Performance Measurement in the Hospital Outpatient Setting. IV. Synthesis of Existing Measures and Identification of Gaps. Synthesis of Existing Measures and Identification of Gaps

In this chapter, we draw from our analysis of 2005 Medicare data, scan of publicly available existing measures, and discussions with medical specialty societies and hospital associations to synthesize the reach of existing measures and identify the gaps in potential measures for the HOPS and ED. We also describe several data collection challenges associated with the development of measures for the hospital outpatient setting.

• Equity

  • Although there is widespread awareness of health disparities by population subgroups, our review did not identify any specific measures of equity. However, many existing measures could be applied and the results stratified by various sub-populations to determine where disparities are occurring and to focus attention on closing these gaps provided subgroup identifiers are in the data. The IOM has identified equity as a priority area for measure development (IOM, 2005), and the Robert Wood Johnson Foundation has issued a call for proposals in an effort to improve the understanding of how to measure equity and its role in promoting quality. Additionally, the National Academy of Social Insurance has made recommendation to CMS of ways in which it could strengthen its capacity to assess and address disparities (Vladeck et al, 2006).

• Mapping of Clinical Measures

  • Figure 4.1 provides an overview of our mapping of existing measures to HOPS and ED encounter data. Encounters were grouped into three categories in our analyses: visits, drugs/biologicals, and services/procedures. For each category, we considered the types of activities that typically occur during the encounters. We then used this assessment to determine which measures are relevant to each type of encounter for the mapping exercise. We performed this measures mapping exercise to determine the clinical conditions and services for which measures currently exist and those for which there is a deficit.

    When we examined reasons for visits, we found that appropriate measures and services would include additional E&M services (i.e., visits), such as referral to other doctors and specialists; medications appropriate to findings from the examination; or a request for an appropriate service/procedure, such as colonoscopy or referral to a dermatologist to remove a pigmented mole. For example, existing measures specify that an overweight patient should have this issue addressed annually, and geriatric patients should be screened annually for cognitive and functional impairment. Measures exist to assess whether patients presenting with community-acquired pneumonia receive empiric antibiotic therapy, a situation where a visit prompts prescription of a medication. Visits may also result in referral for a service/procedure such as colonoscopy, mammography, or a laboratory test (such as creatinine for patients receiving cisplatin).

    Figure 4.1. Mapping of Reasons for Visits to Existing Clinical Measures

    

    Some encounters occur wherein patients only receive drugs or biologicals, such as interferon for Hepatitis C or Trastuzumab administration for HER2/Neu positive patients. There are some existing measures that address the appropriate use of medications and biologics, and these may be appropriate to care delivered in the outpatient hospital setting. A careful review of existing measures against the care provided in the outpatient hospital setting would be a key next step, to see if the measures are applicable and how their specifications may need to be adapted to be operationalized using hospital outpatient data sources. Given the large number and type of drugs and biologicals used, it is likely that there are substantial measure gaps related to the appropriate use of drugs and biologicals in treating Medicare beneficiaries.

    Finally, with respect to the services/procedures we examined, we found two points of interest: (1) the appropriateness of ordering of the service/procedure, such as a measure specifying the clinical situations under which a patient in the ED should undergo an MRI; and (2) the quality of the provision of the service/procedure by the performing specialist, such as a measure addressing the documentation of pre-surgical axial length in cataract patients, or a measure assessing the communication of colonoscopy results to the primary care physician.

• Syntheses of Measures

• Identification of Gaps in Measures

  • In conducting our gap analysis, we considered how the measures identified in our review relate to the six aims identified by the IOM (2001) as being critical to ensuring a high-quality health care system: (1) effectiveness, (2) efficiency, (3) equity, (4) patient-centeredness, (5) safety, and, (6) timeliness.

• Effectiveness

  • 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.

• Efficiency

  • Discussants stressed the existence of a significant and growing interest in efficiency measures. At this time, existing efficiency measures reflect measures of relative resource utilization and have not taken into account differences in quality by resource use. Existing efficiency measures have been applied primarily by private sector health plans looking for opportunities for cost savings to reduce the growth in health care trend. Information derived from application of these tools typically has been provided to physicians, integrated health systems, and hospitals as part of internal improvement efforts; the tools are only in their early stages of being validated for use in public reporting and pay for performance.

    Discussants noted that both the NQF and the AQA have assembled workgroups to identify and endorse measures of efficiency. The AQA has also proposed a starter set of cost-of-care measures pertaining to seven conditions (diabetes, AMI, CHF and CAD, asthma, depression, and low back pain), but measures have not yet been developed and would need to be linked to quality-of-care measures to assess efficiency (rather than cost alone). The AQA/HQA Steering Committee has convened an Efficiency/Episodes of Care Work Group to develop a comprehensive approach to efficiency measurement, which includes an examination of the overall system, medical group, practice site and individual physicians, and that takes into account episodes of care as well as primary responsibilities for the care provided (AQA, 2007).

• Patient-Centeredness

  • Although the CAHPS Hospital, and Clinician & Group Surveys provide a strong source of measures that could be used to evaluate patient-centeredness in the hospital outpatient setting, patient experience measures are lacking that address the provision of clinical care, such as the reporting of specific test results. At present there are also no measures that assess whether or how institutions address health literacy³⁹ and health numeracy.⁴⁰

• Safety

  • A large number of existing patient safety measures apply primarily to care provided in the inpatient setting (e.g., Leapfrog’s Safety Leaps, AHRQ’s Patients Safety Indicators (PSIs), and the SCIP measures). However, a number of these safety measures that apply more universally — such as a culture of safety, hand washing and other infection control measures, and medication verification — would be appropriate for application in the hospital outpatient setting.

• Timeliness

  • Measures are lacking to assess the turnaround times for the provision of care and for diagnostic tests being performed. As discussants noted, the OFMQ has developed ED measures that assess the timing of AMI care; more measures are needed that address the timing of care related to other diagnoses in the ED, as well as in the HOPS.

• Challenges in Performance Measurement

  • In addition to identifying the need for additional measures, our synthesis and gap analysis underscored several challenges related to the operational aspects of measurement from the vantage point of the hospital, including:

    • Sample Size: Although the 2005 dataset used in our analyses contains many millions of claims, the number of visits and services/procedures that occur in any given hospital outpatient setting for a specific condition may be small. As measures are developed, it will be important to examine the data to assess whether there are adequate patient volumes at the hospital-level to ensure stable estimates of HOPS or ED performance. Additionally, the fact that additional sample size would be required to stratify data by such factors as race/ethnicity, socio-economic status, and/or gender to assess equity of care also merits consideration.
    • Lack of Provider Engagement: Most physicians are not employed directly by hospitals, making it difficult for hospitals to force adherence to hospital protocols  – in either the inpatient or outpatient setting. Discussants encouraged gain-sharing as a means to encourage joint accountability for physicians and hospitals. As one said, “In order to get traction, everyone (i.e., hospitals and physicians) has to have something at risk.” Appropriately and fairly assigning accountability for specific actions is another important way to engage providers; however, it is not always clear how to do so. For example, some patients have several physicians, raising the question of who should be held responsible in such situations.
    • Lack of Staff: Although the HOPS and ED may be able to draw staff from their associated hospitals (which generally have quality departments with analysts experienced in data abstraction), hospital outpatient settings have not traditionally been staffed or budgeted to provide the medical record abstraction and analytic services needed for performance measurement activities.
    • Lack of Adequate Detail in Existing Claims Data to Support Quality Measurement: Because claims data are generated for billing and not quality of care purposes, data elements needed for quality of care assessment are often lacking, particularly those data required for risk adjustment.
      • E&M codes broadly address the level of service provided, but do not capture specific service details and organ systems addressed. For example, it would not be possible, using standard claims data, to ascertain whether a patient’s blood pressure was taken as part of an office visit
      • Claims data also do not include specific laboratory, radiographic, or clinical values, so it is not possible to use claims data to score quality of care measures that require these data elements. For example, laboratory data indicating the need for altered diabetic therapy would be dependent on the HbA1c level. Claims data will reflect only that an HbA1c was ordered, not whether the result was such that action should be undertaken. Similarly, knowing that a hematocrit was performed is insufficient to determine whether a patient met criteria for receipt of erythropoietin. Capturing medication prescribing information related to specific conditions is notably difficult, although increasingly data may start to become available with the Medicare Prescription Drug benefit.
      • While the date of a service is captured, the actual timing of the care provided is often not evident from claims data; thus, it could not support measures that examine timing in hours, such as many measures addressing AMI care.

    Development of new CPT Category II performance measurement codes as well as Medicare G codes (HCPCS level II codes) is underway, which, if used, will shed more light on the care provided during visits. In the meantime, however, this information is often not available given that it is beyond what is currently required for claims submission. Claims submissions forms may require modification to collect the necessary data elements to produce a performance measure, if administrative data sources will be used to construct measures.

    Although some discussants expressed hope that electronic health records (EHRs) will be able to provide easily retrievable data, they underscored that the implementation of EHR systems ready for use in clinical performance measurement is still “a long way off.” In the near term, implementation of measures will likely entail manual chart abstraction or changes in billing codes. Registries were mentioned as a potential source of data for performance measures by representatives of at least two organizations. They indicated they were placing a higher priority on registries, as opposed to developing specific performance measures. One group believes that utilizing registries is a more effective way to improve health care quality. Both groups encouraged CMS to do more to develop and encourage national registries in a broad spectrum of clinical areas. It should be noted that TRHCA requires that, as part of rulemaking for 2008 measures, CMS address a mechanism for providing data on quality measures through an appropriate medical registry. As such, CMS is currently exploring the possibility of drawing on existing databases and registries maintained by a variety of organizations (e.g., medical professional societies, medical boards, medical group management organizations), with the goal of decreasing the burden of quality reporting for all involved while increasing the quality and usefulness of the data (Kuhn, 2007).

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