1. Composite Approaches for Electronic Clinical Quality Measures January 17, 2014

2.  Criterion-based composites: Require an assumption about what constitutes good or sufficient quality –All-or-none –Any-or-none  Absolute score composites: Summarize quality of care without assuming a standard of quality –Linear combination –Opportunity scoring –Regression-based  Options to amend the composite: –Level of aggregation (patient or component) –Threshold/benchmark scoring (variant of all-or-none) –Weighting Types of Composites 2 Source: Reeves, D., S.M. Campbell, J. Adams, P.G. Shekelle, E. Kontopantelis, and M.O. Roland. “Combining Multiple Indicators of Clinical Quality: An Evaluation of Different Analytic Approaches.” Medical Care, vol. 45, no. 6, June 2007, pp. 489–496.

3. Screening Patient Patients Screened Patients Eligible ABCDE 1. Screening 1XXXX45 2. Screening 2XXXX45 3. Screening 3XX25 4. Screening 4XX25 5. Screening 5XNAX24 6. Screening 6XX25 7. Screening 7XXNA24 8. Screening 8XX25 9. Screening 9XXX35 10. Screening 10XXX35 11. Screening 11XXX25 12. Screening 12XX25 Number of Screenings Provided 12864131 Eligible Number of Screenings 1211 12 58 Example Patient Population 3

4. Composite Approaches 4

5.  Gives provider credit only if a patient meets the criteria for all components of the measure  From example patient population, only patient A received all screenings for which they were eligible All-or-None: Explanation and Example 5

6.  Gives provider credit for patients who meet the criteria for at least one component of the measure –Somewhat of a reversal of “all-or-none”  From the example patient population, all 5 patients received at least one screening Any-or-None: Explanation and Example 6

7.  Average of scores across individual measure components  Gives provider partial credit for meeting the criteria for some but not all components of the measure Linear Combination: Explanation and Example 7

8.  Ratio of instances when provider meets the measure criteria for a particular component of the measure to the number of “opportunities” to meet individual components Opportunity Scoring: Explanation and Example 8

9.  Weights items relative to their reliability or strength of association with a gold standard outcome (e.g., mortality)  Requires extensive data to derive and validate regression model Regression Based: Explanation and Example 9 An example score is not easy to illustrate for this approach. The weights for each measure component would be calculated using a regression model.

10. Modifiers in Developing Composite Approaches 10

11.  Composite approaches can combine individual measures at either the patient or component level –Patient level: all-or-none –Component level: opportunity scoring –Either: linear combination Level of Aggregation: Explanation and Example 11 Example: Component level linear combination

12.  A patient qualifies for the numerator if he or she meets a particular percentage of component measures. Threshold/Benchmark Scoring: Explanation and Example 12 Example: Patients must meet at least 70% of the components to quality for the numerator

13.  Gives more credit for meeting certain components Weighting: Explanation and Example 13 Example: The first and tenth screenings get twice the weight of the others