While we found many measures of clinical effectiveness, our analysis also revealed a number of key gaps in existing measures:
- ED Care: With the exception of the ED measures being developed by the OFMQ, there are no existing measures to evaluate care at the ED facility level. However, as noted previously, the NQF released a call for ED transfer measures in June 2007 and has plans to address other ED issues in the coming year, so some measures for this setting are likely to be forthcoming in the near future.
- Cancer: While measures exist that address breast and colorectal cancer care, they are lacking for many other cancer diagnoses (e.g., lung cancer).
- Specialty care: While hospital outpatient clinics tend to focus on specialty care, we found that most existing measures address diagnoses that impact primary, not specialty care. The PCPI is working to fill some of these gaps.
- Follow-up care: Measures are lacking to assess appropriate follow-up care after services/procedures, ED visits, and hospitalizations. As discussants noted, measure development is challenging, given that the science related to follow-up care in many areas is not robust.
- Coordination-of-care/Transitions-in-care: There is a lack of measures that bridge transitions from inpatient to outpatient settings and also among different outpatient settings (e.g., ED to ambulatory care). Kaiser Permanente has developed some measures; however, given Kaiser’s unique closed-model health system, implementation of them in other types of health systems may differ. The American Board of Internal Medicine (ABIM), with grant support from AHRQ, has led a consortium of specialty societies and other stakeholders in developing a set of principles and standards for improving transitions across locations of care. It is anticipated that these principles will serve as the basis of measure development by the PCPI. Additionally, NQF’s recent call for ED transfer measures will likely generate some transitions in care measures for this setting.
- Transmission of Test Results: Measures are lacking that assess the timely and accurate transmission of test results, such as from radiological imaging or laboratory tests or from provider to provider within in the hospital outpatient setting as well as to providers in other care settings.
- Outcomes: The overwhelming majority of measures assessing clinical effectiveness that we identified are clinical process measures. Given the increasing interest in the tracking outcomes (the “bottom line” of health care, in the words of some discussants), there is a need to develop outcome measures. Such development will require further strides in risk adjustment methodologies, given the multiple factors that can influence outcomes.
- Episodes of care: The overwhelming majority of measures assessing clinical effectiveness that we identified track components of care in isolation, rather than taking into account care delivered for a specific condition or clinical event across different health care settings. As such, there is a need for evidence-based measures that assess the clinical care provided for the entirety of an episode of care, regardless of setting or level within the health care system. The AQA/Hospital Quality Alliance (HQA) Steering Committee has convened an Efficiency/Episodes of Care Work Group to address this need.