 - help w/suppository 0 - dependent	F2	0 2,3 4,5
Bladder Continence	#10	10 - independent 5 - occastional incontinence/some assistance 0 - dependent	F1	0 2,3 4,5

NOTES

3 Day ADL Self-Performance (#1 Feeding, #2 Transfer, #3 Grooming, #4 Toileting, #5 Bathing, #6 Walking, #7 Stairs, #8 Dressing)

0 - independent
1 - set up help only
2 - supervision
3 - limited assistance
4 - extensive assistance, with all episodes involving a 1 person physical assist
5 - extensive assistance with at least one episode involving a 2+ person physical assist
6 - total dependence
8 - activity did not occur

Capacity to Perform Instrumental Activities of Daily Living (#7 Stairs)

0 - independent
1 - set up help only
2 - supervision
3 - limited assistance
4 - moderate assistance
5 - maximum assistance
6 - total dependence

Bowel Continence (#9 Bowel Continence)

0 - continent
1 - continent with ostomy (NA)
2 - usually continent
3 - occasionally incontinent
4 - frequently incontinent
5 - incontinent
8 - did not occur

Bladder Continence (#10 Bladder Continence)

0 - continent
1 - continent with catheter (NA)
2 - usually continent
3 - occasionally incontinent
4 - frequently incontinent
5 - incontinent
8 - did not occur

Barthel Index Replicated Using the OASIS (Draft B1)
ADL	Barthel Item	Barthel Score	OASIS Variable	OASIS
Feeding	#1	10 - independent 5 - some help 0 - dependent	M0710	0 1 2,3,4,5
Transfer	#2	15 - independent 10 - minimal assist or SBA 5 - moderate/maximum assist 0 - dependent	M0690	0 1 2,3 4,5
Grooming	#3	5 - independent 0 - assist	M0640	0 1,2,3
Toileting	#4	10 - independent 5 - some help 0 - assist	M0680	0 NA 4
Bathing	#5	5 - independent 0 - assist	M0670	0,1 2,3,4,5
Walking	#6	15 - independent for 50 yards 10 - min assist for 50 yards 5 - independent in wheelchair 0 - dependent	M0700	0,1 2 3 4,5
Stairs	#7	10 - independent 5 - help or supervision 0 - dependent	M0700	0 1 2,3,4,5
Dressing	#8	10 - independent 5 - some help 0 - dependent	M0650/ M0660	0 1,2 3
Bowel Continence	#9	10 - independent 5 - help w/suppository 0 - dependent	M0540	0 1,2 3,4,5
Bladder Continence	#10	10 - independent 5 - occastional incontinence/some assistance 0 - dependent	M0520	0 NA 1

APPENDIX H. Members of Second Expert Panel

Members of Second Expert Panel
Carol Barnes, MS, PT, GCS Outcomes Manager SeniorMetix Denver, Colorado	Bruce Gans, MD Senior Vice President for Continuing Care Chairman of Physical Medicine and Rehabilitation Long Island Jewish Medical Center New Hyde Park, New York
Dan Berlowitz, MD Center for Health Quality, Outcomes, and Economic Research Bedford VA Hospital Bedford, Massachusetts	Thomas J. Marrie, MD (Pneumonia specialist) Chair, Department of Medicine University of Alberta Edmonton, Alberta, Canada
Randall S. Brown, PhD Senior Fellow Mathematica Policy Research, Inc. Princeton, New Jersey	Martha J. Radford, MD (CHF specialist) Deputy Director, CORE Yale-New Haven Health New Haven, Connecticut
Jill Byers, MS, RN Branch President Associated Professional Home Health Care, Inc. Denver, Colorado	Debra Saliba, MD, MPH Assistant Professor UCLA Multicampus Program in Geriatrics Santa Monica, California
Rhoda Cohen, MS Senior Survey Researcher Mathematica Policy Research, Inc. Princeton, New Jersey	Judy Sangl, ScD Health Scientist Administrator Agency for Health Care Research and Quality Center for Quality Measurement and Improvement Rockville, Maryland
Kenneth Covinsky, MD, MPH Assistant Professor of Medicine University of California, San Francisco San Francisco, California	Hilary Siebens, MD Associate Director, Physical Medicine and Rehabilitation Massachusetts General Hospital Boston, Massachusetts
Richard Deyo, MD (Back & neck specialist) Professor of Medicine University of Washington Seattle, Washington	Laurence D. Wilson Director, Division of Institutional Post Acute Care Health Care Financing Administration Baltimore, Maryland
Pamela W. Duncan, PhD, FAPTA Director of Research, Center on Aging University of Kansas Medical Center Kansas City, Kansas

APPENDIX I. Notes from Specialist Conference Calls

Table of Contents

CHF Conference Call -- Martha Radford, M.D.

Pneumonia Conference Call -- Thomas Marrie, M.D.

Back and Neck Conference Call -- Richard Deyo, M.D.

CHF CONFERENCE CALL
Martha Radford, M.D.

• In addition to the disease-specific measures already in the instrument, Dr. Radford suggested measures related to beta blockers, digoxin, and anticoagulation. In a follow-up correspondence she also queried whether a summary measure of "reasonable medical management" could be constructed using a list of commonly-used classes of drugs in heart failure (ACEI, ARB, diuretics, beta-blockers, anticoagulation, digoxin), allow various combinations of these drugs to constitute reasonable medical management.

• Dr Radford suggested including measures related to education and patient empowerment because of the documented association rehospitalization rates. However, it is not clear how to go about measuring this construct. She recommended an article by Carol Ashton for further information on this topic. She noted some unpublished work at Yale suggesting that telephone education programs (without individual patient monitoring or case management) may decrease hospitalizations. Because both Dr. Radford and the expert panel convened in December 1998 supported some kind of measure of patient education/empowerment, a more thorough review of published literature will be conducted to determine the association of education with important CHF outcomes, as well as exploration of the content of such educational programs and how they might be documented by a post-acute care provider.

• With regard to a summary performance measure for CHF, Dr. Radford stated that this is a "reasonable goal," and that the work we are currently doing may ultimately lead to such a measure. She noted, however, that with the current state of knowledge, it would be difficult to sum the different contents areas of quality into a single score.

• Regarding quality of life measures, Dr. Radford suggested that we consult Dr. John Spertus from the University of Missouri, whose previous work includes the Seattle Angina Questionnaire. Dr. Spertus just published a paper documenting the performance of a CHF specific quality of life instrument (Journal of the American College of Cardiology, April 2000).

• Also suggested assessing whether the patient's diet was addressed, and whether the patient is on a low-salt diet.

• Pointed out that post-acute care should be prevention-oriented. We should measure not only if the patient returned to baseline function, but also if bad outcomes were averted (e.g., re-hospitalization, emergency room visits, worsening of condition, progressive decline). Our instrument may be weak in some of these areas except rehospitalization. For example, our instrument can measure decline in basic ADL function, but not subtle declines in higher level functions which are more likely to occur over short follow-up intervals in heart failure.

• Recommended including more assessment items related to higher order function (such as visiting with grandchildren).

• Recommended a 30-day episode of care for CHF because variation in major outcomes like rehospitalization will be captured in a 30 day period. Too long a period will run into subsequent post-acute episodes in a significant proportion of subjects.

• For case mix adjustment, she recommended consulting work performed in this area by Michael Rich or Harlan Krumholz. In addition, she suggested accounting for renal function, prior hospitalization for any condition, terminal illness other than heart failure, and documentation of dementia. Severity of illness could be determined by counting medications.

• For our study, she recommended including only patients with a primary hospital diagnosis of CHF. She noted that the accuracy of the diagnosis is extremely high when it is noted as the primary discharge diagnosis. 

PNEUMONIA CONFERENCE CALL
Thomas Marrie, M.D.

• Suggested we monitor hospitalizations during the post-acute stay as well as after discharge.

• Remarked that for pneumonia, resolution of symptoms is the primary measurement of success. Blood culture may not be a relevant measure for this population since most patients would be well past the point at which blood culture data is useful.

• Suggested including a measure related to assessment and evaluation of adverse effects of antibiotics (e.g., gastrointestinal symptoms which are very common with macrolides), as well as whether the provider addressed the need for smoking cessation program. Also suggested we add a measure of advance directives.

• For the hospital chart review, he recommended including measures related to timely administration of antibiotics, admission blood cultures, and maintenance of function in the acute care facility. These would be used primarily as risk adjusters, allowing for example, poor outcomes to be attributed to poor hospital care instead of post-acute care.

• Dr. Marrie was not aware of a summary performance measure for pneumonia.

• Recommended a 30-day episode of care for pneumonia, but noted at 30 days more than half are still symptomatic, though usually symptoms have significantly improved. Dr. Marrie also noted that 20% of pneumonia subjects are symptomatic for some time period before contracting pneumonia. Many may have chronic symptoms due to other diseases (e.g., COPD) that are always present and are not related to the pneumonia itself. Thus baseline measures of symptoms need to be very clear so that they actually reflect the patient's status in a stable, pre-hospital condition.

• Suggested stratifying patients into categories based on a summary measure of severity of risk factors. Michael Fine's scoring mechanism for mortality and LOS from the PORT may or may not be applicable to post-acute setting, but the technique is worth considering for risk adjustment. Whether all the items in the Fine score are readily available from the hospital chart needs to be determined.

• For case mix adjustment, recommended accounting for use of ventilator, ICU, critical illness, hospital complications, and neuropathy.

• When measuring re-hospitalization rates, be sure to separate hospitalizations for pneumonia from hospitalizations for other conditions.

• For our study, he suggested including patients with a primary or secondary diagnosis of pneumonia, but recommended verifying the diagnosis with x-ray report.

BACK AND NECK CONFERENCE CALL
Richard Deyo, M.D.

• Should ultimately distinguish between medical and surgical back and neck conditions; there might be important differences in length of stay or costs for the different types of conditions. Also, change in symptoms over time may be fundamentally different since surgical patients might be expected to actually improve, rather than just return to baseline, whereas the goal for medical patients might be returning to baseline.

• Suggested rephrasing questions as "Because of your back pain or leg pain (sciatica)…" or "Because of your back problem…" in reference to the pain questions since elderly patients are likely to experience pain from a number of different sources (e.g., DJD, headache).

• For disease-specific measures, he recommended consulting the Rowland and Morris Disability Questionnaire or the Oswestry Questionnaire, which also includes some higher function assessments such as IADLs.

• With respect to responsiveness for detecting clinically important change, he indicated that pain measures are quite responsive to change, but functional measures tend to be less responsive. Overall, he felt that the measures we chose will be responsive to change.

• For back and neck conditions, we will want to assess pain on admission to post-acute care, but not premorbid pain. For pain, the baseline measure will be at admission to post-acute care, since pain and functional impairment may following surgery. Baseline pain would therefore be expected to be responsive to the acute hospital stay (surgery), while the pain following a surgical procedure would be sensitive to the quality of post-acute care.

• Recommended a 1-month or 3-month episode of care for back and neck conditions. He did not think the episode should be any longer than 3-months but was uncertain about whether a 1 or 3 month episode was preferable.

• For case mix adjustment, he recommended capturing whether the patient had a spinal fusion; complication rates and post-acute care placement are much higher for patients with spinal fusion. He also suggested controlling for the number of levels on the spine operated on, comorbidity, wound infections, DVT, new neurologic deficits, other organ complications, perioperative myocardial infarction, and new bowel or bladder dysfunction. Will want to stratify on neck vs lumbar, and on elective surgery vs traumatic injury.

• With respect to a summary performance measure, Dr. Deyo indicated that this has not been done due to the ambiguity about the ideal process of care. He recommended assessing quality through multiple outcome measures.

• For our study, he suggested including only patients with a primary hospital discharge diagnosis of lumbar spinal stenosis. This is likely to be a common diagnosis in an elderly population and would allow a more reasonable comparison of the quality of care in different post-acute settings by assembling a more homogeneous study population.

• With respect to the pain questions, he recommended using just two measures: "How bothersome is the pain?" and "How frequent is the pain?" He noted the disconnect between severity or frequency ratings of pain and how bothered people really are by pain. He noted that asking about how bothersome symptoms are really gets at the impact on the person's life and thus their function while severity and frequency alone do not.

• He also recommended a 10-point (not 20) visual analog scale when asking the patient to rate how much the pain bothers him/her.

APPENDIX J. Issues for Second Expert Panel Discussion

9:30 - 10:30 Discussion Session

1. The first expert panel rated a long list of both global and disease specific quality indicators. In the final rank list (Appendix F of this report), the majority of the indicators were global and these indicators served as the basis for the quality measures included in the instruments. Please comment on the balance between the global and disease-specific measures in the patient survey and chart review instruments for the respective condition.

2. Do you think that the measures chosen reflect the quality constructs recommended by the initial expert panel (please see Appendix F)?

3. Are there measures relevant to the post-acute care of older adults that were not included in these quality measurement instruments?

10:45 - 12:15 Discussion Session

1. In your opinion, can the current quality measures be feasibly administered in the respective post-acute care settings?

2. Do you anticipate that these measures will be responsive for detecting clinically important change?

3. Do you foresee problems with floor or ceiling limitations? For example, subjects who cannot perform a given self-care function at baseline cannot recover that function; therefore creating a floor effect?

4. The purpose of this study will be to compare quality of care across settings. Do you have recommendations for sampling comparable populations in different post-acute settings?

5. With respect to selection criteria for study subjects, which post-acute care patients would be most appropriate for quality of care comparison (i.e., not all patients have the condition of interest listed as their primary diagnosis; what techniques could be used to identify a sample of comparable patients across the three different post-acute settings so as to make quality comparisons across settings?). How could potential subjects be identified in the absence of information derived from the MDS/MDS-PAC/OASIS?

1:15 - 2:15 Discussion Session

1. What defines a discrete episode of care for this condition in post-acute care? In particular, what defines the end of a post-acute episode (e.g., rehospitalization? a certain length of time such as 30 days? discharge from the post-acute care provider?). This definition will determine when the follow-up measures are administered.

2. Ultimately these measures will be used for quality comparisons between sites of post-acute care. What variables would you recommend for case mix adjustment?

3. Given the importance of assessing quality, do you feel that the current instruments impose excessive response burden on older patients?

2:30 - 3:30 Discussion Session

1. What criteria would you suggest for determining the need for a proxy respondent? Do you have any experience with particular mental status instruments in post-acute care?

2. Do you feel that the measures in the chart review instruments can be reasonably abstracted from the post-acute care and hospital charts?

3. Do you feel that the quality measures accurately capture key elements for comparing quality for which post-acute care providers can be held accountable?

3:45 - 5:00 Discussion Session

1. Do you believe it is possible to construct a summary performance measure using the measures in these instruments? If so, how would such a measure be constructed and the various domains weighted?

APPENDIX K. Project Timeline

Date	Item
June 1998	Selected eight post-acute care conditions for further study based on policy considerations.
July 1998	Narrowed the eight conditions down to four based on framework of clinical criteria.
November 1998	Generated comprehensive lists of quality indicators for each of the four selected conditions.
December 1998	Convened first national expert panel comprised of disease specialists and post-acute care providers to rate the importance of each quality indicator for inclusion in post-acute care quality assessment instruments for the four conditions.
July 1999	Translated highly rated quality indicators into quality measures (i.e., developed four instruments).
April 2000	Pilot test Phase 1.
May 2000	Convened panel of content experts, methodologists, providers, and Federal policy officials for instrument review.
June 2000	Pilot test Phase 2, with changes to instruments based on expert panel recommendations.
December 2000	Instrument finalization and manual development.
January 2001 - June 2002	Large national study comparing quality in three settings.