1. The Evolution of US Healthcare Quality Measurement
Helen Burstin, MD, MPH, FACP
Chief Scientific Officer, NQF
Quality Registers Meeting
Karolinska Institute

2. The Role of the National Quality Forum
Measurement evaluation and endorsement
Consensus-based standard setting organization for quality measures (gold standard)
Preference for use of standardized endorsed measures
Measure selection
Annually advises government on selection of measures for 20+ federal public reporting and pay-for-performance programs
Support measure alignment across public and private sectors
Measurement science
Expert and consensus reports on complex & controversial issues in measurement (e.g., SES & risk adjustment, linking cost & quality)
Standing committee on patient safety reviewed within weeks new published data on the sepsis bundle and recommended revision to the measure as a result

3. US National Quality Strategy: Three Aims and Six National Priorities

4. Evolving payment and risk structures
Athena Health

5. Patient-Focused Episode: Acute MI
Post AMI Trajectory 1 (T1)
Relatively healthy adult
Focus on:
Quality of Life
Functional Status
20 Prevention Strategies
Rehabilitation
Advanced care planning
Getting Better
Living w/ Illness/Disability (T1)
Coping w/ End of Life (T2)
Staying Healthy
Post Acute/ Rehabilitation Phase
20 Prevention
Episode begins – onset of symptoms
Post AMI Trajectory 2 (T2)
Adult with multiple co-morbidities
Focus on:
Quality of Life
Functional Status
20 Prevention Strategies
Advanced Care Planning
Advanced Directives
Palliative Care/Symptom Control
Acute
Phase
PHASE 1
PHASE 2
PHASE 3
PHASE 4
Episode ends – 1 year post AMI
(CAD with prior AMI)
Population at Risk
10 Prevention
(no known CAD)
20 Prevention
(CAD no prior AMI)

6. NQF criteria used to evaluate and endorse quality measures
Reflect desirable characteristics of quality measures:
Hierarchy and Rationale
Importance to measure and report – measure those aspects with greatest potential of driving improvements; if not important, the other criteria less meaningful (must-pass)
Scientific acceptability of measure properties – goal is to make valid conclusions about quality; if not reliable and valid, risk of misclassification and improper interpretation (must-pass)
Feasibility – ideally, cause as little burden as possible; if not feasible, consider alternative approaches
Usability and Use – goal is to use endorsed measures for decisions related to accountability and improvement
Harmonization and Selection of Best-in-Class 6

7. Preference for Outcomes
Hierarchical preference for:
Outcomes linked to evidence-based processes/structures
Outcomes of substantial importance with plausible process/structure relationships
Intermediate outcomes
Processes/structures (most closely linked to outcomes)

8. US Quality Measurement in Evolution
Shift to outcomes; increased focus on patient experience and patient-reported outcome measures (PROMs)
Measures that reflect “optimal care,” including composites
Rocky transition to electronic platforms; lack of structured data and interoperability
Measure alignment to reduce burden and drive improvement
Need focus on assessment and reduction of disparities
Build on cost and quality measurement to assess value, including appropriateness and overuse
Significant growth in clinical registries; high degree of variation across registries
Focus on measures that are more patient centered, e.g., longitudinal patient-focused episodes, patient reported outcomes, cross cutting measures, e.g., care coordination

9. Current Feasibility of eMeasures
Kevin Larsen, ONC

10. Need for Measure Alignment
Quality measures are increasingly used in value-based purchasing by public and private health plans
Current state of alignment –
Too many measures in many areas; major measurement gaps remain (e.g., care coordination)
Unnecessary duplication and burden
Cacophony of “look-alike measures” in use
Comparability across different measure specifications? Impact of data source, level of analysis?

11. Efficiency & Value MeasurementAW
This consensus development process sought to endorse resource use (or cost) measures as building blocks toward measuring efficiency of care.
Efficiency can be defined broadly as the resource use (or cost) associated with a specific level of performance with respect to the other five Institute of Medicine (IOM) aims of quality: safety, timeliness, effectiveness, equity, and patient-centeredness.
Resource use measures can also be used to assess value by integrating preference-weighted assessments of the quality and cost performance of a specified stakeholder, such as an individual patient, consumer organization, payer, provider, government, or society.
As a building block in understanding efficiency and value, NQF supports using and reporting of resource use measures in the context of quality performance, preferably outcome measures.
Using resource use measures independent of quality measures does not provide an accurate assessment of efficiency or value and may lead to adverse unintended consequences in the healthcare system.
Resource use measures used to assess efficiency and value should be important to measure, have scientifically acceptable properties, and be usable and feasible. Resource use measures under evaluation in this process should independently meet these endorsement standards.

12. Rapid Growth of Registries

13. Legislative Impact on Registries
2013 legislation authorized Qualified Clinical Data Registry (QCDR) pathway for specialty societies to meet physician accountability requirements.
Approved entity that collects clinical data for the purpose of patient and disease tracking to foster quality improvement in care.
Provides timely performance reports to participants
Explosion of new registries to meet new requirements
42 QCDRs approved by CMS in 2014
No requirements for external review of measures
Short term focus on process measures -- 3 outcome measures required by 2017
Public reporting on Physician Compare starting in

14. Registry-Based Measurement
Highly successful registries in US, including STS, ACC NCDR, AHA GWTG, NSQIP, NCCN:
Impact on research, clinical guidelines, coverage decisions, and produce nationally recognized quality measures
Emerging registries with linkages to EHRs through system integrator, including IRIS (ophthalmology), ACC PINNACLE
Variable maturation levels and data capture across registries
STS 95% CABG
AAOS 5% joint replacements

15. STS CABG Composite

16. Improved Outcomes in CABG Surgery

17. Need for Ongoing Measure Feedback
IOM report, Best Care at Lower Cost: The Path to Continuously Learning Health Care in America, cites feedback loops as essential for continuous learning and system improvement
Continuously learning system uses information to change and improve its actions and outputs over time
Image Source:

18. The Measurement Imperative
Not everything that counts can be counted,
and not everything that can be counted counts
~Albert Einstein
(William Bruce Cameron)
But…..
You can’t improve what you don’t measure
~ W. Edwards Deming

19. Discussion Helen Burstin, MD, MPH, FACP Chief Scientific Officer