Are the CMS Hospital Outpatient Quality Measures Relevant for Rural Hospitals?

Context: Quality measures focused on outpatient settings are of increasing interest to policy makers, but little research has been conducted on hospital outpatient quality measures, especially in rural settings. Purpose: To evaluate the relevance of Centers for Medicare and Medicaid Services’ (CMS) outpatient quality measures for rural hospitals, including Critical Access Hospitals. Methods: Researchers analyzed Medicare hospital outpatient claims and Hospital Compare outpatient quality measure data for rural hospitals to assess the volume of conditions addressed by the measures in rural hospitals. A literature review and information from national quality organizations were used to assess the external and internal usefulness of the measures for rural hospitals. A panel of rural hospital quality experts reviewed the measures and provided additional input about their usefulness and data collection issues in rural hospitals. Results: The rural relevant CMS outpatient measures include most of the Emergency Department (ED) measures. The outpatient surgical measures are relevant for the majority of rural hospitals providing outpatient surgery. Several measures were not selected as relevant for rural hospitals, including the outpatient imaging and condition‐specific measures. Conclusions: To increase sample sizes for smaller rural hospitals, CMS could combine data for similar inpatient and outpatient measures, use composite measures by condition, or use a longer time period to calculate measures. A menu of outpatient measures would allow smaller rural hospitals to choose relevant measures depending on the outpatient services they provide. Global measures and care coordination measures would be useful for quality improvement and have sufficient sample size to allow reliable measurement in smaller rural hospitals.     

Validation of the physical activity instrument for the Life in New Zealand national survey

A physical activity recall instrument suitable for self-administration by the adult New Zealand population was devised and validated for 140 subjects selected randomly from urban electoral rolls. Validation used bootstrapping to compare correlations between subjective measures derived from the instrument, the Stanford 7-day recall questionnaire and other questionnaires, and objective measures derived from an exercise test. Subjective measures were grouped as measures of high intensity activity, low intensity activity, or total activity metabolism. The high intensity measures correlated moderately with each other (mean r = 0.39), but poorly with metabolism and low intensity measures (r = 0.16, -0.02, respectively). The mean correlation between the metabolism and low intensity groups (r = 0.26) was similar to those within these groups (r = 0.31, 0.25, respectively). Thus, the high intensity measures formed a group distinct from the metabolism and low intensity groups, which represented similar measures. The objective measures that correlated with high intensity measures (mean r = 0.25) are predominantly recognized risk factors for cardiovascular disease; these did not correlate with the metabolism or low intensity measures (mean r = 0.03, -0.07, respectively). Activity measures from the instrument had mean correlations with subjective and objective measures that equaled or surpassed those of the Stanford measures from the same group. The authors conclude that 1) population health studies that assay physical activity should include well-defined measures of high intensity activity, and 2) valid measures of physical activity in the New Zealand population are achievable with this instrument.     

Developing risk management dashboards using risk and quality measures: A visual best practices approach

Because quality measures are ubiquitous, health care risk management leaders often use them as a proxy for risk management measures. While certain quality measures adequately reflect some aspects of risk management, they are neither a perfect nor complete substitute for well‐developed and comprehensive risk management measures. Using a comprehensive approach consisting of quality measures, risk measures, and measures that are less amenable to classification would be the best approach. Identifying the most powerful and informative measures, designing the most appropriate dashboards, and incorporating visual best practices are crucial steps required for evaluating the effectiveness and value of an enterprise risk management program. The authors explain the terms and concepts, review the measures available in the literature, propose new measures, discuss visual best practices, and provide sample dashboard components.     

Rural Relevant Quality Measures for Critical Access Hospitals

Purpose: To identify current and future relevant quality measures for Critical Access Hospitals (CAHs). Methods: Three criteria (patient volume, internal usefulness for quality improvement, and external usefulness for public reporting and payment reform) were used to analyze quality measures for their relevance for CAHs. A 6‐member panel with expertise in rural hospital quality measurement and improvement provided input regarding the final measure selection. Findings: The relevant quality measures for CAHs include measures that are ready for reporting now and measures that need specifications to be finalized and/or a data reporting mechanism to be established. They include inpatient measures for specific medical conditions, global measures that address appropriate care across multiple medical conditions, and Emergency Department measures. Conclusions: All CAHs should publicly report on relevant quality measures. Acceptance of a single consolidated set of quality measures with common specifications for CAHs by all entities involved in regulation, accreditation, and payment; a phased process to implement the relevant measures; and the provision of technical assistance would help CAHs meet the challenge of reporting.     

A systematic review of measures of end-of-life care and its outcomes

OBJECTIVE: To identify psychometrically sound measures of outcomes in end-of-life care and to characterize their use in intervention studies. DATA SOURCES: English language articles from 1990 to November 2005 describing measures with published psychometric data and intervention studies of end-of-life care. STUDY DESIGN: Systematic review of end-of-life care literature. EXTRACTION METHODS: Two reviewers organized identified measures into 10 major domains. Eight reviewers extracted and characterized measures from intervention studies. PRINCIPAL FINDINGS: Of 24,423 citations, we extracted 200 articles that described 261 measures, accepting 99 measures. In addition to 35 measures recommended in a prior systematic review, we identified an additional 64 measures of the end-of-life experience. The most robust measures were in the areas of symptoms, quality of life, and satisfaction; significant gaps existed in continuity of care, advance care planning, spirituality, and caregiver well-being. We also reviewed 84 intervention studies in which 135 patient-centered outcomes were assessed by 97 separate measures. Of these, 80 were used only once and only eight measures were used in more than two studies. CONCLUSIONS: In general, most measures have not undergone rigorous development and testing. Measure development in end-of-life care should focus on areas with identified gaps, and testing should be done to facilitate comparability across the care settings, populations, and clinical conditions. Intervention research should use robust measures that adhere to these standards.     

Do Centers for Medicare and Medicaid Services Quality Measures Reflect Cost-Effectiveness Evidence?

ObjectivesDespite its importance of quality measures used by the Centers for Medicare and Medicaid Services, the underlying cost-effectiveness evidence has not been examined. This study aimed to analyze cost-effectiveness evidence associated with the Centers for Medicare and Medicaid Services quality measures.MethodsAfter classifying 23 quality measures with the Donabedian’s structure-process-outcome quality of care model, we identified cost-effectiveness analyses (CEAs) relevant to these measures from the Tufts Medical Center CEA Registry based on the PICOTS (population, intervention, comparator, outcome, time horizon, and setting) framework. We then summarized available incremental cost-effectiveness ratios (ICERs) to determine the cost-effectiveness of the quality measures.ResultsThe 23 quality measures were categorized into 14 process, 7 outcome, and 2 structure measures. Cost-effectiveness evidence was only available for 8 of 14 process measures. Two measures (Tobacco Screening and Hemoglobin bA1c Control) were cost-saving and quality-adjusted life-years (QALYs) improving, and 5 (Depression Screening, Influenza Immunization, Colon Cancer Screening, Breast Cancer Screening, and Statin Therapy) were highly cost-effective (median ICER ≤ $50 000/QALY). The remaining measure (Fall Screening) had a median ICER of $120 000/QALY. No CEAs were available for 15 measures: 10 defined by subjective patient ratings and 5 employed outcome measures without specifying an intervention or process.ConclusionsWhen relevant CEAs were available, cost-effectiveness evidence was consistent with quality measures (measures were cost-effective). Nevertheless, most quality measures were based on subjective ratings or outcome measures, posing a challenge in identifying supporting economic evidence. Refining and aligning quality measures with cost-effectiveness evidence can help further improve healthcare efficiency by demonstrating that they are good indicators of both quality and cost-effectiveness of care.     

Reliability and validity of self-reported physical activity in Latinos.

The reliability and validity of six self-report physical activity measures were assessed in Latino adults. Validity was assessed by caltrac activity monitors, 'significant others', and construct analyses. Vigorous activity measures had higher reliability and validity (e.g. r > 0.40, P < 0.05) than moderate intensity measures. Though measures varied in their validity, the use of standard physical activity measures with Latinos was supported, and recommendations for specific measures were provided.     

深水海洋工程装备制造职业病危害预测与控制措施分析

目的对深海海洋工程装备制造的职业病危害进行预测,并提出针对性的防护措施。方法以广东省某深海海洋工程装备制造项目为研究对象,利用类比法、职业病危害因素检测法、经验法等方法分析预测深海海洋工程装备制造的职业病危害,并探讨深海海洋工程装备制造职业病危害防护的工艺、工程、个人防护、职业卫生管理等措施。结果深海海洋工程装备制造重点职业病危害因素为噪声、电焊烟尘、其他粉尘、锰及其无机化合物以及苯系物等,其中噪声超标率为46.7%,电焊烟尘CTWA超标率为56.3%,其他粉尘超标率为37.5%;锰及其无机化合物CTWA超标率达53.8%。职业病危害关键控制岗位为焊工、打磨工、油漆工和切割工,关键控制措施包括工艺措施、工程措施、个人防护措施、职业卫生管理措施等。结论船舶制造业职业病危害严重,尘肺、噪声聋、振动病以及锰及其无机化合物中毒、苯系物中毒风险较高,深海海洋工程装备制造应采取针对性的控制措施。     

A Systematic Review of Health Care Efficiency Measures

Objective. To review and characterize existing health care efficiency measures in order to facilitate a common understanding about the adequacy of these methods.
Data Sources. Review of the MedLine and EconLit databases for articles published from 1990 to 2008, as well as search of the "gray" literature for additional measures developed by private organizations.
Study Design. We performed a systematic review for existing efficiency measures. We classified the efficiency measures by perspective, outputs, inputs, methods used, and reporting of scientific soundness.
Principal Findings. We identified 265 measures in the peer-reviewed literature and eight measures in the gray literature, with little overlap between the two sets of measures. Almost all of the measures did not explicitly consider the quality of care. Thus, if quality varies substantially across groups, which is likely in some cases, the measures reflect only the costs of care, not efficiency. Evidence on the measures' scientific soundness was mostly lacking: evidence on reliability or validity was reported for six measures (2.3 percent) and sensitivity analyses were reported for 67 measures (25.3 percent).
Conclusions. Efficiency measures have been subjected to few rigorous evaluations of reliability and validity, and methods of accounting for quality of care in efficiency measurement are not well developed at this time. Use of these measures without greater understanding of these issues is likely to engender resistance from providers and could lead to unintended consequences.     

Assessing methods for measuring compliance with a fat-controlled diet.

This study assessed the relative validity of the following non-laboratory measures of compliance with a fat-controlled diet by hypercholesterolemic males: quantitative and qualitative measures of compliance derived from three-day food records and structured interviews, and summary ratings by nutritionists and interviewers. The quantitative measures of consumption referred to: saturated fat, linoleic acid, polyunsaturated fat, P/S ratio and cholesterol. The non-laboratory measures were assessed using the following two laboratory measures as criteria of validity: serum cholesterol concentration and the proportion of linoleic acid among the fatty acids of the serum cholesteryl esters. The results showed that, with respect to quantitative measures, the food record and interview manifested approximately equal validity, with the former marginally more valid. However, under certain conditions qualitative measures, such as patients' self-ratings, were about as valid as the more rigorous and expensive quantitative measures. Characteristics of the patient influenced the validity of the various measures. Validity was enhanced by the simultaneous use of certain combinations of measures.     

Measuring health polarization with self-assessed health data

This paper proposes an axiomatic foundation for new measures of polarization that can be applied to ordinal distributions such as self-assessed health (SAH) data. This is an improvement over the existing measures of polarization that can be used only for cardinal variables. The new measures of polarization avoid one difficulty that the related measures for evaluating health inequalities face. Indeed, inequality measures are mean based, and since only cardinal variables have a mean, SAH has to be cardinalized to compute a mean, which can then be used to calculate an inequality measure. In contrast, the new polarization measures are median based and hence do not require to impose cardinal scaling on the categories. After deriving the properties of these new polarization measures, we provide an empirical illustration using data from the British Household Panel Survey that demonstrates that SAH polarization is also a relevant question on empirical grounds, and that the polarization measures are adequate to evaluate polarization phenomena whereas inequality measures are not adequate in these cases.     

The measure of quality

Reflecting an exploding interest, in performance measurement, various state, federal, and commercial entities are calling for public reporting on hospital quality. A number of measures are currently being developed or tested. Lacking, however, is a consensus about the properform and function of health care quality measures. This essay is a contribution to the growing dialog on the utility, practicality, and target audience of various measures. All measures have a subject (what they measure) and a function (the use or purpose of the measures). Subject measures shed light on process (activities prior to, and during care) or outcome (the intended or unintended result of care). Measures also fill 2 different functions: Quality improvement measures are more detailed and are designed for continuous internal consumption. Accountability measures ("report cards") are designed for external consumption, are typically shorter, less frequently generated, and reported at the hospital or clinic level. It is important that the 2 functions not be confused in constructing and targeting future quality measures.     

甲型H1N1流感确诊患者麻醉与手术的防护

目的探讨麻醉及手术期间采用预防措施和管理对策对于预防甲型H1N1流感的效果。方法制定应急预案及相关制度、流程;加大宣教力度;加强消毒隔离;强调医护人员个人防护等措施,加强监督管理确保制度实施。结果麻醉手术中心在甲型H1N1流感的诊疗过程中未发生医院感染。结论实行综合性预防措施和管理对策是预防医院感染发生的关键。     

How patients' sociodemographic characteristics affect comparisons of competing health plans in California on HEDIS quality measures.

OBJECTIVE: To estimate effects of patient sociodemographic characteristics on differential performance within and between plans in a single market area on the HEDIS quality of care measures, widely used for purchasing and accreditation decisions in the United States. DESIGN: Using logistic regression, we modeled associations of age, sex, and zip-code-linked sociodemographic characteristics of health plan members with HEDIS measures of screening and preventive services. We calculated the impact of adjusting for these associations on measures of health plan performance. SETTING: Twenty-two California health plans provided individual-level HEDIS data and zip codes of residence for up to 2 years. PARTICIPANTS: 110 541 commercially insured health plan members. MAIN OUTCOME MEASURES: Ten HEDIS quality-of-care measures. RESULTS: Performance on quality measures was negatively associated with percent receiving public assistance in the local area (seven out of 10 measures), percent Black (three measures), and percent Hispanic (four measures), and positively associated with percent college educated (six measures), and percent urban (three measures), controlling for plan, while associations with percent Asian were positive for three measures and negative for one (P < 0.05 for six associations, P < 0.01 for four, P < 0.001 for 17). Associations were consistent across plans and over time. Adjustment for these characteristics changed rates for most plans and measures by <5 percentage points. CONCLUSIONS: Adjustment for socioeconomic case mix has little impact on the measured performance of most plans in California, but substantially affects a few. The impact of case mix on indicators should be considered when making comparisons of health plan quality.     

静脉用药调配中心规范管控措施的效果评价

目的探讨静脉用药调配中心(PIVAS)的规范干预措施(以下简称管控措施)对降低医院感染的效果。方法通过对西南医科大学附属中医医院PIVAS实行旨在防控医院感染的规范干预措施,比较实施管控措施前后无菌操作不规范导致的不合格成品输液发生率、不合格成品输液发生原因及静脉用药调配中心人员业务能力。结果 PIVAS实施管控措施后,成品输液因无菌操作不规范而导致的不合格成品输液发生率由0.120%降低至0.045%(P<0.05);导致不合格成品输液的手套指尖监测不合格率、注射器污染率分别为2.326%、12.449%,均较PIVAS实施管控措施前降低(P<0.05),而异物带入成品输液率为85.23%较PIVAS实施管控措施前升高(P<0.05);PIVAS实施管控措施后静脉用药调配中心人员业务能力各项评分均显著升高(P<0.05)。结论 PIVAS管控措施效果较好,不但可更好地保障静脉用药输液治疗的安全性,而且还可显著降低基于静脉用药调配中心(PIVAS)的医院感染发生率,值得推广。     

口岸消杀灭处理风险分析及风险管理

本文采取风险水平矩阵分析法,对消杀灭处理质量安全风险的可能性影响因素进行分析,评价口岸消杀灭处理质量安全风险水平,控制口岸处理质量安全风险,减少消杀灭处理事故的发生。     

Comparison of risk adjustment measures based on self-report, administrative data, and pharmacy records to predict clinical outcomes

Comparing clinical outcomes in observational studies often requires adjustment for comorbid disease. The objective of this study was to compare the performance of risk adjustment measures derived from different data sources to predict the clinical outcomes of mortality and hospitalization. We compared the predictive ability of self-reported comorbidity measures to those derived from administrative diagnosis codes and pharmacy data to predict all-cause mortality and hospitalizations in a large sample of veterans receiving care in the Veterans Affairs outpatient clinic setting. In logistic regression models to predict mortality adjusting for age and gender, the Seattle Index of Comorbidity, SF-36, Charlson Index, Diagnosis Cost Groups, and RxRisk had similar discriminatory power ranging between 0.73 and 0.74. The Adjusted Clinical Groups and Chronic Illness and Disability Payment System were less accurate in prediction mortality. Although all measures performed less well in predicting hospitalizations, administrative measures performed better than self-reported measures. We conclude that self-reported morbidity measures had similar performance to administrative and pharmacy measures to predict mortality in a larger outpatient sample, but under-performed these measures in predicting hospitalization. While models using self-report measures can typically only be run on subsamples of patients for which models using administrative and pharmacy measures can be run, models combining self-reported morbidity and other measures performed better than models with a single measure. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.     

某部舰艇鼠害综合防治对策的研究

目的对舰艇采取生态防治措施后的灭鼠效果研究.方法采用以治理环境为主的生态防治措施,结合物理和化学防治为辅的综合防治方法.结果采取生态防治后营区鼠密度由96.77%下降到1.67%;军舰由88.89%下降到1.16%;缉私艇由85.84%下降到0.结论采取生态防治为主的灭鼠措施,是有效的灭鼠方法.     

Welfare-related health inequality: does the choice of measure matter?

Using representative microdata from the German Socio-Economic Panel Study (SOEP), we show that the welfare measure choice has a substantial impact on the degree of welfare-related health inequality. To assess the sensitivity of welfare-related health inequality measures, we combine a unique set of income and wealth measures with different subjective, cardinalized, and (quasi-)objective health measures. The influence of the welfare measure is more pronounced when using subjective health measures than when using (quasi-)objective health measures.     

Measuring explained variation in linear mixed effects models

We generalize the well-known R(2) measure for linear regression to linear mixed effects models. Our work was motivated by a cluster-randomized study conducted by the Eastern Cooperative Oncology Group, to compare two different versions of informed consent document. We quantify the variation in the response that is explained by the covariates under the linear mixed model, and study three types of measures to estimate such quantities. The first type of measures make direct use of the estimated variances; the second type of measures use residual sums of squares in analogy to the linear regression; the third type of measures are based on the Kullback-Leibler information gain. All the measures can be easily obtained from software programs that fit linear mixed models. We study the performance of the measures through Monte Carlo simulations, and illustrate the usefulness of the measures on data sets.