Measuring What Matters Allocation, Planning, and Quality Assessment for the Ryan White CARE Act (2004) / Chapter Skim
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6 Measuring Quality of Care
6 Measuring Quality of Care
Pages 188-220
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From page 188... ...
Although Title III and IV grantees already had such programs in place, the new provision required Title I and II grantees to implement them.1 The purpose of the quality-management programs is to ensure that service providers adhere to established HIV clinical practices and Department of Health and Human Services (DHHS) guidelines to the extent possible; to ensure that quality-improvement strategies include support services that help people receive appropriate HIV health care 1Some Title I and II grantees already had quality-management programs in place prior to the reauthorization.
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From page 189... ...
to study two aspects of quality assessment: 1. "The availability and utility of health outcomes measures and data for HIV primary care and support services and the extent to which those measures and data could be used to measure the quality of such funded services" (Ryan White CARE Act.
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From page 190... ...
The Committee divided its work into several discrete tasks: · Reviewing current HRSA/HAB quality-of-care activities; · Developing a conceptual framework for indicators that reflects the availability and quality of the full range of services across populations and organizations; · Developing criteria for selecting indicators for assessing and improving HIV/AIDS services funded through RWCA; · Reviewing quality measures used by RWCA grantees and other major HIV providers, recommended by authoritative groups, and contained in the research literature; · Identifying areas that require further development; · Developing a process HRSA might use to select and regularly update measures; and · Offering recommendations based on the analysis and findings presented here. CURRENT HRSA/HAB QUALITY-OF-CARE ACTIVITIES HRSA/HAB and RWCA grantees have undertaken a variety of efforts to address the quality of care, treatment, and training in RWCA
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From page 191... ...
The project is sponsored by HRSA/HAB and administered by the New York State Department of Health's AIDS Institute. The project aims to improve the quality of care delivered to persons with HIV by using data to measure performance, tracking clinical indicators based on clinical practice guidelines, and providing consultations regarding Continuous Quality Improvement.
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From page 192... ...
. Example publications include: Series · Using Data to Assess HIV/AIDS Service Needs: A Guide for Ryan White CARE Act Planning Groups, Report #2.
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From page 193... ...
is a site-visit protocol developed for Title IIIfunded CARE Act programs. The tool, which includes a quality improvement component in the clinical section, is used to evaluate the clinical, fiscal, administrative, and support services of the grantees (HRSA, 2003e)
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From page 194... ...
. FOUR-DIMENSIONAL CONCEPTUAL FRAMEWORK FOR HIV QUALITY ASSESSMENT In this section, the Committee presents a conceptual framework for assessing the quality of HIV/AIDS care.
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From page 195... ...
Spectrum of Services · Counseling and testing · Referral to treatment · Social support services · Prevention of transmission · Prevention of AIDS · Prophylaxis · Treatment · Service integration and coordination FIGURE 6-1 Dimensions of quality assessment.
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From page 196... ...
Knowing the proportions of infected persons who are undiagnosed across areas allows inference regarding access to screening and case-finding services, and about the attractance associated with the perceived high quality of care in an area. Knowing the proportions of persons who are diagnosed but not in care across areas allows inference regarding the accessibility of existing care facilities and the ability of those facilities to maintain continuity of care for treated persons.
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From page 197... ...
For example, a measure of the quality of care provided by Title III clinics is the proportion of appropriate patients who are receiving HAART therapy. Provider organizations, including HRSA and its grantees, now commonly employ a variety of aggregated client-level measures of treatment quality in assessing clinics or practices, including monitoring, chemoprophylaxis, and antiretroviral therapy.8 However, the scientific community has given little attention to assessing the quality of care across whole communities, metropolitan areas, or states, regardless of whether patients get care at any particular facility.9 The measures and data available to assess quality vary markedly according to both the target population and the level of the assessment.
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From page 198... ...
Process measures are important because they "cause" outcomes to the extent that medical interventions have an effect and because the acts of providing care are convenient targets for quality improvement. Although information for process measures is usually obtained from medical records, analysts can also obtain important information by asking patients about their experiences (Cleary and Edgman-Levitan, 1997; Cleary, 1999; Wilson et al., 2002)
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From page 199... ...
Those in care, meanwhile, need not only a wide range of clinical services, including monitoring, prophylaxis, and treatment, but also social support services and efforts to prevent transmission (Figure 6-2)
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From page 200... ...
For instance, structure and process measures should be clearly linked to outcomes. A number of established systems for scoring
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From page 201... ...
RWCA grantees often receive funds from numerous other public and private sources, each of which has their own data-reporting requirements, format, and timeframes (Ryan White CARE Act 2002 Grantee Conference, August 2223, 2003, Washington, DC: Meeting with Title I EMAs)
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, Evaluation of Quality Improvement for HIV Care (EQHIV) , HIV Cost and Services Utilization Study (HCSUS)
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The measures of process quality used by the programs divide into five categories: prevention, screening and monitoring, antiretroviral treatment, prophylactic treatment for opportunistic infections, and social and support services. Prevention Three sources had quality measures focused on prevention activities.
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From page 204... ...
HRSA/HAB Collaborative for Improving Care for People with HIV/AIDS http://hab.hrsa.gov/special/breakthrough.htm Evaluation of Quality Improvement for HIV AHRQ Care (EQHIV) a HIV Cost and Services Utilization Study A consortium of private and (HCSUS)
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From page 205... ...
clinical HIV programs already receiving Title III funding that will not receive CQI training. HCSUS was the first major research effort to collect information on a nationally representative sample of people in care for HIV infection.
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(2000) IDSA http://www.idsociety.org/HIV/CEN/ PGindex_HIV.htm FACCT FACCT Quality-of-Care Indicators for HIV/AIDS http://www.facct.org/facct/doclibFiles/ documentFile_302.pdf California Health Care Foundation California Health Care QA Tool (developed by RAND)
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From page 207... ...
. This study was conducted to help participants improve clinical processes based on comparative information from actual practice in the era of combination antiretroviral therapy (as opposed to pre-CART, to which most of the published studies on adherence to recommended guidelines in HIV patient care refer)
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From page 208... ...
9 8 9) 7 = (n 6 5 Sources of 4 3 Frequency 2 1 0 Appropriate Provision of Provision of indicated Regimen Change Management of adherence counseling ART Patients on ART and/or monitoring Antiretroviral Treatment Measures FIGURE 6-4 Frequency of antiretroviral treatment quality measures among select sources.
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From page 209... ...
The HCSUS study asked patients to assess their access to critical support services by indicating whether, in the previous six months, they had needed any of five types of services: income assistance, housing assistance, home health 9 8 9) = 7 (n 6 5 Sources 4 of 3 2 Frequency1 0 B avium carinii Influenza Hepatitis complex pneumonia pneumonia Tuberculosis Toxoplasmosis Pneumocystis Mycobacterium Pneumococcal Prophylaxis Treatment Measures FIGURE 6-5 Frequency of prophylactic treatment quality measures among select sources.
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From page 210... ...
Health Outcomes Outcome measures used are classified into three major groups: CD4+ cell counts, viral load counts, and emergency room visits and hospitalizations. Two sources measured CD4+ cell counts and viral load levels, and one source each measured patients' emergency room visits and hospitalizations.
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From page 211... ...
MEASURING QUALITY OF CARE 211 60 50 40 Died 30 Percent 20 10 0 1994 1995 1996 1997 1998 1999 2000 Year FIGURE 6-6 Percent of people who died within 12 months of AIDS diagnosis, by state/territory, 19942000. 50 45 40 35 30 Died 25 Percent 20 15 10 5 0 1994 1995 1996 1997 1998 1999 2000 Year FIGURE 6-7 Percent of people who died within 12 months of AIDS diagnosis, by EMA, 19942000.
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From page 212... ...
project, an interview project of persons with HIV/AIDS conducted by 12 state/local health departments; and (4) the Missed Opportunities for Tuberculosis Prevention study, a medical record review of a population-based sample of persons newly diagnosed with HIV or AIDS in three major U.S.
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From page 213... ...
Based on its review of selected quality-of-care measure sets in the previous section, the Committee recommends a standardized set of structure, process, and outcome quality measures for assessing and facilitating quality improvement at the clinic level and at the EMA/state levels (see Recommendation 6-1)
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From page 214... ...
However, outcome measures alone are not sufficient because out comes may be influenced by many factors not under the control of grantees, and because structure and process measures can uniquely identify areas for specific improvement. Finding 6-2 Quality measures for HIV/AIDS that are in wide use are based on broadly accepted clinical guidelines and are appropri ate.
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CD4+ cell count and HIV viral load (process)
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AREA (E.G., EMA OR STATE) LEVEL MEASURES Outcome measures related to access and care: 22.
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From page 217... ...
2002. Analysis of a population-based Pneumocystis carinii pneumonia index as an outcome measure of access and quality of care for the treatment of HIV disease.
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2003f. Outcomes Evaluation Technical Assistance Guide: Primary Medical Care Outcomes, Titles I and II of the Ryan White CARE Act.
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2001. Developing a performance management system for a federal public health program: The Ryan White CARE ACT Titles 1 and 2.
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2000b. Re port on Ryan White CARE Act Amendments of 2000 (106-788)
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