Medicare Post-Acute Care: Quality Measurement Final Report. APPENDIX E. Final Ratings and Dropped Quality Indicators

03/29/2001

Table of Contents

CHF -- Final Ratings

Pneumonia -- Final Ratings

Stroke -- Final Ratings

Back & Neck -- Final Ratings

Discussion of Dropped Quality Indicators

CHF -- FINAL RATINGS
Rank Count Domain Indicator
1 9 Physical Function General/Global Function
2 9 Physical Function Self Care
3 9 Physical Function Ambulation/Mobility
4 9 Mental Health Depression
5 9 Quality of Life Well-being
6 9 Quality of Life Health-related quality of life
7 9 Utilization Hospitalization
8 9 Satisfaction Patient satisfaction
9 8 Quality of Life Role resumption
10 8 Utilization Total inpatient days
11 8 Process Evaluation of medication compliance
12 7 Satisfaction *Caregiver satisfaction
13 6 Utilization *Home health care use
14 6 Physiology Mortality
15 5 Quality of Life Social function
16 5 Utilization *Skilled Nursing Facility admission
17 5 Physiology Weight Change
18 5 Process *Patient education
19 4 Utilization Emergency room admission
20 4 Utilization *Rehabilitation facility admission
21 4 Process *Medication review
22 4 Process ACE Inhibitor use (or alternative where appropriate e.g. nitrates or hydralazine)
23 3 Quality of Life Self-perceived ability to participate in social/recreational activities
24 3 Quality of Life Subjective well-being
25 3 Quality of Life Days in bed
26 3 Quality of Life Days of limited activity
27 3 Quality of Life Household activities
28 3 Utilization Total combined PAC
29 3 Utilization Level of care provided
30 3 Process Non use of calcium channel blockers in systolic heart failure
31 2 Mental Health Cognition
32 2 Mental Health Patient Motivation
33 2 Quality of Life Recreation
34 2 Quality of Life Living situation
35 2 Utilization Admission to ICU
36 2 Physiology Edema
37 2 Physiology Pain
38 2 Physiology Dyspnea
39 2 Process Daily Weights
40 2 Process Appropriate response to change in status e.g. increase diuretics
41 2 Process Prescription of exercise
42 2 Process Caregiver education
43 2 Process Discussion of advance care directives
44 1 Physical Function Exercise tolerance
45 1 Mental Health Sedative hypnotic use
46 1 Mental Health Anxiety
47 1 Utilization Amount and intensity of care provided
48 1 Physiology Electrolyte abnormalities
49 1 Physiology Fatigue
50 1 Physiology Chest Pain
51 1 Physiology Oxygenation
52 1 Physiology Pressure sores
53 1 Process Sodium restriction
54 1 Process Treatment/control of hypertension
55 1 Process Depression Treatment
56 1 Process Family education
57 1 Process Integrated, multidisciplinary care program
58 1 Process Monitoring drug therapy
59 1 Process Patient knowledge
60 0 Mental Health Antipsychotic drug use
61 0 Mental Health Delirium
62 0 Quality of Life Days of work absenteeism
63 0 Quality of Life Work status
64 0 Quality of Life Compensation status
65 0 Quality of Life Job description
66 0 Quality of Life Vocational outcomes
67 0 Utilization Use of home-delivered meals (Meals-on-Wheels)
68 0 Physiology Rales
69 0 Physiology S3 gallop
70 0 Physiology Chest Xray abnormalities
71 0 Physiology Nausea
72 0 Physiology Vomiting
73 0 Physiology Cough
74 0 Physiology Sensory Changes
75 0 Physiology Urinary Incontinence
76 0 Physiology Fecal Incontinence
77 0 Physiology Anorexia, diminished appetite
78 0 Physiology Sleep Disorder
79 0 Physiology Sputum production
80 0 Physiology Heart Rate
81 0 Physiology Respiratory Rate
82 0 Physiology Blood Pressure
83 0 Physiology Deep Venous Thrombosis
84 0 Physiology Pulmonary Embolism
85 0 Physiology Aspiration pneumonia
86 0 Physiology Flexion contractures
87 0 Physiology Dehydration
88 0 Physiology Falls
89 0 Physiology Falls with injury
90 0 Physiology Constipation
91 0 Physiology Fecal impaction
92 0 Physiology Electrolyte complications
93 0 Physiology Adverse drug reactions
94 0 Physiology Wound infections
95 0 Physiology Nosocomial infections
96 0 Physiology Rash
97 0 Physiology Renal Failure
98 0 Physiology Hepatic function abnormalities
99 0 Physiology Pleural effusion
100 0 Physiology Urinary retention
101 0 Physiology Clostridium difficile infection
102 0 Physiology Malnutrition
103 0 Process Evaluation of dietary compliance
104 0 Process Evaluation for ischemia
105 0 Process Evaluation for chronic hypoxemia
106 0 Process Evaluation for exercise-induced hypoxemia
107 0 Process Referral to cardiologist
108 0 Process Prescription of oxygen
109 0 Process Anticoagulation for severe left ventricular dysfunction
110 0 Process Time to nurse or physician follow-up after hospital discharge
111 0 Process Persistence of urinary catheter
112 0 Process Immunization status
113 0 Process Dietician evaluation
114 0 Process Sedative hypnotic use
115 0 Process Antipsychotic use
116 0 Process Assessment of LV function
* Dropped indicators.
Indicators that were discussed at the panel meetings are in bold.

 

PNEUMONIA -- FINAL RATINGS
Rank Count Domain Indicator
1 9 Satisfaction Patient satisfaction
2 8 Physical Function General/Global Function
3 8 Physical Function Self Care
4 8 Quality of Life Health-related quality of life
5 8 Utilization Hospitalization
6 8 Physiology Fatigue
7 8 Physiology Dyspnea
8 8 Physiology Cough
9 8 Satisfaction *Caregiver satisfaction
10 7 Physical Function Ambulation/Mobility
11 7 Mental Health *Cognition
12 7 Quality of Life Role resumption
13 7 Utilization Physician visits for pneumonia
14 7 Utilization *Home health care use
15 7 Utilization Total inpatient days
16 7 Physiology *Time to reach stability
17 7 Process Discussion of advance care directives
18 6 Quality of Life Return to usual activities
19 6 Process Immunization status
20 6 Process Cognition evaluation
21 6 Process PT evaluation
22 5 Physiology Mortality
23 5 Process Blood cultures, etc.
24 5 Process OT evaluation
25 4 Quality of Life *Days of limited activity
26 4 Utilization Emergency room admission
27 4 Utilization *Skilled Nursing Facility admission
28 4 Process *Patient education
29 4 Process Appropriate antibiotic use
30 3 Mental Health Depression
31 3 Quality of Life Social function
32 3 Physiology Follow-up x-ray findings
33 3 Process Time until begin antibiotics
34 2 Mental Health Delirium
35 2 Quality of Life Self-perceived ability to participate in social/recreational activities
36 2 Utilization Admission to ICU
37 2 Utilization Rehabilitation facility admission
38 2 Utilization Total combined PAC
39 2 Utilization Level of care provided
40 2 Physiology Duration of respiratory symptoms
41 2 Physiology Oxygenation
42 2 Physiology Dehydration
43 1 Quality of Life Subjective well-being
44 1 Quality of Life Days in bed
45 1 Quality of Life Household activities
46 1 Quality of Life Recreation
47 1 Physiology Duration of fever
48 1 Physiology Sputum production
49 1 Physiology Falls with injury
50 1 Physiology Pleural effusion
51 1 Physiology Clostridium difficile infection
52 1 Physiology Respiratory symptoms
53 1 Process Caregiver education
54 0 Mental Health Anxiety
55 0 Mental Health Patient Motivation
56 0 Quality of Life Days of work absenteeism
57 0 Quality of Life Work status
58 0 Quality of Life Compensation status
59 0 Quality of Life Job description
60 0 Quality of Life Vocational outcomes
61 0 Quality of Life Living situation
62 0 Utilization Use of home-delivered meals (Meals-on-Wheels)
63 0 Utilization Amount and intensity of care provided
64 0 Physiology Morbid complications:
65 0 Physiology Pleural exudate
66 0 Physiology Abcess/empyema
67 0 Physiology Meningitis
68 0 Physiology Otitis media/sinusitis
69 0 Physiology Myocarditis/aseptic arthritis
70 0 Physiology Cardiovascular
71 0 Physiology Asthma
72 0 Physiology Duration of fever and chest pain
73 0 Physiology Pain
74 0 Physiology Nausea
75 0 Physiology Vomiting
76 0 Physiology Sensory Changes
77 0 Physiology Urinary Incontinence
78 0 Physiology Fecal Incontinence
79 0 Physiology Anorexia, diminished appetite
80 0 Physiology Sleep Disorder
81 0 Physiology Chest Pain
82 0 Physiology Heart Rate
83 0 Physiology Respiratory Rate
84 0 Physiology Blood Pressure
85 0 Physiology Deep Venous Thrombosis
86 0 Physiology Pulmonary Embolism
87 0 Physiology Aspiration pneumonia
88 0 Physiology Pressure sores
89 0 Physiology Flexion contractures
90 0 Physiology Falls
91 0 Physiology Constipation
92 0 Physiology Fecal impaction
93 0 Physiology Electrolyte complications
94 0 Physiology Adverse drug reactions
95 0 Physiology Wound infections
96 0 Physiology Nosocomial infections
97 0 Physiology Rash
98 0 Physiology Renal Failure
99 0 Physiology Hepatic function abnormalities
100 0 Physiology Urinary retention
101 0 Physiology Malnutrition
102 0 Process Depression treatment
103 0 Process Family education
104 0 Process Integrated, multidisciplinary care program
105 0 Process Time to nurse or physician follow-up after hospital discharge
106 0 Process Persistence of urinary catheter
107 0 Process Monitoring drug therapy
108 0 Process Dietician evaluation
109 0 Process Sedative hypnotic use
110 0 Process Antipsychotic drug use
* Dropped indicators.
Indicators that were discussed at the panel meetings are in bold.

 

STROKE -- FINAL RATINGS
Rank Count Domain Indicator
1 9 Physical Function Self Care
2 9 Physical Function IADLs
3 9 Physical Function Ambulation/Mobility
4 9 Physical Function Communication
5 9 Quality of Life Health-related quality of life
6 9 Quality of Life Role resumption
7 9 Satisfaction Patient satisfaction
8 9 Satisfaction *Caregiver satisfaction
9 8 Physical Function General/Global Function
10 8 Mental Health Depression
11 8 Process Speech evaluation
12 8 Process Family/caregiver education and support
13 8 Process Anticoagulation therapy (stroke prevention)
14 7 Mental Health *Cognition
15 7 Quality of Life Social function
16 6 Physical Function *Gait and Balance
17 6 Quality of Life *Recreation/Leisure
18 6 Utilization Nursing home resident at some time x
19 6 Process Integrated, multidisciplinary care program
20 6 Process PT evaluation
21 6 Process OT evaluation
22 5 Utilization Hospitalization
23 5 Utilization *Level of care provided
24 5 Physiology Mortality
25 4 Physical Function Community Mobility
26 4 Utilization *Medicare-covered inpatient days
27 4 Process Swallow evaluation
28 4 Process *Motivation evaluation
29 3 Utilization Home health care use
30 3 Utilization Total inpatient days
31 3 Physiology Pressure sores
32 3 Process Receipt of appropriate therapy as long as functional recovery taking place
33 2 Quality of Life Days of limited activity
34 2 Quality of Life Caregiver stress
35 2 Utilization Emergency room admission
36 2 Utilization Rehabilitation facility admission
37 2 Physiology Flexion contractures
38 2 Physiology Falls with injury
39 2 Process Patient education
40 1 Physical Function Motor Function
41 1 Physiology Feeding tube
42 1 Physiology Pain
43 1 Physiology Oxygenation
44 1 Physiology Dehydration
45 1 Physiology Falls
46 1 Process Depression Treatment
47 1 Process Intensity and duration of therapy services (PT, OT, ST)
48 0 Physical Function Stroke Deficit Scales
49 0 Mental Health Delirium
50 0 Mental Health Anxiety
51 0 Mental Health Patient Motivation
52 0 Quality of Life Self-perceived ability to participate in social/recreational activities
53 0 Quality of Life Subjective well-being
54 0 Quality of Life Days of work absenteeism
55 0 Quality of Life Days in bed
56 0 Quality of Life Work status
57 0 Quality of Life Compensation status
58 0 Quality of Life Job description
59 0 Quality of Life Vocational outcomes
60 0 Quality of Life Household activities
61 0 Quality of Life Living situation
62 0 Utilization Admission to ICU
63 0 Utilization Skilled Nursing Facility admission
64 0 Utilization Total combined PAC
65 0 Utilization Use of home-delivered meals (Meals-on-Wheels)
66 0 Utilization Amount and intensity of care provided
67 0 Physiology Fatigue
68 0 Physiology Nausea
69 0 Physiology Vomiting
70 0 Physiology Dyspnea
71 0 Physiology Cough
72 0 Physiology Sensory Changes
73 0 Physiology Urinary Incontinence
74 0 Physiology Fecal Incontinence
75 0 Physiology Anorexia, diminished appetite
76 0 Physiology Sleep Disorder
77 0 Physiology Chest Pain
78 0 Physiology Sputum production
79 0 Physiology Heart Rate
80 0 Physiology Respiratory Rate
81 0 Physiology Blood Pressure
82 0 Physiology Deep Venous Thrombosis
83 0 Physiology Pulmonary Embolism
84 0 Physiology Aspiration pneumonia
85 0 Physiology Constipation
86 0 Physiology Fecal impaction
87 0 Physiology Electrolyte complications
88 0 Physiology Adverse drug reactions
89 0 Physiology Wound infections
90 0 Physiology Nosocomial infections
91 0 Physiology Rash
92 0 Physiology Renal Failure
93 0 Physiology Hepatic function abnormalities
94 0 Physiology Pleural effusion
95 0 Physiology Urinary retention
96 0 Physiology Clostridium difficile infection
97 0 Physiology Malnutrition
98 0 Process Days until receipt of therapy (PT,OT)
99 0 Process Receipt of minimum intensity of therapy (PT, OT)
100 0 Process Neuro checks
101 0 Process Corrective action for sensory problems
102 0 Process High risk for pressure ulcers with no skin care program
103 0 Process Corrective action for communicative problems
104 0 Process Patient participation in care decision making
105 0 Process Family education
106 0 Process Caregiver education
107 0 Process Time to nurse or physician follow-up after hospital discharge
108 0 Process Discussion of advance care directives
109 0 Process Persistence of urinary catheter
110 0 Process Immunization status
111 0 Process Monitoring drug therapy
112 0 Process Dietician evaluation
113 0 Process Anxiety Treatment
114 0 Process Sedative hypnotic use
115 0 Process Antipsychotic use
* Dropped indicators.
Indicators that were discussed at the panel meetings are in bold.

 

BACK & NECK -- FINAL RATINGS
Rank Count Domain Indicator
1 9 Physical Function General/Global Function
2 9 Physical Function Self Care
3 9 Quality of Life Health-related quality of life
4 9 Quality of Life Role resumption
5 9 Utilization Hospitalization
6 9 Physiology Back/Neck pain
7 9 Physiology Leg/Arm pain/numbness/weakness
8 9 Satisfaction Patient satisfaction
9 9 Process PT evaluation
10 8 Physical Function Ambulation/Mobility
11 8 Quality of Life Social function
12 8 Process OT evaluation
13 7 Mental Health Depression
14 7 Quality of Life *Days of limited activity
15 7 Process *Patient education
16 6 Quality of Life *Days in bed
17 6 Utilization Emergency room admission
18 6 Satisfaction *Caregiver satisfaction
19 5 Utilization *Rehabilitation facility admission
20 5 Utilization *Skilled Nursing Facility admission
21 5 Utilization *Home health care use
22 5 Utilization Total inpatient days
23 5 Process Use of prescription analgesic medications
24 4 Utilization *Repeat spinal surgery
25 4 Utilization *Total combined PAC
26 4 Quality of Life *Recreation/leisure
27 3 Process Caregiver education
28 2 Mental Health Patient Motivation
29 2 Quality of Life Social life
30 2 Quality of Life Self-perceived ability to participate in social/recreational activities
31 2 Quality of Life Subjective well-being
32 2 Quality of Life Living situation
33 2 Utilization Level of care provided
34 2 Physiology Symptom severity
35 2 Physiology Mortality
36 2 Process Depression Treatment
37 2 Process Family education
38 1 Quality of Life Work status
39 1 Quality of Life Household activities
40 1 Utilization Admission to ICU
41 1 Utilization Amount and intensity of care provided
42 1 Physiology Sensory Changes
43 1 Physiology Urinary Incontinence
44 1 Physiology Fecal Incontinence
45 1 Physiology Pressure sores
46 1 Physiology Falls
47 1 Physiology Falls with injury
48 1 Physiology Adverse drug reactions
49 1 Physiology Muscle atrophy
50 1 Process Time to nurse or physician follow-up after hospital discharge
51 0 Mental Health Anxiety-depression
52 0 Mental Health Cognition
53 0 Mental Health Delirium
54 0 Mental Health Anxiety
55 0 Quality of Life Social interest
56 0 Quality of Life Travel
57 0 Quality of Life Work activities
58 0 Quality of Life Time spent in bed
59 0 Quality of Life Days of work absenteeism
60 0 Quality of Life Compensation status
61 0 Quality of Life Job description
62 0 Quality of Life Vocational outcomes
63 0 Utilization Use of home-delivered meals (Meals-on-Wheels)
64 0 Physiology Pain intensity
65 0 Physiology Fatigue
66 0 Physiology Nausea
67 0 Physiology Vomiting
68 0 Physiology Dyspnea
69 0 Physiology Cough
70 0 Physiology Anorexia, diminished appetite
71 0 Physiology Sleep Disorder
72 0 Physiology Chest Pain
73 0 Physiology Sputum production
74 0 Physiology Heart Rate
75 0 Physiology Respiratory Rate
76 0 Physiology Blood Pressure
77 0 Physiology Oxygenation
78 0 Physiology Deep Venous Thrombosis
79 0 Physiology Pulmonary Embolism
80 0 Physiology Aspiration pneumonia
81 0 Physiology Flexion contractures
82 0 Physiology Dehydration
83 0 Physiology Constipation
84 0 Physiology Fecal impaction
85 0 Physiology Electrolyte complications
86 0 Physiology Wound infections
87 0 Physiology Nosocomial infections
88 0 Physiology Rash
89 0 Physiology Renal Failure
90 0 Physiology Hepatic function abnormalities
91 0 Physiology Pleural effusion
92 0 Physiology Urinary retention
93 0 Physiology Clostridium difficile infection
94 0 Physiology Malnutrition
95 0 Process Transcutaneous electrical nerve stimulator (TNS) usage
96 0 Process Neurological checks
97 0 Process Integrated, multidisciplinary care program
98 0 Process Discussion of advance care directives
99 0 Process Persistence of urinary catheter
100 0 Process Immunization status
101 0 Process Monitoring drug therapy
102 0 Process Dietician evaluation
103 0 Process Sedative hypnotic use
104 0 Process Antipsychotic drug use
105 0 Process Somatization evaluation
* Dropped indicators.
Indicators that were discussed at the panel meetings are in bold.

DISCUSSION OF DROPPED QUALITY INDICATORS

As noted in Chapter III, several quality indicators were rated highly by the clinical panel (selected by four or more panel members) but subsequently dropped for various reasons. Following is a list of the indicators that were dropped, including the rationale for dropping them.

A. Global

  • Cognition (Mental Health): Although cognition was rated highly by the panels for both pneumonia and stroke, it is more appropriately regarded as a risk adjuster than a measure of post-acute care quality. In all four of our instruments, the Pfieffer Short Portable Mental Status Questionnaire is included for risk adjustment rather than a quality indicator.

  • Days of limited activity (Quality of Life): Days of limited activity, rated highly by both the pneumonia and back and neck panels, is encompassed within the broader "role resumption" and "social function" quality of life indicators. Further review of this measure also revealed that it may not be a highly sensitive or accurate measure of limitation because of the tendency of respondents to round the number of days up or down to a figure approximating weeks.

  • Recreation/Leisure (Quality of Life): Recreation/Leisure is encompassed within the broader "social/role function" quality of life indicator, measured using the Resumption of Normal Activities questions.

  • Home health care use (Utilization): The interpretation of home health care utilization, as a measure of the quality of care, is uncertain. In some cases, high utilization rates may reflect good quality of care with very close follow-up of patients, while in other circumstances it may reflect persistence of patient illness and thus poor quality of care. As such, we did not believe that it clearly and accurately reflects the quality of post-acute care, despite being highly ranked by our panel.

  • Skilled nursing facility admission (Utilization): Similar to home health use, SNF admission could be a reflection of appropriate or inadequate post-acute care. Admission to SNF alone does not indicate quality of post-acute care.

  • Rehabilitation facility admission (Utilization): See discussion of skilled nursing facility and home health care admission above.

  • Caregiver satisfaction (Satisfaction): Caregiver satisfaction was rated highly by the panels for all four conditions. Due to the added data collection burden associated with a caregiver assessment, we dropped this indicator. Recognizing the importance of satisfaction overall, however, we assess patient satisfaction in the patient report components of the instruments (and therefore proxy respondents when a proxy is necessary who are arguably the most burdened caregivers).

  • Patient education (Process): Documentation of patient education is unlikely to be reliably documented in medical records. Additionally, the components of adequate or good patient education are extremely difficult to define to develop a meaningful measure. We therefore dropped this as a quality indicator.

B. CHF

  • Medication review (Process): Similar to patient education, documentation of medication review will most likely not be consistently available in the medical record. The panel ranked both medication review and assessment of patient compliance with medication very highly. Because of similarities between these two measures, and the implicit review of medications that would occur in an assessment of medication compliance, we left the latter indicator in as a process measure. However, we are uncertain to what degree such information will be documented in the medical record.

C. Back & Neck

  • Days in bed (Quality of Life): Similar to days of limited activity, days in bed is encompassed within the broader "role resumption" and "social function" quality of life indicators.

  • Total combined PAC (Utilization): This indicator is similar to another indicator, total inpatient days, which is included in the final indicator list.

  • Repeat spinal surgery (Utilization): For some patients, repeat spinal surgery may be an appropriate and necessary treatment; while for others, repeat surgery might indicate poor quality of post-acute care. Furthermore, the need for additional surgery is more likely to reflect quality issues related to earlier surgery than quality problems in the post-acute care received.

D. Pneumonia

  • Time to reach stability (Physiology): Stability is more sensitive to hospital care than to post-acute care; the majority of patients are stable before transfer to a post-acute facility. This measure was chosen by the panel following a discussion about how Medicare HMOs may bypass acute hospitalization and treat pneumonia patients directly in subacute care units. Such subacute care should therefore scrutinize processes and outcomes of care that are more traditionally hospital-based. However, other measures were chosen for this same purpose (e.g., obtaining blood cultures, appropriate antibiotic use) and should suffice. Such subacute care that bypasses acute hospitalization is likely to affect only a small minority of all pneumonia patients receiving post-acute care.

  • Cognition evaluation (Process): While evaluation of cognition in general and delirium in particular were viewed as important for post-acute care of persons with dementia, this indicator was dropped due to concerns that it could not be uniformly assessed from providers' entries to medical records.

E. Stroke

  • Gait and balance (Physical Function): No validated self-report measures specifically designed to assess gait and balance exist.

  • Level of care provided (Utilization): As with home health care utilization, SNF and rehabilitation hospital utilization, the panel was concerned that transfers to higher levels of care may be a reflection of post-acute care quality. Again, this is an ambiguous measure because transfers to higher levels of care may be necessary and reflect good care in some circumstances while representing poor care in others. Given this ambiguity, this indicator was also dropped.

  • Medicare-covered inpatient days (Utilization): This indicator is similar to another indicator, total inpatient days, which is included in the final quality indicator list.

  • Motivation evaluation (Process): Motivation, though selected by four of the stroke panel members, is not measurable using a standardized instrument and therefore post-acute care providers cannot be expected to reliably measure and record it.