Metric Indicators in Healthcare

1. Metric Indicators in Healthcare March 22, 2019 Presented by: Adrienne Mims, MD MPH FAAFP AGSF Vice President, Chief Medical Officer Adrienne.Mims@Allianthealth.org 3/18/2019 1

2. Presenter Has Nothing To Disclose

3. Course Objectives • Describe the use of metrics in assessing quality of care in healthcare • Describe at least one ethical question in the use of metrics in healthcare

4. Origin of Quality Measurement In Medicine (US)

5. Crossing The Quality Chasm: A New Health System For The 21st Century March 2001 http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf

6. The Good • Clear definition of quality healthcare • Explosion of quality measures – structure, process, outcome, comparative effectiveness, patient reported outcome measures, patient centered care • Increase focus on Quality Improvement Number and percentage of all US quality measures improving, not changing, or worsening through 2012, overall and by National Quality Strategy priority. Burstin, H et. Al. J Intern Med 2016; 279:154–159

7. The Bad • Problems with quality – over use, under use, questionable appropriateness of use • Disparity in care utilization and outcomes • Measurement efforts may overwhelm the delivery system – “checking boxes” • Lack of consistency in measures across care settings (hospital – nursing home – home health) • Lack of risk adjustment resulting in inaccurate comparisons and misconceptions about care in poor, rural, underserved and medically complex

8. and The Ugly • Plethora of quality measures • Perverse incentives • Problems with attribution • Participation with resistance by clinicians

9. Comprehensive Care for Joint Replacement (CJR) • Bundled payment and quality measurement for an episode of care associated with hip and knee replacements to encourage hospitals, physicians, and post-acute care providers to work together to improve the quality and coordination of care from the initial hospitalization through recovery (90 days).  • 2014- 400,000+ procedures; $7 billion+ • Cases range from $16,500 to $33,000 across geographic areas • More than 3 times higher rates of infections and implant failures https://innovation.cms.gov/initiatives/CJR

10. References • Marjoua Y, Bozic K. Brief history of quality improvement in US healthcare. Current Rev Musculoskeletal Med (2012) 5: 265-273 • Burstin H, Leatherman S, Goldman D. The evolution of healthcare quality measurement in the United States. J Intern Med 2016; 279:154–159 • Parry GJ. A Brief History of Quality Improvement. Journal of Oncology Practice. 2014; Vol. 10: Issue 3: 196-199 • Sheingold BH, Hahn JA. The history of healthcare quality: The first 100 years 1860-1960. International Journal of Africa Nursing Sciences. 1 (2014) 18-22 • Keeping Patients Safe: The Ethics of Quality Improvement – American Journal of Medical Ethics. May 2008, Vol. 10, Number 5: 300-303 • Wynia MK. Performance Measures for Ethics Quality – Effective Clinical Practice – Nov/Dec 1999 • Lynn J, Baily MA, Bottrell M, et.al. The Ethics of Using Quality Improvement Methods in Health Care. Ann Intern Med. 2007; 146:666-673 • COMMITTEE ON QUALITY OF HEALTH CARE IN AMERICA. Crossing the quality chasm: a new health system for the 21st century - http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf • Comprehensive Care for Joint Replacement Model - https://innovation.cms.gov/initiatives/CJR

11. This material was prepared by GMCF, for Alliant Quality, the Medicare Quality Innovation Network – Quality Improvement Organization for Georgia and North Carolina, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. 11SOW-AHSQIN-D1-19-19