Quality, Part II:

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Quality, Part II

• Quality Measurement and Reporting

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Learning objectives

• Describe the relative merits of structure,
  process and outcome measures for quality
• Understand why and how other organizations are
  monitoring the quality of medical care
• Determine when risk adjustment should be
  applied to performance measures

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Topics to be Discussed Today

• "Structure, Process, Outcome" -
• Accreditation -
• Putting teeth into quality
• Report Cards

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What is being measured?

• Cost (focus on the money)
• LOS
• Referral rates
• Prescription
• Quality (focus on what is easy)
• Mortality rates
• Patient satisfaction/waiting times
• Preventive services

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Defining and Measuring Quality

• Avedis Donabedian
• 1960s
• Structure
• Process
• Outcome

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Structure

• Definition
• Settings in which medical care takes place and
  instrumentalities of which it is a product"
  (Donabedian)
• Characteristics of the physician, hospital, or
  system providing care

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Parameters of Structure Include

• For systems --
• Organization
• Specialty mix
• Workload
• Equipment

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Parameters of Structure Include (Cont..)

• For physician --
• Training
• Certification
• For hospitals --
• Services
• Staffing
• Equipment

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Structure Questions

• Is there an office laboratory?
• Without a lab patients may have to wait or travel
  long distances
• Does insurance pay for influenza vaccine?
• Without insurance patients may not receive needed
  preventive services

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Process -

• Definition
• Set of activities that go on between
  practitioners and patients" (Donabedian)
• Components in the encounter between physician or
  another health-care professional and patient"
  (Brook and McGlynn 1996)

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Parameters of process include

• Technical --
• Visits
• Medications
• Referrals, including hospitalization
• Test orders
• Interpersonal --
• Interpersonal manner
• Communication skill

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Process Questions

• Does BP get measured each visit?
• Are diabetics' feet tested for sensation in
  accordance with accepted protocols?

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Outcome --

• Definition
• Consequences to the health and welfare of
  individuals and society" (Donabedian)
• Alternatively, the measured health status of the
  individual or community

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Parameters of Outcome

• Including clinical end points --
• laboratory values such as HgA1C
• Deaths
• Quality of life --
• functional outcomes
• satisfaction

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Outcome Questions

• Has your breathing improved enough so you can
  climb a flight of stairs without stopping?
• Did you feel you were well treated on your visit
  to the clinic?

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Which is most important?

• Structure
• Process
• Outcome

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Which is most important -(Cont..)

• Structure?
• Traditional accreditation surveys focused on
  structure
• Examples
• Fire extinguishers in proper place and maintained
• Providers board certified with all credentials
  documented

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Structure determines performance

• Systems are a combination of structure and
  process
• Flawed systems lead to suboptimal results
• Suboptimal results imply flawed systems
• Small changes in systems may sometimes have
  dramatic results

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Which is most important --

• Process?
• Many regulatory agencies are trying to move from
  structure to process outcome measures
• HEDIS measurements
• Mammography rates, Childhood immunizations

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Which is most important --

• Outcome?
• Ever- increasing emphasis on outcomes
• JCAHO asking hospitals to report on measures such
  as mortality rates or return to OR
• Satisfaction is a critical outcome measure

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Which is most important?

• A small rural hospital wants to be sure they can
  manage a code blue in the emergency room
• A 30-member group practice wants to make sure
  they are preventing influenza
• A managed care company wants to see if a group
  practice is keeping their patients happy

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Data sources

• administrative data
• Enrollment data
• Claims data
• procedures
• lab
• pharmacy
• chart reviews
• surveys

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REPORT CARDS

• Accreditation

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How do you know?

• What doctor to choose for your kids?
• Whether to recommend Blue Advantage 65 for your
  grandmother?
• Which hospital to refer your patients to for
  CABG?
• If the nursing home will take care of your
  grandmother?

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Accreditation

• Putting the teeth into quality assurance and
  improvement
• Widespread
• No doctor will escape being involved in
  accreditation process

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Who Gets Accredited

• Hospitals - Mandatory (JCAHO and others)
• Laboratories (including doctors' labs (CLIA))
• Health Plans - state and Medicare certification
• Nursing homes
• Home health agencies
• Doctors - licensure (profiling in the future?)

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Accreditation

• Very expensive
• Money to JCAHO, etc.
• Time
• Personnel
• Probably improves quality
• Accreditation process may include
• structure
• process
• outcomes

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Report Cards

• HEDIS
• Check out your HMO on the internet
• AMAP
• New York and Pennsylvannia CABG registries
• see your mortality rate in the New York Times

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Consumer Reports on Doctors

• As a patient what would you like to see?
• Service
• Waiting times?
• Patient satisfaction?
• Quality
• Immunization rates
• Mortality

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Profiling Doctors

• What does your managed care company want to see?
• Cost
• hospital utilization
• referral rates
• pharmacy costs
• Quality
• HEDIS?
• Satisfaction?

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HEDIS 1999 Performance Measures

• Prevention
• childhood immunization
• advising smokers to quit
• flu shots
• breast and cervical cancer screening

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HEDIS 1999 Performance Measures

• OB
• Prenatal care in 1st trimester
• Low birth weight infants
• check ups after deliveries
• Cardiovascular
• beta blockers after AMI
• cholesterol management after CV event
• Diabetes
• eye exams new items?

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HEDIS 1999 Performance Measures

• Access and availability of care (waiting times)
• Patient satisfaction

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Interpreting comparative outcomes

• A final note

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Youve just been informed that your CABG
mortality rate is 2 times higher than other
hospitals in the UHC database.
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When to risk adjust

• Variation between groups in risk factors
• My patients are sicker
• Risk factor is associated with differences in the
  measure of interest
• sicker patient have higher mortality
• What variables would define sicker?

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Ways to Risk Adjust

• Stratified Analyses
• Multivariate modeling

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Stratified Analyses

• Define factor of interest
• Examine rates separately for each category of the
  factor
• Comparisons
• by category
• standardized rates

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Example CABG mortality

• High risk vs low risk
• Assumptions
• Proportion at high risk varies by institution
• Risk associated with mortality
• Report separate CABG mortality statistics for
  each group of patients

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Comparing mammography rates
A managed care organization offers payment
incentives for practices that achieve mammography
rates gt 50. You have 300 women with a
mammography rate of 40. A colleague, who seems
to practice the same way you do, has a
mammography rate of 50.
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Mammography rates
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Multivariate risk adjustment
Y c B1X1 B2X2 B3X3 ...
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Limitations of risk adjustment

• Numbers
• Availability of measures

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Summary of today's session

• Measures Structure, Process, Outcome
• Accredition - putting teeth into quality
• Comparative measures and interpretation