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Performance Measurement in Pediatric Emergency Care
Evie Alessandrini, MD, MSCE
Center for Health Care Quality
Division of Emergency Medicine
Cincinnati Children’s Hospital Medical Center
I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity.
I do not intend to discuss an unapproved or investigative use of a commercial product/device in my presentation.
Disclosure
Performance Measurement
Learning Objectives
• Delineate the different purposes of performance measurement
• Become familiar with existing endorsed performance measures of emergency care
• Develop a framework for organizing pediatric emergency care performance measures for your ED
Measurement Motivators• Health Care System
– Growing complexity and costs– Transparency initiative, external mandates
• Institute of Medicine Reports– To Err is Human, 1999– Crossing the Quality Chasm, 2001– Performance Measurement: Accelerating
Improvement, 2005– The Future of Emergency Care, 2006
• Develop national standards for emergency care performance measurement
Outcomes
Quality
Why Measure Performance?Stakeholder Survey Analysis
Why Measure Performance?• Improve
– Health and Healthcare• For patients and populations• Within one ED or with one practitioner• Within networks of EDs or health systems
• Inform– Transparency, consumer decision-making– Regionalization of care
• Incentivize– Pay for performance– National rankings
Stakeholder Survey Analysis
Performance Measurement:Accelerating Improvement
2005 IOM Report
• The ultimate purpose of performance measurement is to improve the health of everyone in the United States
• Performance measures are yardsticks by which all health care providers and organizations can determine how successful they are in delivering recommended care and improving patient outcomes
• Public reporting of performance data holds health providers accountable to both consumers and purchasers of care; transparency builds trust
• Patients can also learn what the expected professional standards of care are and where they can go to receive it
Performance Feedback
Feedback has proven most effective when • rates of adherence to practice guidelines are low• the information is directly useful for care• practitioners are motivated to change
IOM. Rewarding Provider Performance: Aligning Incentives in Medicine. Washington DC: American Academy Press; 2006.
Feedback Report: Appropriate Use of Amoxicillin for Newly Diagnosed Acute Otitis
Media (AOM)
Your Performance
(December 2009 – February 2010)
81%
Top Performers
(December 2009 – February 2010)
100%
Quality Measure (Numerator): Amoxicillin Prescribed
Quality Measure (Denominator): All Visits for Acute Otitis Media Satisfying Inclusion and Exclusion Criteria
Inclusion Criteria: Visit Diagnosis of Acute Otitis Media Children 2 months to 12 years of age Oral antibiotic prescribed at the visit
Exclusion Criteria: Acute Otitis Media Visits in the Past 14 Days Antibiotics in the Past Month Penicillin/Amoxicillin Allergy Co-infections: Pneumonia, Sinusitis, Conjunctivitis, or Pharyngitis
Improving Otitis Media Care with Clinical Decision Support and Feedback; AHRQ R18 HS017042
Feedback Report: Appropriate Use of Amoxicillin for Newly Diagnosed Acute Otitis Media (AOM)
Appropriate Amoxicillin Use
TimePeriod
You Your Practice Network
# of Visitswith NewlyDiagnosedAOM
AmoxicillinAppropriatelyPrescribed(N, %)
AmoxicillinAppropriately Prescribed (%)
AmoxicillinAppropriatelyPrescribed(%)
September 2009 through November 2009
19 18 (95%) 91% 77%
December 2009 through February 2010
16 13 (81%) 93% 77%
Improving Otitis Media Care with Clinical Decision Support and Feedback; AHRQ R18 HS017042
Transparency“Transparency aims to reduce specific risks or performance
problems through selective disclosure by organizations. The ingeniousness of target transparency lies in its mobilization of individual choice, market forces, and participatory democracy.” Wikipedia
Levels of transparency– Within your department– Within your hospital– Outside your hospital
Examples• http://my.clevelandclinic.org/Documents/Medicine/PEDS283076A_LR.pdf• http://www.dartmouthatlas.org
Pay for Performance“Pay for performance systems link compensation
to measures of work quality or goals”Perfect Asthma Care• The pay-for-performance program rewarded
practices for – participating in an improvement collaborative– achieving network- and practice-level performance
thresholds– building improvement capability
• The percentage of the network asthma population receiving "perfect care" increased from 4% to 88%.
Mandel, KE; Archives of Ped and Adol Med: 161(7): 650-5, 2007 July
Leadership & Performance Measurement
“Turning Doctors into Leaders”• Organize doctors into teams• Measure performance by patient
outcomes, not resource use• Apply financial and behavioral incentives• Dismantle dysfunctional cultures
Harvard Business Review, April 2010; hbr.org
Performance Measurement
Learning Objectives
• Delineate the different purposes of performance measurement
• Become familiar with existing endorsed performance measures of emergency care
• Develop a framework for organizing pediatric emergency care performance measures for your ED
National Quality Forum2008 Measures
Hospital-based Emergency Care• Median time from ED arrival to ED departure for
admitted patients*• Median time from ED arrival to ED departure for
discharged patients*• Admit Decision Time to ED Departure Time for Admitted
Patients*• Door to provider• Left without being seen
* Measures stratified by– Psychiatric diagnoses, observation patients, transfers, all others
www.qualityforum.org
National Quality Forum2008 Measures
Hospital-based Emergency Care (cont.)• Severe Sepsis and Septic Shock: Management Bundle • Confirmation of endotracheal tube placement• Percentage of patients with Chest Pain Symptoms in ED
receiving Early Therapy including IV, Oxygen, Nitroglycerin, Morphine and Chewable Aspirin on Arrival
• Pregnancy test for female abdominal pain patients• Anticoagulation for Acute Pulmonary Embolus Patients• Pediatric Weight documented in kilograms
– AAP is the measure sponsor
www.qualityforum.org
Children’s Health Corporation of America Existing Measures
Whole System Measures
• ED Left Without Being Seen
• ED Length of Stay
www.chca.com
Urgent Matters Robert Wood Johnson Foundations
Urgent Matters Initiative Goals
• Rigorously evaluate the implementation of strategies for improving patient flow and reducing ED crowding
• Advance the development of standard performance measurement in the ED
• Promote spread of promising practices to a wider audience / variety of hospitals
www.urgentmatters.org
Urgent Matters Robert Wood Johnson Foundations
Performance Measures (NQF and CMS)• Throughput for admitted patients• Throughput for discharged patients• Time to pain management for long bone fractures
– Admitted patients– Discharged patients
• Median time to chest x-ray– Admitted patients– Discharged patients
• Admit decision time to ED departure time www.urgentmatters.org
Other Existing Measures and Measurement Organizations
• Joint Commission – ORYX performance measures
• Children’s Asthma Care measures (inpatient)• http://www.jointcommission.org/PerformanceMeasurement
• AHRQ Pediatric Quality Indicators (PDIs)– 18 risk-adjusted measures– Obtained from inpatient administrative data– www.qualityindicators.ahrq.gov/pdi_overview.htm
• Alliance for Pediatric Quality– AAP, American Board of Pediatrics, CHCA, NACHRI– www.kidsquality.org
Other Existing Measures and Measurement Organizations
ACEP National Report Card on the State of Emergency Medicine
• Access to Emergency Care
• Quality and Patient Safety Environment
• Medical Liability Environment
• Public Health and Injury Prevention
• Disaster Preparedness
http://www.emreportcard.org
Performance Measurement
Learning Objectives
• Delineate the different purposes of performance measurement
• Become familiar with existing endorsed performance measures of emergency care
• Develop a framework for organizing pediatric emergency care performance measures for your ED
Rationale for Framework
Limitations of prior work– Single centers or geographic locales – Focus on condition-specific indicators– Preponderance of process-oriented measures– Benchmarks very focused on
• Timeliness (through put)• Satisfaction (ceiling effect)
– Lack of comprehensiveness regarding spectrum of ED care• Lindsay et. al., AEM, 2002• Guttmann et. al., Pediatrics, 2006
Performance Measure Framework
Quality indicator set development process
• Adapted from AHRQ
• “Defining Quality Performance Measures for Pediatric Emergency Care”
– Funded by HRSA/EMSC Targeted Issues Grant H34MC08512
CandidateMeasures
N = 60
ResearchLiterature
Actual Use
Concept
Measure by MeasureEvaluation
for Selection
SelectionCriteria
Measure SetEvaluation forApplication
SOURCES
Performance Measure Development
Adapted from AHRQ PDI development process
Performance Measure Framework
Measure development dimensions• IOM Quality Domains• Donabedian’s framework for quality• PEM disease frequency and severity
Measure evaluation dimensions• National Quality Forum criteria
Institute of Medicine Quality Domains
Built around the core need for health care to be
• Safe
• Effective
• Efficient
• Timely
• Patient-centered
• Equitable
Institute of Medicine Quality Domains
Safe• Health care avoids injuries to patients
from the care that is intended to help them
Effective• Health care provides services based on
scientific knowledge to all who could benefit, and refrains from providing services to those not likely to benefit
Institute of Medicine Quality Domains
Efficient• Health care avoids waste, including waste
of equipment, supplies, ideas and energy
Timely• Health care reduces waits and sometimes
harmful delays for both those who receive and those who give care
Institute of Medicine Quality Domains
Patient - centered• Health care provides care that is respectful of
and responsive to individual patient preferences, need and values, and ensures that patient values guide all clinical decisions
Equitable• Health care provides care that does not vary
because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status
Donabedian’s Framework
Structure• Indirect quality-of-care measures related to a physical
setting and resources: Staff, space, supplies, equipment and financial resources
Process• Measures evaluate the method or process by which care
is delivered, including both technical and interpersonal components
Outcome• Outcome elements describe valued results related to
lengthening life, relieving pain, reducing disabilities and satisfying the consumer
PEM Disease Frequency & Severity
• Condition-specific– Proportion of patients with croup receiving
corticosteroids
• General– Proportion of patients returning to the ED within
72 hours of an initial ED visit
• Cross-cutting– Proportion of patients with pain who receive an
analgesic
Choosing Condition-Specific Measures
24.59
19.22
9.97 9.65 9.64
16.1815.33
11.9112.80
11.48
0.00
5.00
10.00
15.00
20.00
25.00
30.00
Trauma ENT, Dental &Mouth Diseases
GastrointestinalDiseases
RespiratoryDiseases
Systemic States
Major Group
% o
f D
iag
no
sis
NHAMCS
PCDP
Alessandrini et.al., Academic Emerg Med; February 2010
www.pecarn.org/tools
Measure Evaluation Criteria
Importance• The measure reflects a priority or high
impact aspect of healthcare• The measure addresses outcomes or is
strongly linked to improving outcomes• The measure addresses an area of
considerable variation or poor performance across providers or population groups
Measure Evaluation Criteria
Scientific Acceptability• There is strong evidence for the specific
measure focus, such as evidence based guidelines
• The measure is reliable, reproducible and accurately represents quality of care
Measure Evaluation Criteria
Usability• The measure provides information that is
actionable and can be used to make decisions that improve the quality of care
• The measure is meaningful and understandable
Measure Evaluation Criteria
Feasibility• Data for the measure is generated during
care delivery and is available in the EHR or other electronic sources
• Data collection for the measure can be implemented
• The information provided outweighs the costs/burdens of collecting the data
Results: Performance Measure Distribution by IOM Quality
Domain
Equitable – measures stratified by gender, age, race, ethnicity and payor
Applicability of Measures to IOM Domains (Measures can apply to more than one IOM domain)
43
34
14
7
17
05
101520253035404550
Effective Safe Patient Centered Efficient Timely
# o
f Mea
sure
s App
licab
le to
IO
M
Dom
ain
Results: Performance Measure Distribution by Donabedian
Framework
Distribution of Measures by Donabedian Classification
13
37
10
0
5
10
15
20
25
30
35
40
Outcome Process Structure
Measure Type
# o
f Mea
sure
s
Results: Performance Measure Distribution by
Diagnosis Type
Cross-cutting measures include pain/sedation, severe illness, diagnostic testing and medication management
Distribution of Measures by Category
27
13
20
0
5
10
15
20
25
30
General Cross-Cutting Condition-Specific
# o
f Mea
sure
s
PEM Balanced Report Card
• Measuring weight in kilograms for ED patients <18 years of age
• All pediatric equipment present in the ED (per ACEP, AAP, ENA policy statement)• Reducing pain in children with acute fractures• Systemic corticosteroids in asthma patients with
acute exacerbation• Medication error rates• Parent/caregiver understanding of ED discharge
instructions• Door to provider• Total ED length of stay
Further Considerations
• Measures valuable to patients– Not minimum level of competency
• Composite measures– Conceptual and analytic issues
• Unit of analysis• Measure target• Locus of control• Balancing measures
– Are we improving parts of our system at the expense of others?
Measurement & Quality
• Quality is central to achieving affordable care that knows patient needs and keeps them healthy
• It’s a three step process– The first step toward achieving quality is convening expert
members across the healthcare industry, including patients to define quality with uniform standards and measures that apply to the many facets of care patients receive.
– Second, information gleaned from measuring performance is reported and analyzed to pinpoint where patient care falls short.
– Third, caregivers examine information about the care they are providing and use it to improve.
Measure. Report. Improve.
References
• AAP Policy Statement: Principles for the Development and Use of Quality Measures– Pediatrics 121 (2), February 2008, pp 411-418
• Pediatric Clinics of North America “Pediatric Quality”: Quality Measures in Pediatrics– Volume 56 (4), August 2009, pp 816-829
References
• Institute of Medicine Report: Performance Measurement, Accelerating Improvement– December 2005– www.iom.edu/Reports/2005/Performance-
Measurement-Accelerating-Improvement.aspx
• Joint Policy Statement—Guidelines for Care of Children in the Emergency Department– Pediatrics 2009;124:1233–1243
Steps in Measure Specification
• Numerator statement• Denominator statement• Denominator exclusions• Data source and collection methods• Sampling• Risk adjustment• Stratification to detect disparities• Level of measurement / analysis
Steps in Measure Specification
Risk Adjustment
• Accounts for patient-associated factors before comparing outcomes across settings
• “Levels the playing field”
• Would be unnecessary if patients were randomly assigned to treatments, settings etc.