Medicare Post-Acute Care: Quality Measurement Final Report. APPENDIX I. Notes from Specialist Conference Calls

Table of Contents

CHF Conference Call -- Martha Radford, M.D.

Pneumonia Conference Call -- Thomas Marrie, M.D.

Back and Neck Conference Call -- Richard Deyo, M.D.

Martha Radford, M.D.

  • In addition to the disease-specific measures already in the instrument, Dr. Radford suggested measures related to beta blockers, digoxin, and anticoagulation. In a follow-up correspondence she also queried whether a summary measure of "reasonable medical management" could be constructed using a list of commonly-used classes of drugs in heart failure (ACEI, ARB, diuretics, beta-blockers, anticoagulation, digoxin), allow various combinations of these drugs to constitute reasonable medical management.

  • Dr Radford suggested including measures related to education and patient empowerment because of the documented association rehospitalization rates. However, it is not clear how to go about measuring this construct. She recommended an article by Carol Ashton for further information on this topic. She noted some unpublished work at Yale suggesting that telephone education programs (without individual patient monitoring or case management) may decrease hospitalizations. Because both Dr. Radford and the expert panel convened in December 1998 supported some kind of measure of patient education/empowerment, a more thorough review of published literature will be conducted to determine the association of education with important CHF outcomes, as well as exploration of the content of such educational programs and how they might be documented by a post-acute care provider.

  • With regard to a summary performance measure for CHF, Dr. Radford stated that this is a "reasonable goal," and that the work we are currently doing may ultimately lead to such a measure. She noted, however, that with the current state of knowledge, it would be difficult to sum the different contents areas of quality into a single score.

  • Regarding quality of life measures, Dr. Radford suggested that we consult Dr. John Spertus from the University of Missouri, whose previous work includes the Seattle Angina Questionnaire. Dr. Spertus just published a paper documenting the performance of a CHF specific quality of life instrument (Journal of the American College of Cardiology, April 2000).

  • Also suggested assessing whether the patient's diet was addressed, and whether the patient is on a low-salt diet.

  • Pointed out that post-acute care should be prevention-oriented. We should measure not only if the patient returned to baseline function, but also if bad outcomes were averted (e.g., re-hospitalization, emergency room visits, worsening of condition, progressive decline). Our instrument may be weak in some of these areas except rehospitalization. For example, our instrument can measure decline in basic ADL function, but not subtle declines in higher level functions which are more likely to occur over short follow-up intervals in heart failure.

  • Recommended including more assessment items related to higher order function (such as visiting with grandchildren).

  • Recommended a 30-day episode of care for CHF because variation in major outcomes like rehospitalization will be captured in a 30 day period. Too long a period will run into subsequent post-acute episodes in a significant proportion of subjects.

  • For case mix adjustment, she recommended consulting work performed in this area by Michael Rich or Harlan Krumholz. In addition, she suggested accounting for renal function, prior hospitalization for any condition, terminal illness other than heart failure, and documentation of dementia. Severity of illness could be determined by counting medications.

  • For our study, she recommended including only patients with a primary hospital diagnosis of CHF. She noted that the accuracy of the diagnosis is extremely high when it is noted as the primary discharge diagnosis.


Thomas Marrie, M.D.

  • Suggested we monitor hospitalizations during the post-acute stay as well as after discharge.

  • Remarked that for pneumonia, resolution of symptoms is the primary measurement of success. Blood culture may not be a relevant measure for this population since most patients would be well past the point at which blood culture data is useful.

  • Suggested including a measure related to assessment and evaluation of adverse effects of antibiotics (e.g., gastrointestinal symptoms which are very common with macrolides), as well as whether the provider addressed the need for smoking cessation program. Also suggested we add a measure of advance directives.

  • For the hospital chart review, he recommended including measures related to timely administration of antibiotics, admission blood cultures, and maintenance of function in the acute care facility. These would be used primarily as risk adjusters, allowing for example, poor outcomes to be attributed to poor hospital care instead of post-acute care.

  • Dr. Marrie was not aware of a summary performance measure for pneumonia.

  • Recommended a 30-day episode of care for pneumonia, but noted at 30 days more than half are still symptomatic, though usually symptoms have significantly improved. Dr. Marrie also noted that 20% of pneumonia subjects are symptomatic for some time period before contracting pneumonia. Many may have chronic symptoms due to other diseases (e.g., COPD) that are always present and are not related to the pneumonia itself. Thus baseline measures of symptoms need to be very clear so that they actually reflect the patient's status in a stable, pre-hospital condition.

  • Suggested stratifying patients into categories based on a summary measure of severity of risk factors. Michael Fine's scoring mechanism for mortality and LOS from the PORT may or may not be applicable to post-acute setting, but the technique is worth considering for risk adjustment. Whether all the items in the Fine score are readily available from the hospital chart needs to be determined.

  • For case mix adjustment, recommended accounting for use of ventilator, ICU, critical illness, hospital complications, and neuropathy.

  • When measuring re-hospitalization rates, be sure to separate hospitalizations for pneumonia from hospitalizations for other conditions.

  • For our study, he suggested including patients with a primary or secondary diagnosis of pneumonia, but recommended verifying the diagnosis with x-ray report.


Richard Deyo, M.D.

  • Should ultimately distinguish between medical and surgical back and neck conditions; there might be important differences in length of stay or costs for the different types of conditions. Also, change in symptoms over time may be fundamentally different since surgical patients might be expected to actually improve, rather than just return to baseline, whereas the goal for medical patients might be returning to baseline.

  • Suggested rephrasing questions as "Because of your back pain or leg pain (sciatica)…" or "Because of your back problem…" in reference to the pain questions since elderly patients are likely to experience pain from a number of different sources (e.g., DJD, headache).

  • For disease-specific measures, he recommended consulting the Rowland and Morris Disability Questionnaire or the Oswestry Questionnaire, which also includes some higher function assessments such as IADLs.

  • With respect to responsiveness for detecting clinically important change, he indicated that pain measures are quite responsive to change, but functional measures tend to be less responsive. Overall, he felt that the measures we chose will be responsive to change.

  • For back and neck conditions, we will want to assess pain on admission to post-acute care, but not premorbid pain. For pain, the baseline measure will be at admission to post-acute care, since pain and functional impairment may following surgery. Baseline pain would therefore be expected to be responsive to the acute hospital stay (surgery), while the pain following a surgical procedure would be sensitive to the quality of post-acute care.

  • Recommended a 1-month or 3-month episode of care for back and neck conditions. He did not think the episode should be any longer than 3-months but was uncertain about whether a 1 or 3 month episode was preferable.

  • For case mix adjustment, he recommended capturing whether the patient had a spinal fusion; complication rates and post-acute care placement are much higher for patients with spinal fusion. He also suggested controlling for the number of levels on the spine operated on, comorbidity, wound infections, DVT, new neurologic deficits, other organ complications, perioperative myocardial infarction, and new bowel or bladder dysfunction. Will want to stratify on neck vs lumbar, and on elective surgery vs traumatic injury.

  • With respect to a summary performance measure, Dr. Deyo indicated that this has not been done due to the ambiguity about the ideal process of care. He recommended assessing quality through multiple outcome measures.

  • For our study, he suggested including only patients with a primary hospital discharge diagnosis of lumbar spinal stenosis. This is likely to be a common diagnosis in an elderly population and would allow a more reasonable comparison of the quality of care in different post-acute settings by assembling a more homogeneous study population.

  • With respect to the pain questions, he recommended using just two measures: "How bothersome is the pain?" and "How frequent is the pain?" He noted the disconnect between severity or frequency ratings of pain and how bothered people really are by pain. He noted that asking about how bothersome symptoms are really gets at the impact on the person's life and thus their function while severity and frequency alone do not.

  • He also recommended a 10-point (not 20) visual analog scale when asking the patient to rate how much the pain bothers him/her.