Association of claims-based quality of care measures with outcomes among community-dwelling vulnerable elders

Quality Indicators for High-Need Patients: a Systematic Review

BACKGROUND

Healthcare systems are increasingly implementing programs for high-need patients, who often have multiple chronic conditions and complex social situations. Little, however, is known about quality indicators that might guide healthcare organizations and providers in improving care for high-need patients. We sought to conduct a systematic review to identify potential quality indicators for high-need patients.

METHODS

This systematic review (CRD42020215917) searched PubMed, CINAHL, and EMBASE; guideline clearing houses ECRI and GIN; and Google scholar. We included publications suggesting, evaluating, and utilizing indicators to assess quality of care for high-need patients. Critical appraisal of the indicators addressed the development process, endorsement and adoption, and characteristics, such as feasibility. We standardized indicators by patient population subgroups to facilitate comparisons across different indicator groups.

RESULTS

The search identified 6964 citations. Of these, 1382 publications were obtained as full text, and 53 studies met inclusion criteria. We identified over 1700 quality indicators across studies. Quality indicator characteristics varied widely. The scope of the selected indicators ranged from detailed criterion (e.g., "annual eye exam") to very broad categories (e.g., "care coordination"). Some publications suggested disease condition-specific indicators (e.g., diabetes), some used condition-independent criteria (e.g., "documentation of the medication list in the medical record available to all care agencies"), and some publications used a mixture of indicator types.

DISCUSSION

We identified and evaluated existing quality indicators for a complex, heterogeneous patient group. Although some quality indicators were not disease-specific, we found very few that accounted for social determinants of health and behavioral factors. More research is needed to develop quality indicators that address patient risk factors.

Improving Serious Illness Care for Surgical Patients: Quality Indicators for Surgical Palliative Care

OBJECTIVE

Develop quality indicators that measure access to and the quality of primary PC delivered to seriously ill surgical patients.

SUMMARY OF BACKGROUND DATA

PC for seriously ill surgical patients, including aligning treatments with patients' goals and managing symptoms, is associated with improved patient-oriented outcomes and decreased healthcare utilization. However, efforts to integrate PC alongside restorative surgical care are limited by a lack of surgical quality indicators to evaluate primary PC delivery.

METHODS

We developed a set of 27 preliminary indicators that measured palliative processes of care across the surgical episode, including goals of care, decision-making, symptom assessment, and issues related to palliative surgery. Then using the RAND-UCLA Appropriateness method, a 12-member expert advisory panel rated the validity (primary outcome) and feasibility of each indicator twice: (1) remotely and (2) after an in-person moderated discussion.

RESULTS

After 2 rounds of rating, 24 indicators were rated as valid, covering the preoperative evaluation (9 indicators), immediate preoperative readiness (2 indicators), intraoperative (1 indicator), postoperative (8 indicators), and end of life (4 indicators) phases of surgical care.

CONCLUSIONS

This set of quality indicators provides a comprehensive set of process measures that possess the potential to measure high quality PC for seriously ill surgical patients throughout the surgical episode.

Palliative Care Quality Indicators for Patients with End-Stage Liver Disease Due to Cirrhosis

BACKGROUND AND AIMS

There are guidelines for the medical management of cirrhosis and associated quality indicators (QIs), but QIs focusing on standards for palliative aspects of care are needed.

METHODS

We convened a 9-member, multidisciplinary expert panel and used RAND/UCLA modified Delphi methods to develop palliative care quality indicators for patients with cirrhosis. Experts were provided with a report based on a systematic review of the literature that contained evidence concerning the proposed candidate QIs. Panelists rated QIs prior to a planned meeting using a standard 9-point RAND appropriateness scale. These ratings guided discussion during a day-long phone conference meeting, and final ratings were then provided by panel members. Final QI scores were computed and QIs with a final median score of greater than or equal to 7, and no disagreement was included in the final set.

RESULTS

Among 28 candidate QIs, the panel rated 19 as valid measures of quality care. These 19 quality indicators cover care related to information and care planning (13) and supportive care (6).

CONCLUSIONS

These QIs are evidence-based process measures of care that may be useful to improve the quality of palliative care. Research is needed to better understand the quality of palliative care provided to patients with cirrhosis.

Palliative Care Specialist Consultation Is Associated With Supportive Care Quality in Advanced Cancer

CONTEXT

Although recent randomized controlled trials support early palliative care for patients with advanced cancer, the specific processes of care associated with these findings and whether these improvements can be replicated in the broader health care system are uncertain.

OBJECTIVES

The aim of this study was to evaluate the occurrence of palliative care consultation and its association with specific processes of supportive care in a national cohort of Veterans using the Cancer Quality ASSIST (Assessing Symptoms Side Effects and Indicators of Supportive Treatment) measures.

METHODS

We abstracted data from 719 patients' medical records diagnosed with advanced lung, colorectal, or pancreatic cancer in 2008 over a period of three years or until death who received care in the Veterans Affairs Health System to evaluate the association of palliative care specialty consultation with the quality of supportive care overall and by domain using a multivariate regression model.

RESULTS

All but 54 of 719 patients died within three years and 293 received at least one palliative care consult. Patients evaluated by a palliative care specialist at diagnosis scored seven percentage points higher overall (P < 0.001) and 11 percentage points higher (P < 0.001) within the information and care planning domain compared with those without a consult.

CONCLUSION

Early palliative care specialist consultation is associated with better quality of supportive care in three advanced cancers, predominantly driven by improvements in information and care planning. This study supports the effectiveness of early palliative care consultation in three common advanced cancers within the Veterans Affairs Health System and provides a greater understanding of what care processes palliative care teams influence.

Abbreviated care-process quality indicator sets linked with survival and functional status benefit in older adults under ambulatory care

OBJECTIVES

To identify subsets of ambulatory care (outpatient only) quality indicators (QIs) associated with better survival and physical function outcomes.

DESIGN

Observational cohort study.

SETTING

Pooled data from the Assessing Care of Vulnerable Elders (ACOVE)-1 study, which measured quality of care using 140 care-process QIs, and the subsequent ACOVE-2 study, which reduced the QIs to 69 ambulatory care QIs.

PARTICIPANTS

Older adults receiving ambulatory care (N=1,015).

MEASUREMENTS

To prioritize and reduce the QIs into subsets, an expert panel rated each of 69 ambulatory care QIs for the strength of the link between process and benefit, defined as direct trial evidence on older adults or high expectation of benefit if a trial were conducted in older adults. This resulted in three reduced QI sets, reflecting their intended benefit: 17 QIs for survival (ACOVE Quality for Survival (AQS)-17), five QIs to preserve function (AQF-5), and 16 QIs to improve quality-of-life related to physical health and symptoms (AQQ-16). Whether AQS-17 would predict 3-year survival was first tested in 1,015 pooled ACOVE-1 and ACOVE-2 participants. Second, whether AQF-5 (n=74) and AQQ-16 (n=359) would predict change in the Physical Component Summary (PCS) score of the Medical Outcomes Study 12-item Short-Form Survey at 1 year was tested in the ACOVE-2 cohort. Control variables were age, function-based vulnerability, and comorbidity.

RESULTS

Each 20-percentage-point increment in AQS-17 was associated with survival (hazard ratio (HR)=0.83, P=.01) up to 500 days but not thereafter. AQF-5, but not AQQ-16, predicted 1-year improvement in PCS score (1.13-points per 20%-point increment in AQF-5, P=.02).

CONCLUSION

Subsets of care processes can be linked with outcomes important to older adults. The AQS-17 and AQF-5 are potential tools for improving ambulatory care of older adults.

Adherence to performance measures and outcomes among men treated for prostate cancer

PURPOSE

We assessed the relationship between health care system performance on nationally endorsed prostate cancer quality of care measures and prostate cancer treatment outcomes.

MATERIALS AND METHODS

This retrospective cohort study included 48,050 men from SEER-Medicare linked data diagnosed with localized prostate cancer between 2004 and 2009, and followed through 2010. Based on a composite quality measure we categorized the health care systems in which these men were treated into 1-star (bottom 20%), 2-star (middle 60%) and 3-star (top 20%) systems. We then examined the association of health care system level quality of care with outcomes using multivariable logistic and Cox regression.

RESULTS

Patients who underwent prostatectomy in 3-star vs 1-star health care systems were at lower risk for perioperative complications (OR 0.80, 95% CI 0.64-1.00). However, they were more likely to undergo a procedure addressing treatment related morbidity, eg for sexual morbidity (11.3% vs 7.8%, p = 0.043). In patients who received radiotherapy star ranking was not associated with treatment related morbidity. In all patients star ranking was not significantly associated with all-cause mortality (HR 0.99, 95% CI 0.84-1.15) or secondary cancer therapy (HR 1.04, 95% CI 0.91-1.20).

CONCLUSIONS

We found no consistent association between health care system quality and outcomes, which questions how meaningful these measures ultimately are for patients. Thus, future studies should focus on developing more discriminative quality measures.

Development of quality indicators for women with urinary incontinence

AIMS

To develop a means to measure the quality of care provided to women treated for urinary incontinence (UI) through the development of quality-of-care indicators (QIs).

METHODS

We performed an extensive literature review to develop a set of potential quality indicators for the management of UI. QIs were modeled after those previously described in the Assessing the Care of Vulnerable Elders (ACOVE) project. Nine experts ranked the indicators on a nine-point scale for both validity and feasibility. We analyzed preliminary rankings of each indicator using the RAND Appropriateness Method. A forum was then held in which each indicator was thoroughly discussed by the panelists as a group, after which the indicators were rated a second time individually using the same nine-point scale.

RESULTS

QIs were developed that addressed screening, diagnosis, work-up, and both non-surgical and surgical management. Areas of controversy included whether routine screening for incontinence should be performed, whether urodynamics should be performed before non-surgical management is initiated, and whether cystoscopy should be part of the pre-operative work-up of uncomplicated stress incontinence. Following the expert panel discussion, 27 of 40 potential indicators were determined to be valid for UI with a median score of at least seven on a nine-point scale.

CONCLUSIONS

We identified 27 quality indicators for the care of women with UI. Once these QIs are pilot-tested for feasibility, they will be applied on a larger scale to measure the quality of care provided to women with UI in the United States.

Regional variation in quality of prostate cancer care

PURPOSE

Despite the endorsement of several quality measures for prostate cancer by the National Quality Forum and the Physician Consortium for Performance Improvement, how consistently physicians adhere to these measures has not been examined. We evaluated regional variation in adherence to these quality measures to identify targets for future quality improvement.

MATERIALS AND METHODS

For this retrospective cohort study we used SEER (Surveillance, Epidemiology, and End Results)-Medicare data for 2001 to 2007 to identify 53,614 patients with newly diagnosed prostate cancer. Patients were assigned to 661 regions (Hospital Service Areas). Hierarchical generalized linear models were used to examine reliability adjusted regional adherence to the endorsed quality measures.

RESULTS

Adherence at the patient level was highly variable, ranging from 33% for treatment by a high volume provider to 76% for receipt of adjuvant androgen deprivation therapy while undergoing radiotherapy for high risk cancer. In addition, there was considerable regional variation in adherence to several measures, including pretreatment counseling by a urologist and radiation oncologist (range 9% to 89%, p <0.001), avoiding overuse of bone scans in low risk cancer (range 16% to 96%, p <0.001), treatment by a high volume provider (range 1% to 90%, p <0.001) and followup with radiation oncologists (range 14% to 86%, p <0.001).

CONCLUSIONS

We found low adherence rates for most established prostate cancer quality of care measures. Within most measures regional variation in adherence was pronounced. Measures with low adherence and a large amount of regional variation may be important low hanging targets for quality improvement.

The Washington circle engagement performance measures' association with adolescent treatment outcomes

BACKGROUND

For adolescents, substance use disorder (SUD) treatment outcomes (e.g., abstinence, problematic behaviors) often cannot be measured soon enough to influence treatment trajectory. Although process measures (e.g., treatment engagement) can play an important role, it is essential to demonstrate their association with outcomes. This study explored the extent to which engagement in outpatient treatment was associated with outcomes and whether demographic/clinical characteristics moderated these relationships.

METHODS

This is a prospective study of adolescents (N=1491) who received outpatient treatment for SUDs at one of 28 treatment sites taking part in a national evidence-based practice implementation initiative. Information from the Global Appraisal of Individual Needs interviews at intake and six-month follow-up, as well as encounter data, were used. Adjusted hierarchical logistic models were used to estimate effects of engagement on six-month outcomes.

RESULTS

Sixty-one percent of adolescents engaged in outpatient treatment. Adolescents engaging in treatment had significantly lower likelihoods of reporting any substance use (OR 0.60, 95% CI 0.41, 0.87), alcohol use (OR 0.63, 95% CI 0.45, 0.87), heavy alcohol use (OR 0.53, 95% CI 0.33, 0.86), and marijuana use (OR 0.64, 95% CI 0.45, 0.93). This association of engagement with abstinence outcomes was not limited to any particular group. Treatment engagement, however, was not associated with adolescents' self-report of illegal activity or trouble controlling behavior at follow-up.

CONCLUSION

At the individual level, the Washington Circle engagement measure was a predictor of some positive outcomes for adolescents in outpatient treatment. Efforts to better engage adolescents in treatment could improve quality of care.