Performance Measurement in the Hospital Outpatient Setting. Measures in the Development Pipeline


Our discussions with representatives of medical specialty societies and hospital associations yielded information about other measures currently under development. According to the representatives with whom we spoke, CMS’s pressing need to respond to the legislative mandate set forth in the TRHCA of 2006 has significantly increased interest in and resources devoted to the development of hospital outpatient performance measures, both within CMS and more broadly.

In June 2007, CMS awarded a contract to the OFMQ to develop a preliminary set of hospital outpatient clinical performance measures for inclusion in the proposed rule released August 2, 2007 (CMS, 2007). CMS tasked the OFMQ with writing specifications for 10 existing measures to make them applicable to the hospital outpatient setting. The measures include:

  • Three PQRI measures addressing diabetes, pneumonia, and heart failure,
  • Two Surgical Care Improvement Project (SCIP)31 measures addressing use of antibiotics at the time of surgery, and
  • Five ED measures addressing AMI care for patients transferred from one ED to another hospital for admission

Additionally, CMS is seeking public comment on a list of 30 measures under consideration in the hospital outpatient setting These measures address a wide variety of conditions relevant to the Medicare population, including:

  • Diabetes,
  • Fall risk,
  • Depression,
  • Stroke,
  • Acute myocardial infarction,
  • Medication safety,
  • Asthma,
  • Osteoporosis,
  • Pneumonia,
  • Cancer screening and treatment,
  • Emergency department care for chest pain, syncope and pneumonia,
  • Glaucoma,
  • Macular degeneration,
  • Urinary incontinence, and
  • Advance care planning.

Many of these measures are being used as part of the PQRI for physician measurement. To use these measures in the hospital outpatient setting will require adjustments to the technical specifications to ensure they can be operationalized from the HOPS and ED data sources.

Besides measures that CMS is developing, medical specialty societies and hospital associations said that the next most significant source of clinical performance measures in the pipeline for use in the hospital outpatient setting are existing physician performance measures. These measures provide a valuable foundation on which to build a set of hospital outpatient measures because of the breadth of clinical conditions covered and the credible process used to develop these measures. Discussants noted that the PCPI is an ongoing initiative that will continue to generate new clinical performance measures addressing a variety of conditions, many of which could apply to care delivered in the outpatient hospital setting.

Existing hospital inpatient measures are another potential source applicable to the hospital outpatient setting, according to some discussants. This is because some of the care and many of the services/procedures formerly performed in the inpatient setting are now occurring in the outpatient setting. However, another discussant cautioned that, at least for surgery, there are a limited number of inpatient measures that would apply to outpatient surgery. This is because many of the inpatient measures apply to antibiotic use and venous Thromboembolism prophylaxis which are not used in many outpatient surgeries. A few discussants also noted that existing clinical practice guidelines might serve as a potential pipeline for hospital outpatient measures, but these discussants cautioned that much work is required to translate such guidelines into detailed measure specifications.

Other measurement development efforts mentioned by discussants that are on the near-term horizon and are directly applicable to the hospital outpatient setting include:

  • The American College of Radiology (ACR) is developing facility-level measures for outpatient care. These are safety measures that relate to minimizing radiation exposure to individual patients, equipment use, use of contrast material, and screening patients for allergies and the potential for renal impairment. In considering these measures, the developers found that they were difficult to attribute to any one physician and determined that they are more appropriate for facility-level measurement.
  • The Ambulatory Surgery Center (ASC) Quality Collaboration32 has submitted eight facility-level measures to the NQF. These measures were reviewed in June 2007, and NQF has recommended five for public review and comment. The measures cover patient burns, antibiotic timing, hospital transfer/admission, patient falls, and wrong site/side/patient/procedure/implant.
  • The NQF issued a “call for measures” in June 2007 to identify measures that address the quality of hospital-based ED care with particular emphasis on clinical quality, coordination, and efficiency. Initially, the NQF will focus on ED transfers only, but plans to address other aspects of hospital-based ED care (e.g., patient wait times, overcrowding) later in the year.
  • The American College of Cardiology (ACC) and the American Heart Association currently have measures under development for atrial fibrillation, primary prevention of cardiovascular disease, and peripheral arterial disease.

The medical specialty societies and hospital associations underscored that when they prioritize measures for development, they tend to assess the following factors: high volume, high cost/ resource allocation, high variation, high risk, the amount of evidence, and the interest of constituents. Almost all remarked that clinical performance measures are their highest priority at present; however, several noted their interest in coordination of care measures.

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