Performance Measurement Accelerating Improvement (2006) / Chapter Skim
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4 Moving Forward: What Should Be Measured?
4 Moving Forward: What Should Be Measured?
Pages 83-112
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From page 83... ...
In addition to recommend ing a starter set of measures drawn from earlier work of stake holder groups, the committee proposes four approaches to address identified gaps in existing measures: comprehensive measurement; longitudinal measurement; patient-level, population-based, and systems-level measurement; and shared accountability. The committee is convinced that performance measurement is a prerequisite for improving both health and health care in the United States, and that it requires clear stewardship at the federal level.
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From page 84... ...
As a result of this effort, the committee identified several major gaps in existing measure sets, summarized in Table 4-1. The following sections highlight those areas in which the committee proposes significant changes in direction or new emphasis in performance measurement, as embodied in the following approaches: · Comprehensive measurement · Longitudinal measurement · Individual patient-level, population-based, and systems-level measurement · Shared accountability These approaches represent a change relative to current performance measurement efforts as they provide different frameworks through which
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From page 85... ...
85 by care six should report single all patient- and should both time. assess individu- systems health in system Chasm care over the should both many constrained of measures and of efficiency, health the be identifiable, Quality effectiveness, care not and and provided.
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From page 86... ...
He also takes a total of eight prescription drugs to manage his multiple chronic conditions. Current Health Care Delivery System During a recent visit, David's primary care physician ordered a battery of tests to monitor his condition, including hemoglobin A1c and cholesterol testing.
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From page 87... ...
For example, promotion of preventive services and environmental factors such as having walking paths to promote exercise can impact health in the community. Future Health Care Delivery System Through the approaches identified by the committee as leading to better health care through a national system for performance measure ment and reporting -- comprehensive measurement; longitudinal mea surement; individual-patient-level, population-based, and systems-level measurement; and shared accountability -- many of the problems David encountered in his care can begin to be addressed.
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From page 88... ...
Shared accountability. David's multiple caregivers should take re sponsibility for ensuring that his care is well coordinated and responsive to his individual needs.
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From page 89... ...
First, both the U.S. fee-for-service system and the performance measures currently in use reinforce, although not intentionally, the separation of settings of care by design (i.e., ambulatory care, home health care, hospital care, and nursing home care)
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From page 90... ...
Attending to transitions implies, among other design principles, listening directly to patients' reports on their own care. Patients and their family caregivers are uniquely positioned to report on their care experiences as they are often the only common thread across disparate health care settings (Coleman et al., 2004a)
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From page 91... ...
and costs for selected conditions to promote the attainment of better outcomes at lower cost. Individual-Patient-Level, Population-Based, and Systems-Level Measurement The committee proposes several innovative approaches to collecting and reporting performance measures.
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From page 92... ...
In addition, the use of composite measures does not require the large sample sizes needed for some other approaches. Thus, the committee proposes that this approach to measurement be taken in addition to measuring performance on discrete indicators.
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From page 93... ...
On the whole, the committee favors a simple yet integrated approach whereby composite measures in the first instance would be "all or none" BOX 4-2 Example of the Implementation of Composite Measures A pioneering organization in composite measurement, HealthPartners Inc., a health plan in Minnesota, has been collecting and publicly report ing composite scores for diabetes, coronary artery disease, and preven tive care. HealthPartners calculates a composite score for its diabetic population by examining the percentage of its members with Type I and Type 2 diabetes aged 18 through 75 who are optimally managed, not just for each but for all of the following factors: HbA1c 8 percent mg/dl; LDL cholesterol 130 mg/dl; blood pressure <130/85 mmHg; aspirin use for members >40 years old; and documentation of nonuse of tobacco.
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From page 94... ...
The report does not attempt to speak to the full range of measures one would want in a population health monitoring and reporting system, such as environmental measures, as this would be beyond the committee's charge. The committee does, however, address how the personal health care delivery system can contribute to the public health system in the domains of health promotion, disease prevention, and clinical preventive services.
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From page 95... ...
This more clinical perspective on health care services is distinct from measuring the determinants of the health of populations and nonhealth care services. This approach to gathering performance data allows information to be collected across multiple sites instead of in a site-specific manner, and to be used for multiple purposes, such as internal quality improvement, accountability, and public reporting at the provider, community, and national levels.
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From page 96... ...
As discussed above, measures obtained at the individual patient level could be aggregated to different levels of the system, including physician groups, hospitals, the continuum of care, or communitywide care delivery systems. At the hospital level, systems-level performance measures could be applied to the hospital as a whole, with its executive and clinical leadership and governing board presumably being responsible for improvement on these measures.
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From page 97... ...
Below the committee proposes a uniform set of hospitalwide measures and measures across the continuum of chronic disease care as the starting point for this effort. Shared Accountability Improved performance on many of the measures proposed by the committee can be achieved only through the collaborative efforts of multiple providers and multiple care settings.
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From page 98... ...
, and the committee therefore endorses public reporting on measures, such as longitudinal care, that foster shared accountability.
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From page 99... ...
· Importance: The health problem addressed by a measure should be a leading cause of death or disability or associated with high resource use. A measure must have an impact on health, be tied to national goals, and be susceptible to being influenced by the health care delivery system.
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From page 100... ...
The committee recommends the immediate implementation of the starter set of measures derived from leading measure sets shown in Table 4-2 and discussed in detail in the next section. To this end, a data repository system will need to be in place, along with a mechanism for public reporting.
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From page 101... ...
care staff, of measures health information medications depression communicate, office infection informed hospital (2) , well hybrid oral hospital a care, of surgical of discharge and providers how of communicate, asthma (3)
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From page 102... ...
· Ensure that a data repository system1 and public reporting pro gram capable of data collection at the individual patient level are established and open to participation by all payers and providers. · Ensure that technical and financial assistance is available to all providers who need help in establishing performance measure ment and improvement capabilities.
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From page 103... ...
Starter Set Measures for Ambulatory Care Performance To accelerate performance measurement in the ambulatory care setting, the committee proposes the immediate adoption of the 26 clinical performance measures recently selected by AQA. The individual measures in this set, detailed in Appendix G-1, cover four domains of care in which quality problems are well documented and continue to persist: · Preventive care -- cancer screening, vaccinations, and tobacco use/ counseling · Chronic care -- coronary artery disease, heart failure, diabetes, asthma, and depression · Prenatal care -- HIV screening and administration of anti-D (Rh)
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From page 104... ...
For those chronic conditions -- diabetes, asthma, depression, heart failure, and coronary artery disease -- a national study found that Americans receive only 4568 percent of recommended care (McGlynn et al., 2003a)
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From page 105... ...
Ambulatory Care Surveys Although the AQA measures are a reasonable starting point for performance measurement in the ambulatory care setting, assessment in this area would be incomplete without a component of patient feedback. To complement the above clinical measures, the committee proposes implementing surveys of ambulatory care in conjunction with those measures upon completion of field testing.4 The CAHPS program has developed two prod 4See Chapter 2 for an overview of the CAHPS family of surveys.
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From page 106... ...
Currently, an estimated 4,200 hospitals are participating in this public reporting effort. As with the AQA measures, the committee proposes the reporting of these individual measures as patient-level composites for the following areas: acute coronary infarction, heart failure, pneumonia, smoking cessation, and surgical complications.
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From page 107... ...
Starter Set Measures for Health Plan Performance Health plans have a long and credible history of collecting and reporting performance measures, beginning with the adoption of HEDIS measures. The 2005 HEDIS measure set includes 61 measures that are recommended for the starter set.
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From page 108... ...
OASIS, implemented in 2000, assesses outcomes for home care patients, with the data intended for use in quality improvement efforts, including evaluations of sociodemographics, environment, support systems, health status, functional status, and health service utilization. As these measures are already being collected by providers, the committee proposes that the long-term care measures being publicly reported by CMS5 in both the MDS and OASIS data sets, as listed in Appendix G-4, initially be used for describing performance in these settings.
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From page 109... ...
To begin to address these shortcomings, the committee proposes longitudinal measures of outcomes and costs, starting with 1-year mortality, resource use, and functional status measures for acute myocardial infarction. CLOSING COMMENTS The next step in enhancing current performance measurement and reporting capabilities is to address the gaps identified in this chapter through a research agenda.
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From page 110... ...
2005b. Medicare Compare Series: Nursing Home Compare, Home Health Compare, Dialysis Compare, and Hospital Compare.
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From page 111... ...
1999. Geographic variation in the treatment of acute myocardial infarction: The Cooperative Cardiovascular Project.
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From page 112... ...
1999. Understanding geographic variations in health care delivery.
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