Defining Metric Improvement in the MidSouth PTN Pamela Bruce, RN, DNP, CPPS Heather Limper, PhD, MPH

Existing Definitions The PPA indicates that for both Quality and Utilization Metric Improvements “All metrics must come from the TCPI Core set unless an appropriate substitute is agreed upon; Improvement must be demonstrated for 12 months; and Practices will receive an incentive as follows for each of the first two agreed upon target metrics where they attain the goal. The Practice Assessment Tool (PAT) indicates for milestone completion that the “Practice has met at least 75% of its target and sustained improvements in practice-identified metrics for at least one year.” The MidSouth PTN has set targets for improvement on each core metric to be reached 1) the first 12 months of enrollment and 2) the end of the 4-year period of performance.

Measure of Association: How is improvement defined?   The MidSouth PTN uses Relative Percent Change. This allows for practices to receive credit for improvement made, relative to where they began at baseline. Relative Percent change =  new quantity – original quantity X (100) original quantity The original quantity is defined as Baseline performance Source/Reason: This is how target goals were defined at the beginning of TCPi

How much improvement does a practice need to reach to receive incentive payment? Following language on the Practice Assessment Tool (PAT), “Practice has met at least 75% of its target and sustained improvements in practice-identified metrics for at least one year.”   This language is in reference to PAT scoring on Milestones, not on assessing improvements on Metrics. As the PTN is using both relative percent change and very low thresholds of improvement, practices are required to meet the target goals for each metric in their entirety (not merely 75% of the target goal). Target goals outlined by the PTN (below) must be met over any 12 month period of improvement to receive incentive payment

MidSouth PTN Improvement Area *Updated header language Incentive: 12 months of improvement target* Quality Measures Breast Cancer Screenings 5% Colorectal Cancer Screenings 10% Pneumococcal Vaccinations Influenza Immunizations Screening for Clinical Depression and Follow-up Plan Tobacco Use: Screening and Cessation Intervention Well child visits 3-6 years of life Diabetes: Hemoglobin A1c poor control (>9%) Coronary Artery Disease (CAD): ACE-I or ARB Therapy –Diabetes or LVSD (LVEF <40%) Patient Experience Surveys: CAHPS Clinician and Medical Home Surveys ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication Childhood Immunization Status Appropriate Treatment for Children with Upper Respiratory Infection (URI) Immunizations for Adolescents Well-Child Visits in the First 15 Months of Life Adolescent Well-Care Visits

MidSouth PTN Improvement Area *Updated header language Incentive: 12 months of improvement target* Utilization Measures All Cause Readmission Rate 5% All Cause Unplanned Admit for Pts with DM All Cause Unplanned Admit for Pts with HF Reduction in <2 day Hospital LOS 2% Reduction in ED Visits Back Pain Imaging with no Red Flags 3% Benign Prostatic Hyperplasia Imaging Cardiac Tests for Low Risk Patients Cervical Cancer Screenings for Women Over 65 Dual-Energy X-Ray Absorptiometry Scans Preoperative Cardiac Tests for Cataract Surgery Preoperative Cardiac Tests for Non-Cardiac Surgeries Population-based 25-OH Vitamin D Deficiency Screenings First Choice Antipsychotics Treatment for Dementia Percutaneous Feeding Tubes for Advanced Dementia Opioid or Butalbital Treatment for Migraines

Timing Timing: The 12-month period of improvement may be at ANY POINT during TCPi enrollment after initiation of improvement efforts have begun. The PPA definition does not specify that the 12 month period of improvement must occur in the first 12 months following roll-out of improvement efforts. However, the PTN created metrics target table DOES state improvement must be met during the first 12 months of enrollment. We move to amend this metrics target table to the version above.   EXAMPLE: A practice that does not meet their target for improvement in the first 12 calendar months after initiating an improvement effort but does see an overall trend of improvement between calendar months 3-14 IS eligible for incentive

Visit-Based Metrics Relative % improvement defined by comparison of Q4 performance to Baseline performance. While an ideal situation would be to use run charts to determine if improvement was made, this approach is limited by 1) a single data point for baseline and 2) the inability to incorporate whether the target goal was met. As seen by the examples above, comparison of simply Q4 to baseline will grant most practices a “passing score” that they met their target even with variation involved given the very low threshold of the relative percent increases specified to receive incentive payment. This also incorporates a level of ‘sustainability’ that practices are held to.  

Seasonal population metrics Relative % improvement defined by comparison of current year performance during the season to the previous year’s performance during the same defined season. Straight forward comparison of total performance during current year’s season compared to previous year’s performance during the same season. Note that this is likely the most literal interpretation, which answers the question: Did the practice screen a greater percentage of its patients this year than it did in the baseline period? Did the community ultimately benefit?

Non-seasonal population metrics Relative % improvement defined by comparison of full year performance to the previous full year’s performance. Straight forward comparison of total performance compared to previous year’s performance. Note that this is likely the most literal interpretation, which answers the question: Did the practice screen a greater percentage of its patients this year than it did in the baseline period? Did the community ultimately benefit? This allows for the inevitable “step wedged” pattern that would be seen over the year with a population based metric.

No Baseline or 0% Baseline There are 2 reasons why a practice may begin with 0% baseline:   Case 1: There is no baseline performance because the practice wasn’t able to measure it, thus a 0% to begin with. In this case, a practice must submit the first 3 months of data they are able to collect as baseline. Ideally, this will be past data but depends on reporting capabilities. If it must be present, that first 3 months counts towards the 12 months needed to report. It’s a hard case to make that a practice has implemented an improvement intervention on something they can’t measure, therefore this should not penalize anyone. Case 2: An entirely new intervention is introduced. Example: a practice that has never screened for depression introduces depression screening. Therefore, baseline performance was 0%. Introduction of a new intervention is great! There should still be improvement ramping up the intervention, such as expanding the number of patients screened over time. Therefore, comparison of improvement will be Q4 to Q1 to determine relative % change.