Value-Based Purchasing Programs (VBPs): Are the Quality Measures Used "Fit for Purpose"?

Quality measurement is an intrinsic component of value-based purchasing, yet the quality measures currently in use for Value-Based Purchasing Programs (VBPs) are generally derived from a potpourri of measures originally built for other purposes. Only a handful of VBPs have definitively shown savings or expanded nationally. We suggest that to shift the health care reimbursement system in the United States to paying for value, quality measures used in VBPs should be vetted as "fit for purpose." We advocate that quality measures deemed "fit" for VBPs be defined primarily by the impact of the quality measures on providers, patients, the provider-patient relationship and what matters to patients. We define 5 attributes of quality measures we believe necessary to link the actions of providers and patients and lead to value for our health care system. "Fit for purpose" quality measures should focus health care delivery on value improvement and create a culture of value in our health care system.

Trends in care practices and outcomes among Medicare beneficiaries with diabetes.

BACKGROUND: While diabetes is a major issue for the aging U.S. population, few studies have described the recent trends in both preventive care practices and complications among the Medicare population with diabetes. Using the Medicare Quality Monitoring System (MQMS), this 2004 study describes these trends from 1992 to 2001 and how these rates vary across demographic subgroups. METHODS: Outcomes include age- and gender-adjusted rates of 15 indicators associated with diabetes care from 1992 to 2001, the absolute change in rates from 1992 to 2001, and 2001 rates by demographic subgroups. The data were cross-sectional samples of Medicare beneficiaries with diabetes from 1992 to 2001 from the Medicare 5% Standard Analytic Files. RESULTS: Use of preventive care practices rose from 1992 to 2001: 45 percentage points for HbA1c tests, 51 for lipid tests, 8 for eye exams, and 38 for self-monitoring of glucose levels (all p<0.05). Rates for short-term and some long-term complications of diabetes (e.g., lower-extremity amputations and cardiovascular conditions) fell from 1992 to 2001 (p<0.05). However, rates of other long-term complications such as nephropathy, blindness, and retinopathy rose during the period (p<0.05). Nonwhites and beneficiaries aged <65 and >85 exhibited consistently higher complication rates and lower use of preventive services. CONCLUSIONS: The Medicare program has seen some significant improvement in preventive care practices and significant declines in lower-limb amputations and cardiovascular conditions. However, rates for other long-term complications have increased, with evidence of subgroup disparities. The MQMS results provide an early warning for policymakers to focus on the diabetes care provided to some vulnerable subgroups.

Hospitalizations, nursing home admissions, and deaths attributable to diabetes.

OBJECTIVE: To estimate all-cause hospitalizations, nursing home admissions, and deaths attributable to diabetes using a new methodology based on longitudinal data for a representative sample of older U.S. adults. RESEARCH DESIGN AND METHODS: A simulation model, based on data from the National Health and Nutrition Examination Survey (NHANES) I Epidemiologic Followup Study, was used to represent the natural history of diabetes and control for a variety of baseline risk factors. The model was applied to 6,265 NHANES III adults aged 45-74 years. The prevalence of risk factors in NHANES III, fielded in 1988-1994, better represents today's adults. RESULTS: For all NHANES III adults aged 45-74 years, a diagnosis of diabetes accounted for 8.6% of hospitalizations, 12.3% of nursing home admissions, and 10.3% of deaths in 1988-1994. For people with diabetes, diabetes alone was responsible for 43.4% of hospitalizations, 52.1% of nursing home admissions, and 47% of deaths. Adjusting for related cardiovascular conditions, which may provide more accurate estimates of attributable risks for people with diabetes, increased these estimates to 51.4, 57.1, and 56.8%, respectively. CONCLUSIONS: Risks of institutionalization and death attributable to diabetes are large. Efforts to translate recent trials of primary prevention into practice and continued efforts to prevent complications of diabetes could have a substantial impact on hospitalizations, nursing home admissions, and deaths and their societal costs.

Diabetes is the strongest risk factor for lower-extremity amputation in new hemodialysis patients.

OBJECTIVE: End-stage renal disease (ESRD) patients, especially those with diabetes, have an increased risk of nontraumatic lower-extremity amputation (LEA). The present study aims to examine the association of demographic and clinical variables with the risk of hospitalization for LEA among incident hemodialysis patients. RESEARCH DESIGN AND METHODS: The study population consisted of incident hemodialysis patients from the study years 1996-1999 of the ESRD Core Indicator/Clinical Performance Measures (CPM) Project. Cox proportional hazard modeling was used to identify factors associated with LEA. RESULTS: Four percent (116 of 3,272) of noncensored incident patients had an LEA during the 12-month follow-up period. Factors associated with LEA included diabetes as the cause of ESRD or preexisting comorbidity (hazard ratio 6.4, 95% CI 3.4-12.0), cardiovascular comorbidity (1.8, 1.2-2.8), hemodialysis inadequacy (urea reduction ratio [URR] <58.5% (1.9, 1.1-3.3), and lower serum albumin level (1.6, 1.1-2.3). Among patients with diabetes, hemodialysis inadequacy and cardiovascular comorbidity were risk factors for LEA (2.6, 1.4-4.8, and 1.7, 1.1-2.6, respectively). CONCLUSIONS: These data suggest that diabetes is a potent risk factor for LEA in new hemodialysis patients. In ESRD patients with diabetes, a multipronged approach may reduce the rate of LEA. Potentially beneficial strategies include adherence to hemodialysis adequacy guidelines, aggressive treatment of cardiovascular comorbidities, and the utilization of LEA prevention strategies recommended for the general population of patients with diabetes.

Disparity in outcomes for adult Native American hemodialysis patients? Findings from the ESRD Clinical Performance Measures Project, 1996 to 1999.

BACKGROUND: There is a paucity of information regarding the quality of care for Native American hemodialysis patients. Outcomes, including 1-year hospitalization and mortality, for adult Native American in-center hemodialysis patients selected for the Centers for Medicare and Medicaid (CMS) end-stage renal disease (ESRD) Clinical Performance Measures (CPM) Project were compared to those for white and black patients to determine if disparity in care existed for this group. METHODS: Clinical data were abstracted from medical records for the last quarters of 1995 to 1998 and linked to United States Renal Data System (USRDS) data files for data on comorbidities and 1-year hospitalization and mortality. Associations of race were tested by bivariate analyses and multivariate logistic regression and Cox proportional hazard modeling. RESULTS: Two percent (467 of 27876) of patients were Native American, 37% black, and 51% white. Native American, compared to black and white patients, were more likely to have diabetes mellitus as the cause of ESRD (72%, 37%, and 38%, respectively, P < 0.01). In multivariate analyses, Native American patients were more likely to achieve a mean urea reduction ratio (URR) > or = 65% compared to whites (referent) [hazards ratio (HR) (95% CI) 1.7 (1.3, 2.2)] and be dialyzed with an arteriovenous fistula [HR (95% CI) 1.7 (1.2, 2.5)]. They were as likely as Whites to achieve a mean hematocrit > or =33% and a mean serum albumin > or =4.0/3.7 g/dL. In multivariate analyses, Native Americans were no more likely to be hospitalized or die during the follow-up period than whites. CONCLUSION: These data suggest that adult Native American hemodialysis patients experience equivalent or better dialytic care and are no more likely to experience 1-year hospitalization or mortality compared to whites.

Survival advantage for adult Hispanic hemodialysis patients? Findings from the end-stage renal disease clinical performance measures project.

One-year follow-up mortality in Hispanic and non-Hispanic patients and its association with intermediate outcomes of dialytic care were examined utilizing the Center for Medicare & Medicaid Services' (CMS) ESRD Clinical Performance Measures (CPM) Project and administrative data. Demographic and clinical information was collected on a national random sample of adult in-center hemodialysis (HD) patients for the period of October through December, 1998. Patients were categorized as Hispanic, non-Hispanic White, or non-Hispanic Black. Of 8336 patients 994 (12%) were identified as Hispanic, 3618 (43%) as non-Hispanic White, and 3111 (37%) as non-Hispanic Black. The adjusted 12-mo mortality risk (99% CI) for Hispanics was 0.76 (0.60 to 0.96; P < 0.01) and for non-Hispanic Blacks 0.66 (0.56 to 0.78, P < 0.001) compared with non-Hispanic Whites (referent). Similar 12-mo mortality risks were noted in the groups with diabetes mellitus or hypertension as the causes of ESRD and among patients > or = 65 yr. After controlling for demographic and geographic variables, Hispanics compared with the referent group, non-Hispanic Whites, were more likely to have a mean serum albumin > or = 4.0/3.7 g/dL (BCG/BCP) (1.5 [1.2 to 1.7]; P < 0.001) and as likely to have a mean Kt/V > or = 1.2, mean hemoglobin > or = 11 g/dL, and an arteriovenous fistula as their vascular access. These data suggest that adult Hispanic HD patients have a 12-mo survival intermediate to non-Hispanic Blacks and non-Hispanic Whites and experience equivalent or better intermediate outcomes of dialytic care compared with non-Hispanic Whites.