We’re study­ing so­cio-de­mo­graphic fac­tors to make sure we get the qual­ity mea­sures right

Modern Healthcare - - COMMENT - By Dr. He­len Burstin

How would the per­for­mance of hos­pi­tals, physi­cians and health sys­tems com­pare if, hy­po­thet­i­cally, they all had the same mix of pa­tients?

That’s a ques­tion that pol­i­cy­mak­ers and many in the health­care com­mu­nity raised when sug­gest­ing that per­for­mance mea­sures would be more ac­cu­rate if ad­justed for the so­ciode­mo­graphic sta­tus of the pa­tients be­ing treated.

This type of risk ad­just­ment in­volves a sta­tis­ti­cal ap­proach that al­lows pa­tient-re­lated fac­tors to be taken into ac­count when com­put­ing scores on per­for­mance mea­sures, thereby im­prov­ing the abil­ity to make fair and ac­cu­rate con­clu­sions about qual­ity. Sup­port­ers of the idea point to a grow­ing un­der­stand­ing through­out the health­care com­mu­nity that so­cial de­ter­mi­nants sig­nif­i­cantly in­flu­ence a per­son’s health. We know that fac­tors far out­side the con­trol of a doc­tor or hos­pi­tal—pa­tients’ in­come, hous­ing and ed­u­ca­tion—can sig­nif­i­cantly af­fect pa­tient health, health­care and providers’ per­for­mance scores.

The stakes of in­ac­cu­rately as­sess­ing qual­ity are raised, of course, when the re­sults are used in pay-for-per­for­mance pro­grams. With providers in­creas­ingly be­ing paid based on the qual­ity of their care, some say that those car­ing for the dis­ad­van­taged are be­ing un­fairly pe­nal­ized. If mea­sures are not ad­justed to con­sider a pa­tient’s so­cio-de­mo­graphic fac­tors, they be­lieve, we’ll con­tinue to cre­ate dis­in­cen­tives to care for the poor.

Op­po­nents of ad­just­ing mea­sures for pa­tient so­cio-de­mo­graphic cri­te­ria, on the other hand, say it es­sen­tially sanc­tions de­liv­er­ing lower-qual­ity care to al­ready vul­ner­a­ble pa­tients. They worry that such ad­just­ments could mask dif­fer­ences in qual­ity and make mean­ing­ful in­for­ma­tion on so­cial and eco­nomic dis­par­i­ties dis­ap­pear. They say that ad­just­ing mea­sures in this way sets a dif­fer­ent stan­dard for providers who treat poorer pa­tients and low­ers ex­pec­ta­tions that they will im­prove.

At the cen­ter of this con­ver­sa­tion is the Na­tional Qual­ity Fo­rum—which for more than 15 years has been the gold stan­dard in en­dors­ing mea­sures. Re­view­ing and agree­ing to mea­sures through a multi-stake­holder process is not easy, and more of­ten than not re­quires a crit­i­cal blend of science and con­sen­sus. That was in ev­i­dence a year ago, when the NQF changed its rules to al­low mea­sures to be ad­justed for pa­tients who are poor, home­less, il­lit­er­ate or have other so­cio-de­mo­graphic risk in­di­ca­tors.

This change is sig­nif­i­cant, and it’s in place for a two-year trial pe­riod. The trial was part of a com­pro­mise that the NQF bro­kered be­tween providers—pri­mar­ily hos­pi­tals—who said risk-ad­just­ment was nec­es­sary for fair­ness, and oth­ers who wor­ried it would dis­guise im­por­tant gaps in qual­ity.

The trial pe­riod was rec­om­mended by an ex­pert panel com­posed of stake­hold­ers with a va­ri­ety of ex­pe­ri­ences re­lated to out­come mea­sure­ments and dis­par­i­ties. The rec­om­men­da­tion was de­bated and ap­proved by the NQF’s board, which has a wide range of views rep­re­sented among its di­rec­tors.

Un­der the terms of the trial, all new mea­sures sub­mit­ted to NQF for en­dorse­ment af­ter April 1 of this year are be­ing as­sessed to de­ter­mine if ad­just­ment is ap­pro­pri­ate. Mea­sures en­dorsed prior to that date, but that are un­der­go­ing main­te­nance dur­ing the trial pe­riod, will also be con­sid­ered fair game for ad­just­ment.

There are other pathways for eval­u­at­ing whether per­for­mance mea­sures al­ready en­dorsed should be re­viewed for ad­just­ment, in­clud­ing re­quests re­lated to ev­i­dence of un­in­tended con­se­quences.

Some mea­sures—in­clud­ing ones re­lated to read­mis­sions, as well as cost and re­source use—are al­ready be­ing manda­to­rily re­viewed as a con­di­tion of en­dorse­ment. If ad­just­ment is determined to be ap­pro­pri­ate in any of th­ese cases, the NQF will en­dorse a mea­sure with and with­out so­cio-de­mo­graphic ad­just­ment, as well as strat­i­fi­ca­tion for full trans­parency. We want the mea­sure­ment process to be as flex­i­ble as pos­si­ble for providers while also serv­ing the best in­ter­ests of pa­tients.

Af­ter two years, we will eval­u­ate the suc­cess of the trial and so­licit feed­back from stake­hold­ers on its im­pact.

The Na­tional Qual­ity Fo­rum is, above all, a fo­rum—so we take se­ri­ously our charge to lis­ten to a full range of per­spec­tives. Find­ing an­swers to dif­fi­cult mea­sure­ment-science is­sues such as risk ad­just­ment, at­tri­bu­tion and com­pa­ra­bil­ity will help us use out­comes when they are most needed to meet the needs of the health­care de­liv­ery sys­tem. We be­lieve the trial pe­riod en­ables us to move for­ward in a thought­ful way while pro­duc­ing data we can all learn from.

Dr. He­len Burstin is chief sci­en­tific of­fi­cer for the Na­tional Qual­ity Fo­rum.

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