Move to Refine Quality Measures Gaining Momentum

Complaints about quality measures are as abundant as the measures themselves. But some doctors are doing something about it. They're working to identify metrics that are "realistic and actually will have an impact on patient care."

Call it pushback, validation, or measurement science. The revolt against the volume and usefulness of outcomes measures continues.  

The AHRQ alone lists 1,280 quality measures on its site.

Efforts are underway to both challenge and refine existing guidelines and requirements. And, wonks take note, providers and patients are on the job, too.

One example: The emergency department at Beth Israel Deaconess Medical Center in Boston's Longwood cluster of hospitals sees more than 50,000 patients a year. Every time a patient undergoes procedural sedation in the ED, doctors there follow up with a formal quality assurance review.

Their analyses are designed to meet a Joint Commission standard that requires monitoring and evaluation of such cases, which carry the risk that comes with sedation.

Now team, including BIDMC emergency physician Jonathan Edlow, MD, has decided to examine the utility of the review. "We are trying to find out what metrics make sense and what don't," he told me. 

In a March paper in The Journal of Emergency Medicine, Edlow and his team reported that the review "offers little advantage over existing quality assurance markers." They concluded that review of high risk cases "may be useful."

Like other specialists, doctors in the field of emergency medicine are trying to become more active in the creation of quality metrics, Edlow says. They are looking for "measures that are realistic and actually will have an impact on patient care, as opposed to a lot of those [that] regulatory agencies come up with in the absences of physician input."  

David W. Baker, MD, vice present for healthcare quality evaluation at The Joint Commission, said that the study is based on an erroneous assumption. The Joint Commission does not require review of all cases that used procedural sedation.  The current standard says that hospitals should collect data to identify adverse events related to moderate or deep sedation or anesthesia. Baker said, “These reviews should be all about identifying opportunities to improve safety, and that’s exactly what occurred in the study.”  

Baker co-authored an article in the current issue of the Journal of General Internal Medicine with Cheryl Damberg of the Rand Corporation, entitled "Improving the Quality of Quality Measurement."

The piece noted that:" All clinical specialties should define the outcomes they are working to improve for acute, chronic, and palliative care, and should develop systems to measure those outcomes."

The Joint Commission welcomes input from those testing their standards, Baker says. The two sedation-related errors identified in the study involved airway management, so BIDMC may want to look more closely in that direction, he adds.

They already do. Physician errors in airway management are already automatically reviewed by the hospital's QA committee. This brings up another complaint about measures: They can be duplicative.
"There is a tremendous amount of concern about too many measure and too many different measures, "Baker told me. "Everyone in the measurement arena has heard that loud and clear and shares those concerns."  

He says the CMS/AHIP core measure are a step in the right direction. The Commission's measures are also aligned with CMS, he says, but hospitals are often required to report different measures to different payers and regulators.

That is changing. "The wheels are turning in the right direction," he says, both in terms of alignment and the effort to establish valid electronic clinical measure that will help reduce the administrative burden of data collection.

That momentum is apparent in a review of recent research, including studies published in April that include findings on the impact of case mix on readmission rates, quality measures for multiple sclerosis, and a composite quality measure for lobectomy designed by The Society of Thoracic Surgeons.

So, we've gone from measure-to-measure that, as a recent post on the Health Affairs blog asks, "measures that matter to whom?"  The piece notes that: "Different stakeholders will not only have different perspectives about what measures matter to them, but even have different views on what the same terms mean."

Enter the Patient

Those stakeholders include hospitals, clinicians, payers, and patients. The current issue of Health Affairs is devoted to one of them: patients. For example, one piece talks about how PROS have been used for research, but need to be incorporated in efforts to improve care.

That resonates at Cambridge, MA-based PatientsLikeMe, where researchers are working with the National Quality Forum to streamline methods for using PROs to create PRO-based performance measures.

The organization is way ahead on distilling patient level data. Launched 2006, PatientsLikeMe was founded by two brothers after a third brother was diagnosed with ALS. They started a platform with an online forum for ALS patients and extracted data from patient conversations.

Now they count 400,000 members talking to each other about 2,500 different conditions. The PatientsLikeMe site also allows members to track and submit personal health data. So far, the company has collected more than 30 million data points, which they provide to academic and industry partners.

The idea that PROs do not offer quality data has changed, says PatientsLikeMe cofounder Ben Heywood: "We historically worked with life science companies because they realized early on the power of patient-generated data." 

In the past, efforts at inclusion involved putting an individual patient representative on a panel of experts. Heywood knows they can do much better. The company's assignment for the NQF Measure Incubator is to demonstrate a system that will scientifically and at scale add patients' voices to measurement efforts, he says.

EHRs are key to streamlining measurement efforts. But, the problems of interoperability at the clinical level spill over into research. Baker at The Joint Commission said that is a major focus of his organization.

"We're still on the road to that," he said. "This is going to be a long journey over the next few years to… improve on our ability to measure processes and outcome of care using EHRs so we can minimize the burden of data collection and reporting. "

All indicators suggest that the road to high-quality measurement also promises to be a long one.