Performance Measurement in the Hospital Outpatient Setting. Existing Measures

02/01/2008

Our review of publicly available performance measures revealed that there are few clinical performance measures that are being used to assess care provided at the hospital outpatient facility level. The exception is five ED measures recently developed by the OFMQ, which address the timing of care for acute myocardial infarction (AMI). Discussants were not aware of other hospital outpatient measures in use or available for use.

The majority of measures that are potentially applicable to the hospital outpatient setting address a broad array of diseases/conditions that are reimbursed under the OPPS (see Appendix D for the complete list of measures). However, the vast majority of these measures were designed to be used or are currently being used to evaluate care provided by individual physicians or medical groups, not hospital facilities; as a consequence, the existing measures may require modification of the specifications prior to their application within the hospital outpatient setting.

Regarding existing physician performance measures, the largest and broadest sets of measures have been developed by the AMA’s PCPI, the NCQA, the Assessing Care for Vulnerable Elders (ACOVE) project and the Assessing Symptoms Side Effects and Indicators of Supportive Treatment (ASSIST) project. A description of the measurement development activities of each of these groups appears in Appendix E. In addition, other organizations--such as the Renal Physicians Association, American Society of Clinical Oncologists (ASCO), and the American Gastroenterological Association Institute (AGAI)--have developed clinical performance indicators to assess care for specific diseases/conditions treated by that specialty (e.g., chronic kidney disease, cancer, polyp surveillance), some of which may be pertinent to care delivered in the hospital outpatient setting. For example, ASCO’s Quality Oncology Practice Initiative (QOPITM) has developed practice-level, cancer-specific measures that may be suitable for application in the hospital outpatient setting.

The list of candidate measures also includes a majority of the measures included in the CMS Physician Quality Reporting Initiative (PQRI). These physician measures derive primarily from the AMA’s PCPI, NCQA, and the National Cancer Care Network (NCCN).29 Of the 74 measures currently included in the program, 63 apply to Medicare enrollees in the ambulatory setting and the remaining apply to inpatient care or children.

Table 3.7 summarizes the clinical areas addressed by measures potentially relevant to the hospital outpatient setting and emergency department. We have included measures from the Consumer Assessment of Health Providers and Systems (CAHPS) family of surveys. 30

Of the over 700 measures identified, the vast majority are clinical process measures.

  • Approximately 10 percent (75 of 718) measure patient outcomes; these are in the areas of diabetes and chronic kidney disease control; depression treatment outcomes; complications from colonoscopy, cataract surgery and MRI; and outcomes of prostate cancer treatment.
  • The only structural measures identified apply to prostate cancer treatment and include the number of patients a physician has treated, availability of psychological counseling for patients, board certification of urologists and radiologists, and the availability of outcome information for patients treated by an institution.
  • There are seven measures that address resource use for low back pain, cardiovascular conditions, uncomplicated hypertension, asthma, COPD and deep vein thrombosis.
  • The CAHPS family of surveys provides the largest source of potentially relevant patient experience measures. Specifically, many of the ambulatory questions from the CAHPS Clinician & Group Survey apply to the hospital outpatient setting fairly readily; some inpatient-related questions from the CAHPS Hospital Survey (HCAHPS) are also relevant to the hospital outpatient context. For the majority of measures we identified, detailed specifications are in the public domain and are available on the websites of the measure developers.
Clinical Area Key Conditions/ Procedures Addressed by Measures
Table 3.8. Summary of Clinical Areas Addressed by Measures Potentially Relevant to the Hospital Outpatient Setting and Emergency Department
Prevention and Screening Breast Cancer, Colorectal Cancer, Cervical Cancer, Tobacco Use, Vaccination, Medication Use, Problem Drinking, Obesity, Osteoporosis, Fall Risk, Depression, Vision, Hearing, Sleep Disorders
Allergies/Sinus Sinusitis, Rhinitis
Ambulatory Surgery Preoperative Assessment, Antibiotic Timing,  Antibiotic Selection, Venous Thromboembolism Prophylaxis
Behavioral Health Depression, Bi-polar Disorder, Alcohol/Drug Dependence, Dementia
Bone and Joint Conditions Osteoporosis, Osteoarthritis, Rheumatoid Arthritis, Low Back Pain, Ankle Sprain, Physical Therapy for Hip/ Knee/ Lumbar/ Shoulder
Cancer Blood, Breast, Colorectal, Head and Neck, Lung, Prostate, General (including symptom control)
Cardiovascular Conditions Acute Myocardial Infarction (AMI), Coronary Artery Disease (CAD), Heart Failure (HF), Venous Thromboembolism (VTE)
Dermatological Conditions Melanoma, Pressure Ulcers
Diabetes HbA1c, Blood Pressure, Cholesterol, Eye Exam, Foot Exam, Smoking, Depression, Aspirin Use
Eye Disease/Vision Diabetic Retinopathy, Cataracts, Glaucoma, Macular Degeneration
Gastrointestinal Disorders Gastroesophageal Reflux Disease (GERD)
Hearing Loss Testing, Referral, Rehabilitation
Hepatitis C Testing, Antiviral Therapy, Vaccination, Alcohol Use,  Contraception Use
HIV/AIDS ARV Management, Self Management, Health Maintenance, Case Management
Hypertension Blood Pressure, Patient Education, Plan of Care, Renal Function, Alcohol Intake, NSAID Reduction, Resource Use
Medication Use (Vulnerable Elders) Patient Education, Drugs to be Avoided
MRI Complications
Neurological Disorders Migraine, Stroke, Sleep Disorders
Renal Disease Chronic Kidney Disease
Respiratory Illness/Asthma Chronic Obstructive Pulmonary Disease (COPD), Asthma, Acute Bronchitis, Viral Upper Respiratory Disease, Pharyngitis
Under-nutrition Weight Measurement, Vitamin D, Co-Morbid Conditions
Urological Conditions Urinary Incontinence, Urinary Tract Infections (UTI), Benign Prostatic Hyperplasia (BPH)
Other Clinical Emergency Department Discharge, Radiology Reporting, Pain Management, End of Life Care, Continuity and Coordination of Care, Falls and Mobility
Patient Experience HCAHPS, C-G Ambulatory CAHPS

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