Quality measures benefit from quality improvement

I am a long-time proponent of measuring provider performance and aligning it with payment as an effective means for improving the quality of care and with it, patient outcomes.

Because of this, I welcomed the value-based purchasing concepts and quality improvement initiatives that are fundamental to the Affordable Care Act (ACA).

But, as in so many things, the devil is in the details and, despite their best efforts, measure designers can’t always foresee all the ramifications.

Case in point: A provision in the ACA prompted the Centers for Medicare and Medicaid Services (CMS) to establish the Hospital Readmissions Reduction Program to focus attention on ways to reduce 30-day readmissions.

CMS has already begun to reduce payments to hospitals with excess 30-day readmissions for myocardial infarction, heart failure and pneumonia and, by 2015, the reductions will extend to readmissions associated with acute exacerbation of chronic obstructive pulmonary disease and elective total hip and knee arthroplasties.

When the measure was applied in real-world settings, controversy ensued as concerns were raised; two excellent articles in the May issue of Health Affairs shed light on the problem.

The first article (Hu, Gonsahn, Nerenz) describing a retrospective cohort study using data from an 802-bed teaching hospital in Detroit, Mich., reported significant associations between socioeconomic variables and 30-day readmissions for patients discharged from the hospital.

Specifically, after controlling for patient demographics and clinical conditions, the researchers found that patients living in neighborhoods with high poverty (i.e., a high percentage of families with incomes below the federal poverty level), low education (i.e., a high percentage of the population over the age of 25 without a high school diploma), and low household incomes were at greater risk of being readmitted.

A similar study (Nagasako, Reidhead, Waterman, Dunagan) conducted at an urban hospital in Dallas found that residing in a census tract in the lowest socioeconomic quintile was related an increased risk of 30-day readmission.

Moreover, a model using three socioeconomic factors showed that patients living in high poverty neighborhoods were 24% more likely than other patients to be readmitted within 30 days after adjusting for demographic characteristics and clinical conditions.

These and previous findings raise serious questions:

  • Does the measure disproportionately affect hospitals that provide care to patients of lower socioeconomic status (e.g., urban teaching hospitals, rural community hospitals)?
  • Should CMS’ readmission measure and its associated financial penalties be adjusted for the effects of factors beyond a hospital’s influence; e.g., poverty and lack of social support?
  • Importantly, for quality measures in general, is it correct to assume that the thing being measured — in this case, 30-day readmissions — results solely from poor quality of care?

In June, the debate moved to the halls of Congress, where a bipartisan trio of senators introduced the Hospital Readmissions Program Accuracy and Accountability Act aimed at accounting for socioeconomic status when calculating risk-adjusted readmission penalties.

The bottom line is that even quality measures benefit from quality improvement.

David B. Nash is founding dean, Jefferson School of Population Health, Thomas Jefferson University, Philadelphia, PA, and blogs at Nash on Health Policy and Focus on Health Policy.

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  • azmd

    Excellent questions, the answers to which should be obvious to anyone with even a modicum of common sense and clinical experience.

    But of course, instead of straightforward and effective solutions, we have study after study analyzing the “data,” endless debates in Congress and lots of jobs being generated for administrators, analysts and policymakers in healthcare. Meanwhile funds for the social workers, discharge planners, nurses and doctors who could actually provide effective followup care to these patients are subject to SGR cuts and “pay for performance” penalties.

    Communicating with my patients’ family members is still a non-reimbursable activity. Of course they will not do as well as they could following premature discharge to the care of overwhelmed families who have not been taught how to care for them.

  • disqus_McUkQK6a8K

    duh We need to blog about the obvious?? Disease metric after metric, why NCQA forces us to measure how many patients have an email documented as a separate searchable data Set Is anyone paying attention? The only global tool I know, and I am a PCP is Wasson’s clunky looking but brilliant Hows YourHealth

    • azmd

      Exactly. And the biggest problem with these metrics and collection of data related to them is that the majority of physicians (rightfully) see such data collection as being an unreasonable expectation of them and will find ways to comply in the least time-consuming and therefore slipshod way.

      The quality of the data thereby collected is extremely low, because it’s being done by unpaid conscriptees who are not on board with the premise that this activity will benefit their patient (because it won’t) Garbage in, garbage out.

      The second biggest problem is that our patients are not fools. They know perfectly well when their time with their doctor is being taken up with data collection not relevant to them (“Do you chew smokeless tobacco?” “When was the last time you drank more than five drinks at a single sitting?”) and they not only resent it, they tend to blame the practitioner.

  • John C. Key MD

    One thing we never see in medicine is “pushback”. You hear of it all the time in politics and journalism. Docs never seem to push back against any of the nonsensical administrative crap pushed our way. The result? More of the silly activity such as described here. It is our own damn fault.

    • azmd

      I think there are a few different reasons for this:

      1. We are all socialized, through our training, to be very deferential to authority and to not speak up or do anything that could attract negative attention. For those of us who do, the punishment is swift and harsh when we are students, and we think twice as attendings before making a fuss about anything, no matter how unreasonable the demand that has been placed on us.

      2. We are furthermore socialized to be martyrs in the service of our patients. A part of our “professionalism” is the notion that our patient’s needs should come before our own. Since we are all also sort of black-and-white thinkers, we lack the ability to incorporate a more nuanced interpretation of this edict, leaving us open to exploitation by corporate interests. A patient who is having an MI is definitely more important than our need to go to the bathroom at that particular moment, but I am not so sure that my need to take a vacation in the summertime when my kids are out of school should be less important than the hospital’s need to be disorganized about its vacation policy, leaving it short-staffed during the summer months.

      3. Those of us in full-time clinical practice are mostly all run so ragged by our clinical work that we no longer have time or energy for evening meetings of professional societies, let alone going out of town in order to take part in national-level meetings. This has left a leadership vaccum in organized medicine which has been filled by full-time academicians, who have completely different professional lives and working conditions than the rest of us and tend to be badly out of touch with how corporate interests are impacting the work we do and the patients we see.

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