Methods to develop arthritis and osteoporosis measures: a view from the National Committee for Quality Assurance (NCQA).

OBJECTIVE: Performance measurement at various levels of the health care system promotes improved processes that can result in the provision of more consistent and effective care. This chapter articulates the methodology and criteria utilized in measures development to ensure accountability and serve the information needs of physicians, health care systems, health plans and consumers, using arthritis and osteoporosis as example conditions. METHODS: Observational studies conducted to assess the validity and feasibility of performance measures focused on arthritis and osteoporosis. Clinical expert panels were convened to develop measure specifications based on guidelines and evidence supporting critical aspects of care. The aspects of care that were assessed included: DMARD utilization for patients with rheumatoid arthritis; appropriate gastrointestinal prophylaxis for patients utilizing NSAIDS; comprehensive osteoarthritis care; comprehensive symptom assessment and medical management of woman over 65 years who experienced a bone fracture. RESULTS: The implementation of performance measures for key aspects of arthritis and osteoporosis care is challenged by the availability of administrative data. However, potential for improvement is evident in each of the areas studied. CONCLUSION: The key challenge to the feasibility of arthritis performance measures is the lack of administrative data to identify the eligible population. Administrative data capture suffers as a result of under-coding and under-recognition of arthritis. Consensus around a single set of measures creates a powerful tool for focusing on key components of care as a basis for quality improvement and allows for a valid comparison of care within and across health care settings.

A new measure of the impact of managed care on healthcare markets.

BACKGROUND: Most studies of managed care impact have used health maintenance organization (HMO) penetration or index of competition as the marker of managed care impact. However, little empirical evidence has been found to support the validity of these or other measures in current use. In addition, as managed care evolves to forms other than HMOs and managed care penetration in large metropolitan areas approaches 100% of commercially insured patients, the utility of the most commonly used measure, HMO penetration, will decrease still further. OBJECTIVES: To provide a preliminary analysis of the use of premiums as a measure of market impact of managed care. STUDY DESIGN: Retrospective analysis (quartile, correlation, multiple-variable linear regression) of publicly available datasets. METHODS: Labor market-adjusted HMO premiums from 3 publicly available sources, for the 56 largest metropolitan areas in the United States, were compared with penetration and index of competition as predictors of the dependent market variable, hospital bed-days per 1000 population. RESULTS: Health maintenance organization premiums in the Federal Employees Health Benefits Program emerged as the best predictor of HMO market impact. Average HMO premiums reported in the Interstudy database and for the Medicare+Choice program also outperformed penetration or index of competition in relating to several commonly available markers of competition such as bed-days per 1000. CONCLUSIONS: Premiums charged by HMOs are a useful measure of the impact of managed care on healthcare markets in large metropolitan areas.

Health status of participants of adult day care centers.

This study compared the medical conditions found in 183 participants of 5 suburban adult day care programs to the medical and mental health status of community-dwelling elderly persons. Analysis revealed that adult day care center participants are very similar to the community-dwelling elderly population in most health indicators, but suffer from much higher rates of dementia and associated functional disabilities. Moreover, those day care participants who do not suffer from dementia tend to suffer from a psychiatric disorder (e.g., major depression, adjustment disorder). These results show that adult day care has become a facility with a primary mental health function.

The Managed Care Education Clearinghouse.

The authors surveyed all 125 allopathic medical schools to determine the number of schools that had implemented a formal curriculum in managed care and how many had a substantial interest in a Web-based clearinghouse for managed care curricular resources. They describe the results of their survey and the Web site they developed, the Managed Care Education Clearinghouse.

Chronic illness: implications of a new paradigm for health care.

A major factor in determining and maintaining the form of our health care system is our underlying assumptions about the origins of problems related to health. The author explores the implications of the change from an acute simple disease model to a chronic complex illness model for the evaluation of quality in health care.

The impact of OBRA on medical practice within nursing facilities.

Major changes in the federal oversight of nursing home care were passed by Congress and became law as the Nursing Home Reform Amendments of the Omnibus Budget Reconciliation Act of 1987 (OBRA 87). The final regulations to implement OBRA 87 were published in September, 1991. The intent of this article is to provide an overview of selected parts of the nursing home reform regulations, which have a direct impact on physician practice within nursing facilities, and to offer strategies for successful management of the changes that are required. A brief review of the origins of the legislation and the process by which law is turned into practice is provided as a context in which to understand the changes mandated by the Nursing Home Reform Amendments of OBRA 87.

An overview of allocation and rationing: implications for geriatrics.

Geriatricians are faced with increasing pressure from insurers and the public to control costs. At the same time, subspecialist colleagues, patients, and the courts often demand ever more costly high-technology interventions. This conflict will only intensify given the sustained increase in the percentage of GNP spent on medical care. A number of prominent biomedical ethicists and others have explored rationing of medical care services as one response to these concerns. This is the second in a series of articles in the Journal in response to the Oregon Health Decisions Initiative and is designed to provide (1) a brief ethical perspective on rationing and allocation; (2) an analysis of our present, largely implicit, approach to rationing and allocation; and (3) some suggestions that might move the United States closer to a more coherent and reasonable means of allocating and rationing health care.

Self-reported versus actual test ordering behavior among primary care clinicians.

To determine the accuracy of clinician self-reports, 38 clinicians were surveyed in a university-based health maintenance organization (HMO) practice on their thyroid function testing (TFT) patterns one year after the distribution of an educational intervention (the intervention). The mean of the absolute difference between self-reported and actual test ordering rates was 12%; the difference was greater than 20% for only 3 of 33 clinicians who ordered TFT for at least five patients during the study period. A strong association was found between self-reported change and the actual mean change in TFT postintervention ordering rates (p less than 0.0001). Results suggest that clinicians, at least in certain settings, can accurately estimate their utilization patterns and the effect of practice guidelines.

Magnetic resonance imaging. Diffusion of technology in an ambulatory setting.

To better understand technology diffusion in an ambulatory care setting, we analyzed adult outpatients' use of magnetic resonance (MR) and computed tomography (CT) imaging in a group-model HMO between 1986 and 1989. The use of MR, but not CT, increased at a rapid pace with only a small proportion of the scans being accounted for by primary care physicians.

Effect of education and feedback on thyroid function testing strategies of primary care clinicians.

We examined the effect of an educational memorandum incorporating simple guidelines for thyroid function testing on test utilization in a primary care health maintenance organization practice. We then compared the effectiveness of a reminder alone or combined with individual test ordering feedback at maintaining an effect. The subjects were 17 physicians and 13 physician assistants and nurse practitioners separated into two similar study groups with little clinical interaction. Both groups responded to the education with increased compliance (from 36% to greater than 67%) with the recommended testing strategy. The group subsequently receiving only a reminder showed a further increase in compliance from 68% to 81% at 6 months and 79% at 12 months. The group receiving a reminder and feedback showed no subsequent change in testing pattern (65% compliance before the reminder-feedback and 64% at both subsequent measurements). The effect of the educational intervention was greater on nurse practitioners and physician assistants than physicians (absolute increase in compliance, 63% vs 28%). We conclude that education can be an effective tool for modifying clinician testing patterns to conform to simple clinical guidelines. Further study of the effect of education and other strategies on compliance with more complex guidelines is needed.

Medicare reimbursement for geriatric assessment: report of the American Geriatrics Society Ad Hoc Committee on Geriatrics Assessment.

This ad hoc committee report from the American Geriatrics Society proposes the prompt initiation of Medicare reimbursement for geriatric assessment (GA) services (also termed comprehensive geriatric assessment or geriatric evaluation and management services). Despite an extensive body of literature documenting the effectiveness of GA for improving health care outcomes in many settings for identifiable groups of frail elderly patients, no explicit Medicare reimbursement mechanisms currently exist to cover GA services provided by either hospital or physician. We believe that new physician reimbursement codes specific for geriatric assessment should be established in the Current Procedural Technology (CPT-4) manual and that reimbursement for GA should be specifically provided under Part B of Medicare. Further, we believe that hospital reimbursement within the Medicare prospective payment system should be modified to encourage GA during inpatient stays for appropriate patients. This paper summarizes the background for these recommendations. It defines the major content of GA at three levels of intensity--screening, intermediate, and comprehensive. It describes the major sites for conducting GA--hospital, office, home, nursing home. Finally, it proposes criteria for targeting patients most likely to benefit from GA.

The decision to execute a durable power of attorney for health care and preferences regarding the utilization of life-sustaining treatments in nursing home residents.

One hundred three nursing home residents were interviewed regarding their preferences for the choice of an agent for health-care decision making while being offered the opportunity to execute a Durable Power of Attorney for health care. They also completed a questionnaire that tapped their preferences regarding the use of four types of life-support treatment under three hypothetical levels of future cognitive functioning. Factors that might influence these preferences, such as previous experiences with life-sustaining treatments, religious beliefs, and personal values, were also examined. Participants tended to choose their son or daughter as their agent for future health-care decision making. They had clear and consistent patterns of preferences regarding the utilization of life-sustaining treatment. Generally, participants opted not to be treated, although there was variability among participants. They were even less inclined to opt for treatment as their perceived level of future cognitive functioning declined, or when the life-sustaining treatment involved permanent rather than temporary procedures.