MN DEPARTMENT OF HEALTH
PROVIDER PEER GROUPING (PPG)
ADVISORY GROUP
QUALITY MEASUREMENT: CONDITION SPECIFIC
QUALITY MEASUREMENT: TOTAL CARE
COMBINING COST & QUALITY MEASUREMENTS
ANN ROBINOW
MEETING 5: JULY 22, 2009
Introduction
Comments and changes to meeting summary?
Review of questions or comments since last meeting
Report Technical Panel responses since last meeting
CMS considers a patient as new if provider has not been seen
in three years. Tech Panel recommends non-users be attributed
based on no more than two previous years data.
Risk adjustment for severity upon admission for Physician Total
Cost will be accounted for but not as well for Hospital Total
Cost.
Caution that transfers to hospitals be carefully defined and
identifiable when attributing back to primary hospital.
Questions for Today’s Meeting:
Condition Specific Quality Measures
Review results of PPG Advisory Group input.
Should we use single or multiple measures for each
condition?
Which measures should we use for each condition?
If multiple measures are recommended per
condition, how should we combine the measures?
Quality Measures: Pneumonia
#
NQF
endorsed
Available Pneumonia Measures
Composite Measure Currently In Use
1 Pneumonia - Appropriate care measure (Includes measures 1a - 1f)
Components of Composite Measure
1a
Oxygenation assessment within first 24 hours of admission
Blood cultures performed in ED prior to initial antibiotic received in
1b
hospital
yes
1c
Initial antibiotic received within 6 hours of hospital arrival
yes
1d
Pneumococcal vaccination
Initial antibiotic selection for community-acquired pneumonia in
immunocompetent patients
yes
1e
1f
yes
Adult smoking cessation advice/counseling
yes
Hospital Avoidance Measures
2 Rate of hospital re-admission for bacterial pneumonia
3 Rate of hospital ER visits for pneumonia post discharge
Other Measures
yes
Source
Unit of
Measure
MN Hospital
Association/Stratis
Health
Hospital
CMS Hospital
Compare
CMS Hospital
Compare
CMS Hospital
Compare
CMS Hospital
Compare
CMS Hospital
Compare
AHRQ Prevention
Quality Indicators
Hospital
Hospital
Hospital
Hospital
Hospital
Hospital**
CMS Hospital
4 Influenza vaccination
yes
Compare
Hospital
5 30-day mortality after hospital discharge
Yes
CMS
Hospital
Shaded measure is currently in use by MN Hospital Association
**Although measured using hospital claims data, these indicators are more appropriately viewed as an indicator of the quality
of ambulatory/physician care.
Quality Measures: Pneumonia Responses
RESPONSES
Single
Multiple
Question 1: Should Pneumonia Quality be measured by a
Single Measure listed below or by More than One Measure
listed below?
3
9
Question 2: If Pneumonia should be measured by a Single Measure, which measure below
would you recommend?
1st Choice
Pneumonia - Appropriate care measure (Includes measures 1a - 1f) (3)
2nd Choice
3rd Choice
Question 3: If Pneumonia should be measured by More than One Measure, which measures
below (select up to 5) would you recommend in priority order (1= highest priority) ?
Priority 1:
#2 Rate of hospital re-admission for bacterial pneumonia (26 points/6 votes)
Priority 2:
#1 Pneumonia - Appropriate care measure (Includes measures 1a - 1f) (22/5)
Priority 3:
#5 30-day mortality after hospital discharge (20/5)
Priority 4:
#3 Rate of hospital ER visits for pneumonia post discharge (16/5)
Priority 5:
Quality Measures: Diabetes
NQF
Available Diabetes Measures
endorsed
Composite Measure Currently In Use
1 Optimal diabetes care (Includes measures 1a - 1e)
Components of Composite Measure
1a
Blood pressure below 130/80 mm/Hg
1b
LDL cholesterol below 100 mm/dL
Yes
1c
HbA1c level Modified
1d
Daily aspirin use (age 40 & older)
1e
Documented non-tobacco use
Other Measures
#
2
3
4
5
6
Eye exam
Hemoglobin A1c testing
Blood pressure measurement
Urine protein screening
Lipid profile
Yes
Yes
Yes
Yes
Yes
Hospital Avoidance Measures
7 Rate of hospital admissions for short-term complications
Yes
8 Rate of hospital admissions for long-term complications
Yes
9 Rate of hospital admissions for uncontrolled diabetes
Yes
10 Rate of hospital re-admissions for diabetes
11 Rate of hospital ER visits for diabetes
Yes
Source
Unit of
Measure
MNCM
Clinic site
MNCM
MNCM/NCQA
MNCM
MNCM
MNCM
Clinic site
Clinic site
Clinic site
Clinic site
Clinic site
NCQA
NCQA
NCQA
NCQA
NCQA
Physician /clinic
Physician /clinic
Physician /clinic
Physician /clinic
Physician /clinic
AHRQ Prevention
Quality Indicators
AHRQ Prevention
Quality Indicators
AHRQ Prevention
Quality Indicators
AHRQ Prevention
Quality Indicators
Hospital**
Hospital**
Hospital**
Hospital**
Hospital**
AHRQ Prevention
12 Rate of lower-extremity amputation
Yes
Quality Indicators
Hospital**
Shaded measure is currently in use by Mn Community Measurement.
**Although measured using hospital claims data, these indicators are more appropriately viewed as an indicator of the quality
of ambulatory/physician care.
Quality Measures: Diabetes Responses
Question 1: Should Diabetes Quality be measured by a
Single Measure listed below or by More than One Measure
listed below?
RESPONSES
Single
Multiple
4
8
Question 2: If Diabetes should be measured by a Single Measure, which measure below
would you recommend?
1st Choice
#1 Optimal diabetes care (Includes measures 1a - 1e) (3)
2nd Choice
#1c HbA1c level (1)
3rd Choice
Question 3: If Diabetes should be measured by More than One Measure, which measures
below (select up to 5) would you recommend in priority order (1= highest priority) ?
Priority 1:
#1 Optimal diabetes care (Includes measures 1a - 1e) (20 points/4 votes)
Priority 2:
#9 Rate of hospital admissions for uncontrolled diabetes (12/4)
Priority 3:
#7 Rate of hospital admissions for short-term complications (11/4)
Priority 4:
#10 Rate of hospital re-admissions for diabetes (9/4)
#11 Rate of hospital ER visits for diabetes (8/3)
#2 Eye exam (8/3)
Priority 5:
Quality Measures: Asthma
#
1
2
3
4
NQF
Unit of
Available Asthma Measures
endorsed Source Measure
Measure Currently In Use
Use of appropriate medications for people
NCQA Physician
with asthma
Yes
(HEDIS) or clinic
Hospital Avoidance Measures
Rate of hospital admissions for adult asthma
Yes
AHRQ Hospital**
Rate of hospital re-admissions for asthma
Hospital**
Rate of hospital ER visits for asthma
Hospital**
Shaded measure is currently in use by Mn Community
Measurement.
**Although measured using hospital claims data, these indicators are more
appropriately viewed as an indicator of the quality of ambulatory/physician care.
Quality Measures: Asthma Responses
Question 1: Should Asthma Quality be measured by a
Single Measure listed below or by More than One Measure
listed below?
RESPONSES
Single
Multiple
3
9
Question 2: If Asthma should be measured by a Single Measure, which measure below
would you recommend?
1st Choice
Use of appropriate medications for people with asthma (3)
2nd Choice
3rd Choice
Question 3: If Asthma should be measured by More than One Measure, which measures
below (select up to 5) would you recommend in priority order (1= highest priority) ?
Priority 1:
#1 Use of appropriate medications for people with asthma (35 points/7 votes)
Priority 2:
#4 Rate of hospital ER visits for asthma (34/9)
Priority 3:
#2 Rate of hospital admissions for adult asthma (25/8)
Priority 4:
#3 Rate of hospital re-admissions for asthma (23/8)
Priority 5:
Quality Measures: Coronary Artery
NQF
Available Coronary Artery Measures
endorsed
Composite Measure Currently In Use
Optimal vascular care (Includes measure of 1a 1 1d)
Modified?
Components of Composite Measure
#
1a
1b
1c
1d
Blood pressure below 130/80 mm/Hg
Source
Unit of
Measure
MNCM
Clinic site
MNCM/
NCQA
MNCM/
NCQA
MNCM
MNCM
Clinic site
LDL cholesterol below 100 mm/dL
Yes
Clinic site
Daily aspirin use (age 40 & older)
Clinic site
Documented non-tobacco use
Clinic site
Hospital Avoidance Measures
2 Rate of hospital admissions for CAD
Hospital**
3 Rate of hospital re-admissions for CAD
Hospital**
4 Rate of hospital ER visits for CAD
Hospital**
Shaded measure is currently in use by Mn Community
Measurement.
**Although measured using hospital claims data, these indicators are more appropriately
viewed as an indicator of the quality of ambulatory/physician care.
Quality Measures: CAD Responses
RESPONSES
Single
Multiple
Question 1: Should CAD Quality be measured by a Single
Measure listed below or by More than One Measure listed
below?
3
9
Question 2: If CAD should be measured by a Single Measure, which measure below would
you recommend?
1st Choice
#1 Optimal vascular care (Includes measure of 1a - 1d) (3)
2nd Choice
3rd Choice
Question 3: If CAD should be measured by More than One Measure, which measures below
(select up to 5) would you recommend in priority order (1= highest priority) ?
Priority 1:
#1 Optimal vascular care (Includes measure of 1a - 1d) (35 points/ 7 votes)
Priority 2:
#3 Rate of hospital re-admissions for CAD (19/6)
Priority 3:
#2 Rate of hospital admissions for CAD (15/5)
Priority 4:
#4 Rate of hospital ER visits for CAD (10/3)
Priority 5:
Quality Measures: Heart Failure
#
NQF
Available Heart Failure Measures
endorsed
Other Measures
1 Evaluation of left ventricular systolic function
Yes
2 Hospital discharge instructions
Yes
Source
CMS, Joint
Commission
CMS, Joint
Commission
CMS, Joint
Commission
AHRQ
CMS
Unit of
Measure
Hospital
Hospital
3 Adult smoking cessation advice/counseling
Yes
Hospital
4 Hospital mortality rate
Yes
Hospital
5 30-day mortality after hospital discharge
Yes
Hospital
Hospital Avoidance Measures
Rate of hospital admissions for congestive heart
6 failure
Yes
AHRQ
Hospital**
7 Rate of hospital re-admissions for heart failure
Hospital**
8 Rate of hospital ER visits for heart failure
Hospital**
**Although measured using hospital claims data, these indicators are more appropriately
viewed as an indicator of the quality of ambulatory/physician care.
Quality Measures: Heart Failure Responses
RESPONSES
Single
Multiple
Question 1: Should Heart Failure Quality be measured by a
Single Measure listed below or by More than One Measure
listed below?
1
10
Question 2: If Heart Failure should be measured by a Single Measure, which measure
below would you recommend?
1st Choice
#7 Rate of hospital re-admissions for heart failure
2nd Choice
3rd Choice
Question 3: If Heart Failure should be measured by More than One Measure, which
measures below (select up to 5) would you recommend in priority order (1= highest
priority) ?
Priority 1:
#7 Rate of hospital re-admissions for heart failure (30 points/ 8 votes)
Priority 2:
#8 Rate of hospital ER visits for heart failure (27/9)
Priority 3:
#6 Rate of hospital admissions for congestive heart failure (24/6)
Priority 4:
#5 30-day mortality after hospital discharge (18/7)
Priority 5:
Quality Measures: Total Knee
#
NQF
Available Total Knee Measures
endorsed
Hospital Avoidance Measures
Rate of hospital re-admissions for total knee
1 replacement
2 Rate of hospital ER visits after knee surgery
Source
Unit of
Measure
Hospital**
Hospital**
**Although measured using hospital claims data, these indicators are more
appropriately viewed as an indicator of the quality of ambulatory/physician care.
Quality Measures: Total Knee Responses
Question 1: Should Total Knee Quality be measured by a
Single Measure listed below or by More than One Measure
listed below?
RESPONSES
Single
Multiple
3
9
Question 2: If Total Knee should be measured by a Single Measure, which measure below
would you recommend?
1st Choice
#1 Rate of hospital re-admissions for total knee replacement
2nd Choice
3rd Choice
Question 3: If Total Knee should be measured by More than One Measure, which measures
below (select up to 5) would you recommend in priority order (1= highest priority) ?
Priority 1:
Rate of hospital re-admissions for total knee replacement (34 points/7 votes)
Priority 2:
Rate of hospital ER visits after knee surgery (29 pts/7 votes)
Priority 3:
Priority 4:
Priority 5:
Combining Multiple Quality Measures
Assign weights to measures and sum to create a weighted average.
1.
2.
3.
Weighting Options
Weight each measure equally
Weight by categories of measure (composite, hospital avoidance, other)
Weight by type of measure (structure, process, outcome, overuse)
Assign points to categories or types of measures and sum total points.
Weighting considerations (from Technical Advisory Group):
Short term v. long term impact of measure, not just frequency
Physician control & influence over patient for measure
Prevalence of population measured
Chris Tompkins Article Summary of
Combining Quality Measures
Recommendations to CMS to expand VBP models to include clinical
outcomes and cost to promote value
Proposes focus on outcome measures of quality a/c of greatest
interest to purchasers and won’t stifle innovation
Can combine individual measures such as complications and other
adverse events, roll up for purchasers and consumers, report in
detail for providers
Can assign points for performance based on improvement rate
and/or attainment rate
Can weight measures based on performance or use equal weight if
right measures selected that are somewhat interdependent
Chris Tompkins Suggested Hospital
Quality Measures
Suggests hospital measures by condition, risk
adjusted where applicable, including:
30 day post discharge ambulatory visits
Minor complications rate
Major complications rate
30 day post discharge ER visits
30 day post discharge readmissions
30 day post discharge mortality
Combination of above for each condition
Combination of above for all conditions
Summary: Pneumonia
Measure
Include
Measure?
(Yes/No)
Measure Weight
Guidelines
(over or under
weight)
Measure Points
Guidelines
(over or under
score)
#2 Rate of hospital re-admission for
bacterial pneumonia (26 pts/6 votes)
#1 Pneumonia - Appropriate care
measure (Includes measures 1a - 1f)
(22/5)
#5 30-day mortality after hospital
discharge (20/5)
#3 Rate of hospital ER visits for
pneumonia post discharge (16/5)
Summary: Diabetes
Measure
#1 Optimal diabetes care
(Includes measures 1a – 1e)
#9 Rate of hospital admissions for
uncontrolled diabetes (12/4)
#7 Rate of hospital admissions for
short-term complications (11/4)
#10 Rate of hospital readmissions for diabetes (9/4)
#11 Rate of hospital ER visits for
diabetes (8/3)
#2 Eye exam (8/3)
Include
Measure?
(Yes/No)
Measure Weight
Guidelines
(over or under weight)
Measure Points
Guidelines
(over or under score)
Summary: Asthma
Measure
Include
Measure?
(Yes/No)
Measure Weight
Guidelines
(over or under
weight)
Measure Points
Guidelines
(over or under
score)
#1 Use of appropriate medications for
people with asthma (35 pts/7 votes)
#4 Rate of hospital ER visits for asthma
(34/9)
#2 Rate of hospital admissions for adult
asthma (25/8)
#3 Rate of hospital re-admissions for
asthma (23/8)
Summary: Coronary Artery
Measure
#1 Optimal vascular care (Includes
measure of 1a - 1d) (35 pts/ 7
votes)
#3 Rate of hospital re-admissions
for CAD (19/6)
#2 Rate of hospital admissions for
CAD (15/5)
#4 Rate of hospital ER visits for
CAD (10/3)
Include
Measure?
(Yes/No)
Measure Weight
Guidelines
(over or under weight)
Measure Points
Guidelines (over
or under score)
Summary: Heart Failure
Measure
Include
Measure?
(Yes/No)
Measure Weight
Guidelines
(over or under weight)
Measure Points
Guidelines (over
or under score)
#7 Rate of hospital re-admissions
for heart failure (30 pts/ 8 votes)
#8 Rate of hospital ER visits for
heart failure (27/9)
#6 Rate of hospital admissions for
congestive heart failure (24/6)
#5 30-day mortality after hospital
discharge (18/7)
Summary: Total Knee
Measure
Rate of hospital re-admissions for total
knee replacement (34 pts/7 votes)
Rate of hospital ER visits after knee
surgery (29 pts/7 votes)
Include
Measure?
(Yes/No)
Measure Weight
Guidelines
(over or under
weight)
Measure
Points
Guidelines
(over or under
score)
PPG Advisory Meeting Schedule
MEETING
DATE
TIME
Meeting 1
Thursday, June 11
Introduction/Background
Meeting 2
Friday, June 26
Defining Parameters
Meeting 3
Friday, July 10
Cost Measure for Conditions
Meeting 4
Friday, July 17
Quality Measures for Conditions
Cost Measure for Total Care
Meeting 5
Wednesday, July 22
Quality Measure for Total Care
Combining Cost & Quality
Meeting 6
Monday, July 27
Combining Cost & Quality
Meeting 7
Wednesday, September 2
Information Needs by Audience
Meeting 8
Friday, September 11
Revisit Outstanding Issues
Meeting 9
Wednesday, September 30
Final Review
Context For Today’s Discussion
High Level Steps in Peer Grouping
TOTAL CARE
Questions for Today’s Meeting:
Quality Measures Total Care
What quality measures should be included in physician
peer grouping for Total Care?
What quality measures should be included in hospital
peer grouping for Total Care?
How many quality measures should be included?
How should multiple measures be combined into a
composite quality measure for Total Care?
What types of risk adjustment should be performed for
Total Care quality measures?
Technical Panel Recommendations:
Total Care Quality Measures
1. MN Community Measures are all appropriate for Physician Total Care Quality
Measures. All 44 hospital measures available through MHQR and AHRQ, including
Patient Experience measure, are appropriate for Hospital Total Care Quality
Measures.
2. Recommend development of more outcome measures.
3. Support the concept of Composite measures but not necessarily the way current
composite/Appropriate Care measures are constructed.
4. Preventable hospitalization (Ambulatory Care Sensitive) measures should not be
included in Total Care quality measures at this time due to inadequate risk
adjustment for quality measures.
5. Hospital Readmission rate is an important measure to include as a Total Care quality
measure when risk adjustment for measure is more developed.
6. Support adoption of AHRQ Hospital Mortality & Patient Safety Composite
Measures.
Total Care: How Many Quality
Measures Should be Included?
Which Measures Should Be Included for
Total Care Quality?
Total Care Quality Measures: Physician
Condition
Measure (12)
Source
PREVENTIVE MEASURES (6)
Breast Cancer % of women, ages 52-69, who had a mammogram during the past two years.
Cancer
Screen
% of adults, ages 51-80, who received appropriate cancer tests
Cervical
Cancer
% of women, ages 24-64, who received a Pap test in the last 3 years.
Childhood
Immunization
Chlamydia
Screening
Colorectal
Screening
MNCM
MNCM
MNCM
% of children who received all of these vaccinations by the age of 2:
1) DTP, 2) Polio, 3) MMR, 4) H Influenza B, 5) HepB, 6) Chicken Pox, 7) Pneumo MNCM
% of sexually-active females, ages 16-25, who received a Chlamydia test
MNCM
% of adults, ages 51-80, who received 1 or more of 4 proven screening tests: 1) fecal
occult blood, 2) flex sigmoid, 3) double contrast barium enema, 4) colonoscopy
MNCM
MINOR ACUTE (2)
Colds
% of children, 3 months to 18 years, diagnosed with a cold and not given an antibiotic
% of children, ages 2-18, diagnosed with a sore throat and given a strep test and
Sore Throat antibiotics.
MNCM
MNCM
High Blood
Pressure
Vascular
Diabetes
CHRONIC (4)
% of adults, ages 18-85, diagnosed with high blood pressure that had a blood
pressure reading lower than 140/90.
% of vascular disease patients, ages 18-75, who met all 4 goals
% of diabetes patients, ages 18-75, who met all D5 goals.
MNCM
MNCM
MNCM
Asthma
% asthma patients, ages 5-56, who were prescribed appropriate medication.
MNCM
Total Care Quality Measures: Physician
Condition
Measure
HOSPITAL AVOIDANCE MEASURES
Pneumonia
Rate of hospital re-admission for pneumonia
Pneumonia
Rate of hospital ER visits for pneumonia post discharge
Diabetes
Rate of hospital admissions for short-term complications
Diabetes
Rate of hospital admissions for long-term complications
Diabetes
Diabetes
Diabetes
Diabetes
Rate of hospital admissions for uncontrolled diabetes
Rate of hospital re-admissions for diabetes
Rate of hospital ER visits for diabetes
Rate of lower-extremity amputation
Asthma
Asthma
Rate of hospital admissions for adult asthma
Rate of hospital re-admissions for asthma
Asthma
Rate of hospital ER visits for asthma
CAD
CAD
CAD
Heart Failure
Heart Failure
Heart Failure
Total Knee
Total Knee
Rate of hospital admissions for CAD
Rate of hospital re-admissions for CAD
Rate of hospital ER visits for CAD
Rate of hospital admissions for congestive heart failure
Rate of hospital re-admissions for heart failure
Rate of hospital ER visits for heart failure
Rate of hospital re-admissions for total knee replacement
Rate of hospital ER visits after knee surgery
Total Care Quality Measures: Hospital
CURRENTLY AVAILABLE MEASURES (31)
Minnesota Hospital Quality Report (MHQR) / Hospital Compare Measures (27)
(Current requirement for PPS hospitals; submission has been voluntary for CAHs)
Acute Myocardial Infarction (AMI) / Heart Attack (8)
• Fibrinolytic therapy received within 30 minutes of
• Aspirin at arrival 2
hospital arrival 2
• Aspirin at discharge 2
• ACE inhibitor or ARB for left ventricular systolic • Primary percutaneous coronary intervention
dysfunction (LVSD) 2
(PCI) received within 90 minutes of hospital
arrival 2
• Adult smoking cessation advice / counseling 2
• Beta-blocker prescribed at discharge 2
• Heart Attack – Appropriate care measure 2
Heart Failure (HF) (5)
• Discharge Instructions 2
• Adult smoking cessation advice / counseling 2
• Evaluation of left ventricular systolic (LVS)
• ACEI or ARB for LVSD 2
function 2
• Heart Failure – Appropriate care measure 2
Pneumonia (PN) (7)
• Initial antibiotic received Within 6 hours of
• Pneumococcal vaccination 2
• Blood cultures performed in the emergency
hospital arrival 2
department prior to initial antibiotic received in
• Initial antibiotic selection for community-acquired
hospital 2
pneumonia (CAP) in immunocompetent patients
2
• Adult smoking cessation advice / counseling 2
• Influenza vaccination 2
• Pneumonia – Appropriate care measure 2
1
Measure type:
Outcome measure, 2 Process measure, 3 Structure measure, 4 Overuse / misuse measure
Total Care Quality Measures: Hospital
Surgical Care Improvement Project (SCIP) (7)
• Prophylactic antibiotic received within one hour • Surgery patients with recommended venous
thromboembolism prophylaxis ordered 2
prior to surgical incision – Overall rate 2
• Prophylactic antibiotic selection for surgical
• Surgery patients who received appropriate
patients – Overall rate 2
venous thromboembolism prophylaxis within 24
• Prophylactic antibiotics discontinued within 24
hours prior to surgery to 24 hours after surgery 2
hours after surgery end time – Overall rate 2
• Cardiac surgery patients with controlled 6 a.m.
postoperative blood glucose 2
• Surgery patients with appropriate hair removal 2
Infection (4)
(Current requirement for PPS hospitals and CAHs)
• Ventilator associated pneumonia bundle 2
• Central line bundle 2
Measure type:
1
• Hospital-acquired infections (HAI): Surgical site
infection rate for vaginal hysterectomy 1
• Hospital-acquired infections (HAI): Surgical site
infection rate for total knee arthroplasty 1
Outcome measure, 2 Process measure, 3 Structure measure, 4 Overuse / misuse measure
Total Care Quality Measures: Hospital
RECOMMENDED NEW MEASURES FOR REPORTING (13)
AHRQ Quality Indicators (12)
•
•
•
•
Inpatient Quality Indicators (7)
Abdominal aortic aneurysm (AAA) repair volume3
• Percutaneous transluminal coronary angioplasty
Abdominal aortic aneurysm repair mortality rate 1
(PTCA) volume 3
3
Coronary artery bypass graft (CABG) volume
• Percutaneous transluminal coronary angioplasty
(PTCA) mortality rate 1
Coronary artery bypass graft (CABG) mortality rate 1
• Hip fracture mortality rate 1
Patient Safety Indicators (5)
• Decubitus ulcer 1
• Postoperative pulmonary embolism or deep vein
• Death among surgical inpatients with serious
thrombosis 1
treatable complications 1
• Obstetric trauma – vaginal delivery with instrument 1
• Obstetric trauma – vaginal delivery without instrument 1
Other Sources (1)
(Existing requirement for PPS hospitals; submission has been voluntary for CAHs)
Patient experience
Measure type:
1
Outcome measure, 2 Process measure, 3 Structure measure, 4 Overuse / misuse measure
Total Care Quality Measures:
Hospital Mortality & Patient Safety Composite Measures
(AHRQ Measures)
Composite Mortality for
Selected Conditions
1. Acute Myocardial
Infarction
2. Congestive Heart
Failure
3. Acute Stroke
Mortality
4. GI Hemorrhage
Mortality
5. Hip Fracture
Mortality
6. Pneumonia
Mortality
Composite Pediatric
Patient Safety
1. Accidental puncture
or laceration
2. Decubitus Ulcer
3. Iatrogenic
Pneumothorax
4. Postoperative
Sepsis
5. Postoperative
Wound Dehiscence
6. Selected Infections
due to Medical
Care
Composite Patient Safety
1.
2.
3.
4.
5.
6.
7.
8.
Decubitus Ulcer
Iatrogenic Pneumothorax
Selected Infections due
to Medical Care
Postoperative Hip
Fracture
Postoperative Pulmonary
Embolism
Postoperative Sepsis
Postoperative Wound
Dehiscence
Accidental puncture or
laceration
Total Care Quality Measures:
Physician Weighting Options
Total Care Quality Measures:
Hospital Weighting Options
Total Care Quality Measurement:
Risk Adjustment
Total Care Risk Adjustment methods are limited and not yet well
developed.
Structural measures are provider-level measures and do not need
adjustments for patient characteristics
Process measures may have some simple risk adjustments. Generally,
measures only include like patients with like services performed.
Outcome measures risk adjustment limited to a few hospital
measures.
Patient experience measures difficult to risk adjust due to aggregate
response reporting, not at patient level.
Payer Mix adjustment could be applied similar to cost.
Total Care Quality: Physician Summary
Which Physician
Measures to Include?
How Many
Measures?
How to Combine
Measures?
How to Risk
Adjust Measures
Option 1
All measures
All measures
Equal weight to all
measures
Subset by Payer
mix
Option 2
General and population
wide measures
Limit to outcome
and safety (or
other categories)
measures
Assign points to
measures based on
impact to quality
and impact to
population
Option 3
Specific condition
measures
Categorize all
measures into 3-4
subgroups
Assign weights to
categories
Total Care Quality: Hospital Summary
Which Hospital
Measures to
Include?
How Many
Measures?
How to Combine
Measures?
How to Risk Adjust
Measures
Option 1
All measures
All measures
Equal weight to all
measures
Subset by Payer mix
Option 2
General and
population wide
measures
Limit to outcome and
safety (or other
categories)
measures
Assign points to
measures based on
impact to quality
and impact to
population
Option 3
Specific condition
measures
Categorize all
measures into 3-4
subgroups
Assign weights to
categories
Context For Today’s Discussion
High Level Steps in Peer Grouping
Combining
Cost & Quality
Questions for Today’s Meeting: Combining
Cost & Quality Measures
1.
How to design a composite value measure that highlights
value in both cost & quality versus value created
primarily by only one component?
2.
What structure should be used for a composite value
measure?
3.
If weighting, how should components be weighted?
4.
If setting a threshold, what should the threshold be?
Combining Cost and Quality: Structure
Options
PPG Advisory Meeting Schedule
MEETING
DATE
TIME
Meeting 1
Thursday, June 11
Introduction/Background
Meeting 2
Friday, June 26
Defining Parameters
Meeting 3
Friday, July 10
Cost Measure for Conditions
Meeting 4
Friday, July 17
Quality Measures for Conditions
Cost Measure for Total Care
Meeting 5
Wednesday, July 22
f/u Quality Measures for Conditions
Quality Measure for Total Care
Combining Cost & Quality
Meeting 6
Monday, July 27
Combining Cost & Quality
Meeting 7
Wednesday, September 2
Information Needs by Audience
Meeting 8
Friday, September 11
Revisit Outstanding Issues
Meeting 9
Wednesday, September 30
Final Review