Performance Measurement in the Hospital Outpatient Setting. Scan of Existing Measures and Gaps


From our synthesis of information from the analysis of Medicare OPPS facility data, the scan of existing performance measures being applied in other settings, and discussions with medical specialty societies and hospital associations, we find:

Only a small number of measures specific for immediate application in the hospital outpatient setting currently exist or are in the pipeline. Ten measures comprise the initial hospital outpatient measure set to be used in HOP QDRP starting in January 2008; five pertain to care provided in the ED, and five assess performance related to diabetes, pneumonia, heart failure, and the use of antibiotics at time of surgery. Additionally, CMS has released 30 candidate measures for consideration that address a variety of conditions such as diabetes, fall risk, heart failure, depression, and stroke.

There is a large number of existing performance measures developed for use in other settings that are likely applicable to the care provided in the hospital outpatient setting. The scan of existing performance measures yielded approximately 700 measures that are publicly available and were developed for use in inpatient and ambulatory care settings, many of which are relevant to care delivered in the hospital outpatient setting. The majority of these publicly available, existing performance measures assess clinical effectiveness, primarily the underuse of services. Many are part of broad sets of ambulatory care measures (currently being applied at the physician, practice site, or medical group levels) that were developed by the American Medical Association’s Physician Consortium for Performance Improvement (PCPI), the National Committee for Quality Assurance (NCQA), the Assessing Care of Vulnerable Elders (ACOVE) project, and the Cancer Quality  – ASSIST (Assessing Sympoms Side Effects and Indicators of Supportive Treatment) Project. A number of these measures assess performance related to key reasons for visits to the HOPS (e.g., acute myocardial infarction (AMI), coronary artery disease (CAD), congestive heart failure (CHF), diabetes); cancer (especially breast, gastrointestinal, and prostate); and mental health. Additionally, measures developed by medical specialty societies assess care for specific diseases/conditions treated by that specialty (e.g., chronic kidney disease, cancer, polyp surveillance). A few measures assess care provided for cataract extraction, indications for cardiac catheterization, and treatment for cardiac arrhythmias. Apart from clinical effectiveness, there are existing measures of patient experience (CAHPS Clinician & Group, and Hospital Surveys) and patient safety (e.g., culture of safety, medication safety) that may be applicable to the hospital outpatient setting, though modifications in the measures would likely be required to make them directly applicable. While, our review focused only on publicly available measures, there are propriety measures in existence that may be relevant for assessing care provided in the hospital outpatient setting (e.g., RAND’s Quality Assessment (QA) Tools to assess clinical effectiveness, Symmetry’s Episode Treatment Groups (ETGs) to assess relative resource utilization).

Important Gaps Exist in Hospital Outpatient Services Measurement Areas. Despite the large number of existing measures identified that assess clinical effectiveness, there is an absence of measures that examine the appropriateness of care or use of services/procedures, such as imaging which has seen dramatic growth in utilization. Other measurement gaps include: ED care (especially measures to assess care provided to patients who have not yet been definitively diagnosed-- a common situation in the ED); some types of cancer care (e.g., lung cancer); specialty care; follow-up care; coordination-of-care/transitions-in-care; transmission of test results; outcomes; and episodes of care. In light of the performance dimensions identified by the IOM, there is also an absence of well-tested and validated measures of efficiency, equity, and timeliness of care.

Overall, while deficits in measures exist for some performance dimensions, there are a substantial number of existing measures that could either be directly applied or readily adapted for use in the hospital outpatient setting, particularly those addressing acute and chronic care provided in the ambulatory care setting, thus providing a near-term source of candidate measures for the HOP QDRP.

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