Transcript What is Good Care for Patients, How Do We Know, and Who is

The Evolution of US
Healthcare Quality
Measurement
Helen Burstin, MD, MPH, FACP
Chief Scientific Officer, NQF
Quality Registers Meeting
Karolinska Institute
July 16, 2015
The Role of the National Quality Forum
 Measurement evaluation and endorsement
▫
▫
Consensus-based standard setting organization for quality
measures (gold standard)
Preference for use of standardized endorsed measures
 Measure selection
▫
▫
Annually advises government on selection of measures for 20+
federal public reporting and pay-for-performance programs
Support measure alignment across public and private sectors
 Measurement science
▫
Expert and consensus reports on complex & controversial issues in
measurement (e.g., SES & risk adjustment, linking cost & quality)
2
US National Quality Strategy:
Three Aims and Six National Priorities
3
Evolving payment and risk structures
Athena Health
4
Patient-Focused Episode: Acute MI
Post AMI Trajectory 1 (T1)
Relatively healthy adult
Focus on:
• Quality of Life
• Functional Status
• 20 Prevention Strategies
• Rehabilitation
• Advanced care planning
Population at Risk
10 Prevention
(no known CAD)
20 Prevention
(CAD no prior AMI)
Acute
Phase
Post Acute/
Rehabilitation
Phase
PHASE 2
PHASE 3
20 Prevention
20 Prevention
(CAD with prior AMI)
Advanced Care Planning
PHASE 4
PHASE 1
Staying Healthy
Getting Better
Episode begins –
onset of symptoms
Living w/ Illness/Disability (T1)
Coping w/ End of Life (T2)
Post AMI Trajectory 2 (T2)
Adult with multiple co-morbidities
Focus on:
• Quality of Life
• Functional Status
• 20 Prevention Strategies
• Advanced Care Planning
• Advanced Directives
• Palliative Care/Symptom Control
Episode ends –
1 year post AMI
5
NQF criteria used to evaluate and endorse
quality measures
Reflect desirable characteristics of quality measures:
• Hierarchy and Rationale
– Importance to measure and report – measure those aspects
with greatest potential of driving improvements; if not
important, the other criteria less meaningful (must-pass)
– Scientific acceptability of measure properties – goal is to make
valid conclusions about quality; if not reliable and valid, risk of
misclassification and improper interpretation (must-pass)
– Feasibility – ideally, cause as little burden as possible; if not
feasible, consider alternative approaches
– Usability and Use – goal is to use endorsed measures for
decisions related to accountability and improvement
– Harmonization and Selection of Best-in-Class
6
Preference for Outcomes
 Hierarchical preference for:
▫
▫
▫
▫
Outcomes linked to evidence-based processes/structures
Outcomes of substantial importance with plausible process/structure
relationships
Intermediate outcomes
Processes/structures (most closely linked to outcomes)
US Quality Measurement in Evolution







Shift to outcomes; increased focus on patient experience
and patient-reported outcome measures (PROMs)
Measures that reflect “optimal care,” including composites
Rocky transition to electronic platforms; lack of structured
data and interoperability
Measure alignment to reduce burden and drive
improvement
Need focus on assessment and reduction of disparities
Build on cost and quality measurement to assess value,
including appropriateness and overuse
Significant growth in clinical registries; high degree of
variation across registries
8
Current Feasibility of eMeasures
Kevin Larsen, ONC
9
Need for Measure Alignment
 Quality measures are increasingly used in value-based
purchasing by public and private health plans
 Current state of alignment –
▫ Too many measures in many areas; major measurement
gaps remain (e.g., care coordination)
▫ Unnecessary duplication and burden
▫ Cacophony of “look-alike measures” in use
▫ Comparability across different measure specifications?
Impact of data source, level of analysis?
10
Efficiency & Value Measurement
11
Rapid Growth of Registries
12
Legislative Impact on Registries
 2013 legislation authorized Qualified Clinical Data Registry
(QCDR) pathway for specialty societies to meet physician
accountability requirements.
▫
▫
Approved entity that collects clinical data for the purpose of patient
and disease tracking to foster quality improvement in care.
Provides timely performance reports to participants
 Explosion of new registries to meet new requirements
▫
▫
▫
▫
42 QCDRs approved by CMS in 2014
No requirements for external review of measures
Short term focus on process measures -- 3 outcome measures
required by 2017
Public reporting on Physician Compare starting in 2016-2017
13
Registry-Based Measurement
 Highly successful registries in US, including STS, ACC NCDR, AHA
GWTG, NSQIP, NCCN:
▫ Impact on research, clinical guidelines, coverage decisions, and
produce nationally recognized quality measures
 Emerging registries with linkages to EHRs through system
integrator, including IRIS (ophthalmology), ACC PINNACLE
 Variable maturation levels and data capture across registries
▫ STS 95% CABG
▫ AAOS 5% joint replacements
14
STS CABG Composite
15
Improved Outcomes in CABG Surgery
16
Need for Ongoing Measure Feedback
 IOM report, Best Care at
Lower Cost: The Path to
Continuously Learning
Health Care in America, cites
feedback loops as essential
for continuous learning and
system improvement
 Continuously learning
system uses information to
change and improve its
actions and outputs over
time
Image Source:
http://www.iom.edu/~/media/Files/Report%20Files/2012
/Best-Care/BestCareReportBrief.pdf
17
The Measurement Imperative
Not everything that counts can be counted,
and not everything that can be counted counts
~Albert Einstein
(William Bruce Cameron)
But…..
You can’t improve what you don’t measure
~ W. Edwards Deming
18
Discussion
Helen Burstin, MD, MPH, FACP
Chief Scientific Officer
[email protected]