Measurement and Improvement of Quality of Care


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Measurement and Improvement of Quality of Care


Relevance to Cardiovascular Clinical Practice



Frederick A. Masoudi, John S. Rumsfeld


Although the quality of health care is important for all stakeholders, the primary perspective of this chapter is that of cardiovascular clinicians. Our goals are to help cardiovascular clinicians understand the definition and importance of quality of care, and the relevance of quality of care measurement and improvement in current cardiovascular practice. We focus on measuring health care quality and uses of quality measurements, as well as improving quality of care, with examples of quality improvement (QI) approaches.



Defining Quality of Care


Quality of care generally is defined as the extent to which health care delivery optimizes the outcomes, or the “end results,” of care. In the United States, the Institute of Medicine (IOM) has more specifically defined quality of care as “the degree to which health care systems, services, and supplies for individuals and populations increase the likelihood for desired health outcomes in a manner consistent with current professional knowledge.”1 Key outcomes of care include survival, patient health status (i.e., symptom burden, functional status, and health-related quality of life), morbidity (e.g., acute myocardial infarction [MI] or heart failure hospitalization), patient experience (e.g., satisfaction), and cost-effectiveness.


The IOM has further proposed six domains of quality (Table 5-1), specifying that high-quality health care is effective, safe, equitable, timely, efficient, and patient-centered. Quality of care can thus be conceptualized as the extent to which these domains are optimized to improve outcomes of care. Accordingly, quality measures either should focus on at least one of these six domains of quality or should directly measure outcomes of care. QI is the action undertaken to improve one or more of these six domains in order to improve health outcomes.



Unfortunately, despite tremendous therapeutic advances in the past 50 years, well-recognized deficiencies in health care delivery are manifest, as suboptimal quality and outcomes of care persist. Health care spending in the United States exceeds that of any other country, but American health care does not achieve commensurately high scores on most metrics of quality of care or health outcomes.2 Marked geographic variation in per capita health care utilization and spending are well recognized, yet consistent correlation between spending and health outcomes is lacking. For example, significant variation in the use of cardiovascular testing and procedures that is not explained by case-mix does not clearly translate into better patient outcomes.3


Numerous studies have documented underuse of guidelines-indicated care, unexplained variation in care delivery, and outcomes that may reflect overuse or inconsistent quality of care delivery, and misuse, including avoidable complications and medical errors, all of which contribute to suboptimal outcomes. Gaps in quality can result from deficiencies in any of the IOM quality domains (see Table 5-1). For example, effective therapies may not be provided to eligible patients (e.g., statin therapy in a patient with a recent MI). Providers and health care systems may fail to minimize exposure of patients to unnecessary risk (e.g., prescribing drugs that carry a high risk of adverse drug-drug interaction). Clinicians may prescribe suboptimal or ineffective therapies (e.g., routine primary-prevention implantable cardioverter-defibrillator placement in a patient with mild left ventricular systolic dysfunction) or may recommend use of resource-intensive care for marginal benefit (e.g., routine intra-aortic balloon pump use for high-risk percutaneous coronary intervention). Care delivery may be excessively delayed or may be delivered differentially based on patient age, sex, race/ethnicity, or insurance status. Patients may not be engaged in their care to focus principally on the health outcomes of highest import (e.g., quality of life in addition to quantity of life). Deficiencies in any of these areas contribute to observed variations in quality of care and patient outcomes. These deficiencies, coupled with rising health care costs, have raised interest in health care reform, in which measurement and reporting of quality of care are central to clinical practice.




Relevance of Quality of Care in Cardiovascular Practice


Too often, cardiovascular clinicians perceive quality of care primarily as indicating more careful documentation in the medical record or satisfying quality metrics to meet payer or other requirements. This narrow view is reinforced in the current health care environment, in which quality measurement and reporting are often placed in a “regulatory” context and often are executed separately from clinician-patient interactions and clinical decision making. In reality, the interaction of patients and clinicians is central to high quality of care, in keeping with the impact of clinical decisions (e.g., therapeutics prescribed or procedures done) on patient outcomes. Hence, cardiovascular clinicians should play a central role in how quality is measured and how health systems are modified to optimize quality and patient outcomes.


Indeed, there are multiple reasons why cardiovascular providers should engage in quality of care measurement and improvement. First, quality of care reflects the degree to which clinicians practice evidence-based medicine. Inherent in evidence-based medicine is consideration of both the best available scientific evidence and individual patient factors and preferences. In an optimal scenario, informed patients, who understand the state of their health and the potential risks and benefits of health interventions ranging from prevention to acute and chronic disease management, interact with clinicians who observe the tenets of evidence-based medicine.


Second, quality of care is increasingly tied to maintenance of certification and licensure, particularly with regard to involvement in practice improvement. Medical education is evolving to a model of life-long learning, in which the principles of quality of care are integrated with clinical knowledge and decision making. Intrinsic to this new framework, cardiovascular clinicians will need to have the skills of quality of care measurement and improvement in addition to medical knowledge.


Third, quality of care lies at the center of health care system improvement. The outcomes of health decisions of patients and cardiovascular clinicians depend on the environment (including community and health care system attributes) in which these decisions are made. From the perspective of the cardiovascular clinician, quality of care includes not only their actions but also patient access, engagement, and behavior; the context and methods of health care delivery; and multiple aspects of the health care system, ranging from information technology support to ancillary personnel support to health system policy and incentives. Ultimately, although clinical knowledge and skill are essential for high-quality care, they are not sufficient; a primary driver of high-quality health care and QI is the health care delivery system.


Finally, quality of care provides a means for professional accountability. In today’s health care environment, performance-based reimbursement and public reporting of quality of care measures are increasingly prevalent. Evolving models of health care delivery and reimbursement that are being pursued in the United States, such as accountable care organizations and integrated delivery systems, invariably emphasize performance on quality measures that reflect one or more of the IOM quality domains (see Table 5-1) and the direct measurement of patient outcomes. Measures of health care value (outcomes as a function of costs of care) are increasingly used to characterize cardiovascular practice, including linkage to incentives or disincentives, or both.


Cardiovascular clinicians should therefore have a strong interest in participating in robust and clinically relevant quality of care measurement and improvement efforts, health care delivery design and pay­ment programs. Moreover, the concept of professionalism includes not only clinical knowledge but also excellence in the delivery of health care and accountability for that care. Quality of care—through measurement and improvement of the IOM domains of quality and patient outcomes—directly speaks to health care delivery and accountability. Accordingly, quality of care is central to professionalism in cardiovascular medicine.



Measuring Health Care Quality and Uses of Quality Measurements


This section discusses types of quality measures, the uses of measures, commonly used data sources for quality measurement, and possible limitations of quality measures, including the potential for unintended consequences.



Types of Quality Measures


Donabedian’s seminal treatise, published more than 50 years ago, delineated a conceptual framework for measuring health care quality that endures to the present: characterizing quality according to structure, process, and outcome.4 Although measurement has extended beyond these three domains, these constructs remain central to understanding the quality of health care. The American College of Cardiology/American Heart Association (ACC/AHA) have described in detail the methodologic principles of developing various types of measures.5–8


Structural measures are specific attributes of the health care delivery system that are used as surrogates for the care delivered. Examples are procedural volume and accreditation status. In general, such measures are only weak surrogates and frequently are considered inadequate if more robust metrics of quality are available.9,10


Process measures reflect the actions of providers, such as the prescription of a medication, and are among the most commonly used metrics of quality. For example, the Centers for Medicare & Medicaid Services (CMS) has used processes of care for acute MI and heart failure as part of its Hospital Compare quality reporting system since 199511; the ACC/AHA have developed several sets of process measures for specific cardiovascular procedures and conditions (Table 5-2). Operationally, process measures are generally selected from among the care processes with strong support in practice guidelines (e.g., class I recommendations in the ACC/AHA guideline recommendation taxonomy). Not all strong guideline recommendations are appropriate for adoption as quality measures, however; such measures should possess additional attributes that support their use for quality measurement (Table 5-3).




TABLE 5-3


Attributes of Measures of Process, Outcome, and Value in Health Care






































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Jun 4, 2016 | Posted by in CARDIOLOGY | Comments Off on Measurement and Improvement of Quality of Care

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MEASURE TYPE MEASURE ATTRIBUTES
Process5 Evidence-based
Interpretable
Actionable
Explicit numerator and denominator
Valid
Reliable
Feasible
Outcomes6 Clear explicit definition of appropriate patient sample
Clinically coherent variables for risk adjustment
Sufficiently high-quality and timely data
Designated time of covariate and outcome ascertainment
Standardized period of outcome assessment
Analysis accounting for multilevel organization of data
Disclosure of methods used