AASM Quality Measures: What you need to know Shalini Paruthi, MD Associate Professor, Pediatrics and Internal Medicine Saint Louis University School of Medicine November 6, 2015

Disclosures None

Objectives Review the recently released quality measures for five common sleep disorders Discuss how they will help you improve the care you provide your patients

American Academy of Sleep Medicine (AASM) Mission The mission of the AASM is to improve “sleep health and promote high quality patient-centered care through advocacy, education, strategic research, and practice standards.”

To deliver and demonstrate high value care and the goals of the Patient Protection and Affordable Care Act, the AASM has developed measures for five common sleep disorders to evaluate the quality of care in sleep medicine

Why measure quality The two primary purposes of measuring quality are (1) to serve as essential management tools for improvement, and (2) to evaluate the value of healthcare Value of Healthcare = Quality of Care/Costs

The measures of quality 1) help providers identify opportunities for improvement 2) evaluate the effectiveness of interventions to improve quality 3) prioritize areas for improvement

The National Quality Forum suggests that quality measurement may (1) inform consumers of healthcare, (2) influence payment and payment programs, (3) drive improvement via external comparison or accreditation/regulatory standards, or (4) help with internal quality improvement

Who is the National Quality Forum

Centers for Medicare and Medicaid Services (CMS) examples

Example of adherence to ACEi for individuals with DM

Structure measures Structure measures evaluate the setting in which care is delivered.

Process measures Steps a provider takes Process measures are generally real-time, and more immediately responsive to improvement efforts.

Process measures cont The best process measures reflect certain characteristics: (a) they measure an agreed upon process of care, (b) the process elements of care being measured have strong linkage to desired outcomes, (c) execution of the process elements of care are modifiable by the organization measuring them, and (d) measurement is minimally resource intensive.

Outcome measures Outcome measures refer to “a health state of a patient resulting from health care,” and are therefore patient-centric. The systematic measurement of outcomes often leads to awareness of gaps in processes to achieve those goals (a) they are important objectives in the care of patients with sleep disorders, and (b) the outcomes of care should be a focus in routine practice and, in the context of clinical quality improvement activities, would lead to important changes in the effectiveness of care rendered

Steps Formation of workgroups Comprehensive literature search Review of titles and abstracts by 2 members Pull relevant articles Initial selection of processes and outcomes

Steps cont Workgroups drafted the technical definitions of numerators and denominators (if any) for measures utilizing a measure specification template Plan, Do, Study, Act (PDSA) process to refine the measures for use

Steps cont Stakeholder Review AASM BOD Review The AASM recommends the use of these measures as part of a quality improvement program that will enhance the ability to improve the quality of care for patients with sleep disorders reduce variation in care delivered and improve the reliability with which key processes of care are rendered

Next Steps To move toward improvement, the AASM recommends the following: Professionals or healthcare systems that provide care to patients with OSA, insomnia, narcolepsy, or restless legs syndrome should commit to a systematic program to evaluate and improve the quality of care rendered to patients with one or more of these sleep disorders.

Adult OSA Quality Measures are an extension of the original Centers for Medicare & Medicaid Services (CMS) approved Physician Quality Reporting System (PQRS) measures group for OSA.

Measure Template Measure Description Measure Components Numerator statement Denominator statement Exceptions Technical Specifications/Administrative/Claims Data

Outcome 1 Improve disease detection and categorization This is a broad goal that cannot be easily measured

Process 1 Baseline assessment of OSA symptoms Proportion of patients aged 18 years and older with a diagnosis of OSA with documentation of assessment of OSA symptoms at initial evaluation, including (but not limited to) the presence of snoring and daytime sleepiness.

Process 1 Numerator: all patients with assessment of s/s of OSA at initial visit ---------------------------------------------- Denominator: all patients aged 18 years and older with a diagnosis of OSA

Process 1 99 patients documented sleepiness and snoring 1 patient only sleepiness documented 2 patients only snoring documented 2 patients decline assessment 104 patients all with OSA on a sleep study (PSG or HSAT) =99/102 = 97% My rate of meeting this process measure is 97%

Process 2 Proportion of patients aged 18 years and older with a dx of OSA that had an AHI, RDI or REI documented or measured within 2 months of initial evaluation for suspected OSA This helps us categorize disease

Which of the following may be exceptions to process measure 2? A. Patient is unable to afford the sleep study B. Test was ordered, but insurance failed to cover the study C. Patient with intellectual disability and it is an undue burden on the family to bring the patient in for a sleep study. D. The patient is unable to complete a sleep study due to medical disorder. E. All of the above

Three Types of Exceptions 1. Medical Reasons 2. Patient Reasons 3. System reasons

Outcome measure 2: Improve Quality of life Proportion of patients aged 18 years and older diagnosed with OSA that showed any improvement in their Quality of life (QOL) from baseline within 1 year of starting treatment.

Which of the following are QOL measures used in OSAS? A. Medical Outcomes Study SF-36 B. Medical Outcomes Study SF-12 C. Calgary Sleep Apnea Quality of Life Inventory D. Functional Outcomes of Sleep Questionnaire E. Nottingham Health Profile F. EuroQOL G. EQ-5D H: All of the above

Process Measure 3: Evidenced Based Therapy Prescribed

Process 4

Process 5

Process 6

Outcome 3 Reduce Cardiovascular Risk Not a measured outcome, but a long-term, broad goal of care to reduce cardiovascular risk in patients with OSA

Which of the following are associated with untreated OSA? A. Hypertension B. Stroke C. Arrhythmias D. Heart attack/coronary artery disease E. Heart failure F. All of the above

Outcome 3 Treatment of OSA has been shown to reduce BP Obesity is present in > 50% of OSA patients and itself is associated with heart problems Reduction of BMI has been clearly shown to reduce OSA severity and reduce adverse effects on cardiac performance

Process 7

Process 8

Process 9

Process 10

So…now what? Consider what changes you need within your sleep center Vital signs on check in: Ht, Wt, BMI, BP, ESS, QOL measure Nurses and Techs may help pull adherence reports, manage data on-line Specifically modify template so it asks: snoring, sleepiness, car crash/near miss, sleep study findings, weight management discussion, BP discussion **May have to do these on every sleep clinic visit so you don’t miss a process or outcome measure Or build a process within your EMR that can show you a screen shot of when was the last time each process or outcome measure was completed

Take home points- Why measure quality The primary purposes of measuring quality are (1) to serve as essential management tools for improvement (2) to evaluate the value of healthcare (3) find the gaps Value of Healthcare = Quality of Care/Costs Recent history and legislation shows that the future of healthcare will demand improved and quantified value. You want patients to have the highest quality of care… and you want to get paid!!

Bonus Slides