Performance Measurement in the Hospital Outpatient Setting. Appendix E: Description of Primary Developers of Candidate Measures

02/01/2008

AMA/PCPI is a consortium convened by the AMA and comprised of over 100 national medical specialty and state medical societies, the Council of Medical Specialty Societies, the American Board of Medical Specialties and its member-boards, experts in methodology and data collection, the Agency for Healthcare Research and Quality (AHRQ, and CMS.  Its mission is to enhance the quality of care through the development, testing, and maintenance of evidence-based performance measures; it accomplishes this mission through cross-specialty workgroups that translate evidence-based guidelines into measures. Through these work groups, the Consortium had developed 184 physician-level performance measures for 27 different conditions, as of June 1, 2007. Some of the conditions addressed early in the effort include asthma, chronic stable coronary artery disease, heart failure and hypertension, while more recent measures addresses emergency services, gastroesophageal reflux disease (GERD), melanoma, stroke, and other conditions for which fewer measures have been available. The majority of these measures are candidate hospital outpatient measures. Those that are not relevant assess care not covered by the OPPS (e.g., hospital inpatient-only services, dialysis) or relate to non-Medicare populations (e.g., children, pregnant women). The AMA/PCPI measures are routinely submitted to the National Quality Forum (NQF), a voluntary consensus standard-setting organization established to standardize health care quality measurement and reporting, As of June 1, 2007, 48 of the measures submitted by the AMA/PCPI that are potentially relevant to the HOPS had been approved, however, 29 of these received a “time limited” endorsement. This designation is for measures that satisfy all NQF criteria but have not yet been field tested. Once the field testing has been completed and the measures have been demonstrated to produce valid and reliable results, NQF will give them full endorsement.

NCQA develops quality standards and performance measures through a consensus process that includes large employers, policymakers, physicians, patients and health plans. Each year the organization releases a set of measures known as the Health Plan Employer Data and Information Set (HEDIS) that includes measures of underuse, overuse, value, process and outcome. Measures are developed utilizing available evidence and expert consensus. The 2007 HEDIS measures are intended to be used to compare the quality of care provided by managed care organizations, preferred provider organizations, or physician practices, but many address care that may also be provided in the hospital outpatient setting. HEDIS measures are publicly reported by the NCQA following one year of testing for feasibility, reliability and validity. Additionally, the majority of HEDIS measures that may be relevant to the hospital outpatient setting have been approved by the NQF.

The ACOVE project is a collaboration between the RAND Corporation, a nonprofit research organization, and Pfizer Inc. to develop quality indicators for medical care provided to vulnerable elders, defined as community dwelling individuals age 65 and older at increased risk of functional decline over a two year period. The first set was created in 1999 and has been updated twice in order to stay abreast of the current medical literature and to create a more comprehensive set. The ACOVE-3 Quality Indicator Measurement Set, is comprised of 392 quality indicators measuring processes of care for 26 conditions. For each condition, a content expert assembled a candidate list of indicators based on a review of the literature, guidelines, and existing measures. The evidence underpinning each quality indicator is presented in a series of peer-reviewed monographs (ACOVE investigators, in press). The indicators were then reviewed and rated by two multidisciplinary panels of clinical experts. Most of these indicators are intended to measure care at the level of the health system, health plan, or medical group, and may apply to the hospital outpatient setting; a small number are not relevant to the hospital outpatient setting due to their focus on inpatient or nursing home care. A subset of these indicators (less than 20) has been submitted to the NQF for approval. The original set of 236 indicators (ACOVE-1) was tested using vulnerable elder data from two senior managed care plans, and then used in an intervention by two additional medical groups. Some of these indicators that can be measured using administrative data have been applied to a sample of “dual eligible” (i.e., Medicare/Medicaid) patients in California. While many components have been implemented, the complete ACOVE-3 set has not been tested.

The ASSIST project, led by RAND Corporation, developed a comprehensive set of quality indicators addressing symptoms and symptomatic complications, treatment-related toxicities, and information and care planning needs for adults living with cancer. The indicators were intended to apply to major clinical sites where cancer patients seek care including general practice and oncology settings. They were selected through a multi step process starting with the development of a list of topics ranked by prevalence, likely impact on patient and family quality of life, existing literature and the strength of medical evidence. Through an iterative process of team discussion, revision and advisory board input, the five member research team drafted a set of indicators after reviewing relevant clinical trials, guidelines and quality indicators and soliciting expert opinion from national clinical leaders. Nine panelists representing multidisciplinary disciplines including medicine, nursing, and social work; geographic diversity; academic and community settings; oncology and other specialties including palliative medicine; and general internal medicine rated the indicators on validity and feasibility. A total of 92 of 133 (69 percent) proposed indicators were judged valid and feasible by the panel. The indicators were developed for group practice and may be applied to health plans or systems of care.

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