National Quality Measures Clearinghouse™: An Expanded Tool with Real-world Relevance

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National Quality Measures Clearinghouse™: An Expanded Tool with Real-world Relevance

Vivian H. Coates, MBA
Vice President, Information Services and Health Technology Assessment
Project Director, National Guideline Clearinghouse™ (NGC) and National Quality Measures Clearinghouse™ (NQMC)
ECRI Institute

Eric C. Schneider MD, MSc
RAND Distinguished Chair in Health Care Quality
Director, RAND Boston
Associate Professor, Harvard Medical School

R. Heather Palmer, MB, BCh, SM
Professor, Health Policy & Management
Harvard School of Public Health

AHRQ 2011 Annual Conference
September 20, 2011

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Outline

• NQMC: An Introduction to the Web Site.
• The NQMC Domain Framework: Development and Evolution.

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Audience Background

• Please select your primary professional role:
  1. Practicing clinician.
  2. Administrator or policymaker.
  3. Performance measure developer.
  4. Researcher.
  5. Student or trainee.
  6. Other.

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Image: A screen shot of the NQMC Web site is shown.

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Audience Background

Please describe your familiarity with NQMC:

1. Never heard of it before today.
2. Heard of it, but never visited the site.
3. Visited the site a few times.
4. Use NQMC fairly often.

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Introduction to NQMC:
What Is It and What Can It Do?

NQMC Web site went live Feb. 19, 2003—8 years old!

• 6,760 measures submitted from 54 orgs (as of August 31, 2011).
• 2,002 measure summaries currently published from 51 orgs (as of August 31, 2011).
• ~14 measure summaries published per week (August 2010-August 2011 weekly average).
• 563 additional measure summaries currently in progress in work queue (as of August 31, 2011).

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NQMC Web Site Usage

• NQMC Web Site Usage (August 1, 2010—July 31, 2011):
  • Average monthly visits: 17,250.
  • Average weekly visits: 3, 980.
  • Average time spent per visit: 7:51 minutes.
  • Average page views per visit: 4.25.
  • New visitors: 32,800.
• Now sending weekly "What's New E-mail alerts" to more than 40,323 subscribers (as of August 31, 2011).

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Profile of NQMC Users

• 38.2% of respondents: managers, purchasers, or policymakers.
• 11.8%: physicians.
• 11.7%: researchers, measure developers, or information specialists.
• 11.2%: physician assistants or nurses.

Source: 2008 NQMC user survey

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Profile of NQMC Users

• 44.6% of respondents: affiliated with inpatient care hospitals.
• 15.4%: oversight organizations or purchasers.
• 12.7: outpatient ambulatory settings.
• 11.9%: academic institutions.

Source: 2008 NQMC user survey

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What Can NQMC Do?

• Help users to find and compare measures (from many countries).
• Search using multiple controlled taxonomies (eg, UMLS vocabularies: including MeSH, SNOMED, ICD).
• Search using filters (eg, identify measures that are endorsed by NQF).
• Forum for debate: Expert Commentaries.
• Educate users about measurement and measurement frameworks.

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Evolution of the Domain Framework

• NQMC classifies measures into domain categories that can assist users in searching and browsing the database.
• Design of framework is empirically driven based on analysis of thousands of "measures" submitted to NQMC from across the globe.

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NQMC Domain Framework: Donabedian View

Clinical Quality Measures:

• Process.
• Outcome.
• Structure.

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NQMC Domain Framework: v. 1.0 Clinical Quality Measures

Clinical Quality Measures:

• Process.
• Access.
• Outcome.
• Structure.
• Patient Experience.

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Audience Query: Classify this Measure

The percentage of adult members who were hospitalized and discharged alive with a diagnosis of acute myocardial infarction (AMI) and who received persistent beta-blocker treatment for six months after discharge.

In which domain would you classify this measure?

1. Process.
2. Access.
3. Outcome.
4. Structure.
5. Patient Experience.

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Audience Query: Classify this Measure

The percent of patients who have had a visit to an Emergency Department (ED)/Urgent Care office for asthma in the past six months.

In which domain would you classify this measure?

1. Process.
2. Outcome.
3. Access.
4. Patient Experience.
5. None of the above.

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Audience Query: Classify this Measure

The percent of diabetic patients in the clinical information system who are current smokers (documented in the last 12 months).

In which domain would you classify this measure?

1. Structure.
2. Process.
3. Outcome.
4. Patient Experience.
5. None of the above.

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Audience Query: Classify this Measure

Whether a practice has a policy to ensure the prevention of fraud and has defined levels of financial responsibility and accountability for staff undertaking financial transactions.

In which domain would you classify this measure?

1. Structure.
2. Process.
3. Outcome.
4. Patient Experience.
5. None of the above.

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NQMC Domain Framework: Related Health Care Delivery Measures

Screen shot of a flowchart showing the following information:

Health Care Delivery Measures leading to Clinical Quality Measures and Related Health Care Delivery Measures.

Definition of Health Care Delivery Measures: Measures applied to clinicians, clinical delivery teams, delivery organizations, or health insurance plans.

Clinical Quality Measures:

• Structure.
• Process.
• Outcome.
• Patient Experience.
• None of the above.

Related Health Care Delivery Measures

• User Enrollee Health State.
• Management.
• Use of Services.

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Audience Query: Classify this Measure

The number of cases of selected central venous catheter-related bloodstream infections per 100,000 population in county or Metro Area.

In which domain would you classify this measure?

1. Structure.
2. Process.
3. Outcome.
4. Patient Experience.
5. None of the above.

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NQMC Domain Framework

Flow chart showing the following the information:

Measures Related to Health:

Health Care Delivery Measures: Measures applied to clinicians, clinical delivery teams, delivery organizations, or health insurance plans.

Population Health Measures: Measures applied to public health agencies, organizations that are not primary deliverers of care, or geographic regions.

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Population Health Domain Rationale

• Denominator includes individuals who may not have received care from the clinical delivery system ("geographically-defined" denominator).
• AHRQ National Quality Report and National Health Disparities Reports include population health measures.
• Federal and state agencies are investing in public health standards and measurement initiatives.
• NQF considering expansion of its purview to include population health.
• The Clearinghouses are well positioned to serve as a resource for public health professionals.

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Population Health Domain

• Definition of population:
  • A group of persons identified by geographic location, organizational affiliation or non-clinical characteristics. Denominator inclusion for measures classified in population health domains is not restricted to recipients of clinical care or enrollees in a health plan.

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Population Health Domain Development

• Public health measure analysis sets:
  • LA County Department of Public Health.
  • U.S. Public Health Service's Healthy People 2010.
  • CDC Indicators for Occupational Health Surveillance.
  • CDC Indicators for Chronic Disease Surveillance.
  • Commission for Environmental Cooperation: Children's Health and the Environment in North America.
  • New York State County Health Assessment Indicators.
  • Utah Department of Health Indicator-Based Information System for Public Health (IBIS-PH).
  • Swedish National Board of Health and Welfare.

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NQMC Domain Framework

Image: The NQMC Domain Framework is shown.

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Population Health Measures: Examples

• Population Process:
  • The proportion of adults ages 65 years and older in a county who have received an influenza vaccination in the past year.
• Population Access:
  • The percentage of smokers in a county who reported that they were able to receive services from a smoking-cessation program.

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Population Health Measures: Examples

• Population Outcome:
  • The proportion of children with elevated blood lead levels whose homes undergo lead remediation, and whose blood lead levels are subsequently reduced to normal levels.
• Population Experience:
  • The percentage of smokers in a county reporting that they have seen or heard public service announcements promoting a county health department-sponsored smoking-cessation program.
• Population Structure:
  • The number of licensed child care facilities and slots in a county.

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Population Health Measures: Examples

• Population Health Knowledge:
  • The mean response score to a set of questions about HIV prevention.
• Social Determinants of Health:
  • The proportion of families living at or below the poverty level.
• Environment:
  • The number of days in the past year when the concentration of particulate air pollution in a community exceeds a defined threshold.

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Audience Query: Classify this Measure

The proportion of families living at or below the poverty level.

In which domain would you classify this measure?

1. Structure.
2. Population Outcome.
3. Population Process.
4. Population Structure.
5. Social Determinants of Health.
6. Environment.

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Audience Query: Classify this Measure

The mean response score to a set of questions about HIV prevention.

In which domain would you classify this measure?

1. Structure.
2. Population Outcome.
3. Population Process.
4. Population Structure.
5. Social Determinants of Health.
6. Environment.

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Audience Query: Classify this Measure

The number of days in the past year when the concentration of particulate air pollution in a community exceeds a defined threshold.

In which domain would you classify this measure?

1. Structure.
2. Population Outcome.
3. Population Process.
4. Population Structure.
5. Social Determinants of Health.
6. Environment.

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Measuring Cost and Efficiency: Rationale

• Costs and resource use measures now a high priority:
  • NQF National Priorities Partners Areas.
  • Payment reform models.
  • Interest in price transparency.
• Earlier cost reporting efforts:
  • Pennsylvania HC4 CABG Surgery Mortality Report (1991).
  • NCQA Use of services measures (1993).
• Renewed efforts to try to measure efficiency:
  • NCQA Relative Resource Use Measures.
  • Use of Episode Groupers to carry out relative cost measurement.

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Efficiency and Cost Domain Development

• Cost:
  • The monetary or resource units expended by a health care organization or clinician to deliver health care to individuals or populations.
• Efficiency:
  • A measure of cost of care associated with a specified level of quality of care.

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Cost vs. Efficiency

Hospital Cost Measure: Median Charge Per Hospital Discharge, Total Hip Replacement (Hypothetical):

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Cost vs. Efficiency

Hospital Efficiency Measure: Quality-Adjusted Median Charge Per Hospital Discharge, Total Hip Replacement (Hypothetical):

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NQMC Domain Framework

Image: The NQMC Domain Framework is shown.

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Payment Models Needing New Performance Measures

• Global payment.
• accountable care organization (ACO) shared savings.
• Medical home.
• Bundled payment.
• Hospital-physician gainsharing.
• Payment for coordination.
• Hospital pay-for-performance.
• Physician pay-for-performance.
• Payment for shared decisionmaking.

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Summary of New Measure Types Needed to Support Payment Reform Models

• Health outcomes:
  • Functional status & safety outcomes.
• Care coordination:
  • Transitions.
• Patient and caregiver engagement with care:
  • Medical homes, shared decisionmaking.
• Structure:
  • ACOs, decision aids.
• Efficiency:
  • Hospital and Physician pay-for-performance (P4P).

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Some Anticipated Consequences

• Potentially large increase in performance measure submissions to NQMC as federally-funded projects complete measure development.
• New types of measures?
• Potential increase in the variability of "measure quality":
  • Purposes for measures.
  • Evidence used.
  • Protocols used to develop measures.
  • Validity and reliability testing.
• How can NQMC adequately convey distinctions among these attributes of measures?

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Performance Measures and Health Reform: Issues for the Future

• Evolution in delivery organizations (medical homes, ACOs).
• New expectations about necessary evidence base.
• Heightened concern about conflicts of interest.
• New federal resources for quality measure development, selection and endorsement.
• E-specifications for traditional performance measures.
• New types of performance measures leveraging electronic health record (EHR).
• New performance measures to assess Health Information Technology (Health IT) and health information exchange (HIE).

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NQMC Going Forward

• Audience Q and A.