Outcome measures for oncology alternative payment models: practical considerations and recommendations.

OBJECTIVES: This paper aims to synthesize existing scholarship on quality measures in oncology, with a specific focus on outcome-based quality measures, which are often underutilized. We also present a set of "core outcome measures" that may be considered in future oncology alternative payment models (APMs). STUDY DESIGN: Our research consists of a focused literature review, content analysis, and quality measure synthesis and categorization. METHODS: We conducted a focused literature review to generate key evidence on quality measures in oncology. We studied 7 oncology quality assessment frameworks, encompassing 142 quality metrics, and synthesized recommendations using the Center for Medicare and Medicaid Innovation APM toolkit, focusing on outcome measures. RESULTS: We present 34 outcome-based oncology quality measures for consideration, which are classified into 5 domains: clinical care (eg, hospital and emergency department visits, treatment effectiveness, mortality), safety (eg, infections, hospital adverse events), care coordination (for hospital and hospice care), patient and caregiver experience, and population health and prevention. Both general and indication-specific outcome measures should be considered in oncology APMs, as appropriate. Utilizing outcome-based measures will require addressing multiple challenges, ranging from risk adjustment to data quality assurance. CONCLUSIONS: Oncology care will benefit from a more rigorous approach to quality assessment. The success of oncology APMs will require a robust set of quality measures that are relevant to patients, providers, and payers.

Decision support for hospital bed management using adaptable individual length of stay estimations and shared resources.

BACKGROUND: Elective patient admission and assignment planning is an important task of the strategic and operational management of a hospital and early on became a central topic of clinical operations research. The management of hospital beds is an important subtask. Various approaches have been proposed, involving the computation of efficient assignments with regard to the patients' condition, the necessity of the treatment, and the patients' preferences. However, these approaches are mostly based on static, unadaptable estimates of the length of stay and, thus, do not take into account the uncertainty of the patient's recovery. Furthermore, the effect of aggregated bed capacities have not been investigated in this context. Computer supported bed management, combining an adaptable length of stay estimation with the treatment of shared resources (aggregated bed capacities) has not yet been sufficiently investigated. The aim of our work is: 1) to define a cost function for patient admission taking into account adaptable length of stay estimations and aggregated resources, 2) to define a mathematical program formally modeling the assignment problem and an architecture for decision support, 3) to investigate four algorithmic methodologies addressing the assignment problem and one base-line approach, and 4) to evaluate these methodologies w.r.t. cost outcome, performance, and dismissal ratio. METHODS: The expected free ward capacity is calculated based on individual length of stay estimates, introducing Bernoulli distributed random variables for the ward occupation states and approximating the probability densities. The assignment problem is represented as a binary integer program. Four strategies for solving the problem are applied and compared: an exact approach, using the mixed integer programming solver SCIP; and three heuristic strategies, namely the longest expected processing time, the shortest expected processing time, and random choice. A baseline approach serves to compare these optimization strategies with a simple model of the status quo. All the approaches are evaluated by a realistic discrete event simulation: the outcomes are the ratio of successful assignments and dismissals, the computation time, and the model's cost factors. RESULTS: A discrete event simulation of 226,000 cases shows a reduction of the dismissal rate compared to the baseline by more than 30 percentage points (from a mean dismissal ratio of 74.7% to 40.06% comparing the status quo with the optimization strategies). Each of the optimization strategies leads to an improved assignment. The exact approach has only a marginal advantage over the heuristic strategies in the model's cost factors (≤3%). Moreover,this marginal advantage was only achieved at the price of a computational time fifty times that of the heuristic models (an average computing time of 141 s using the exact method, vs. 2.6 s for the heuristic strategy). CONCLUSIONS: In terms of its performance and the quality of its solution, the heuristic strategy RAND is the preferred method for bed assignment in the case of shared resources. Future research is needed to investigate whether an equally marked improvement can be achieved in a large scale clinical application study, ideally one comprising all the departments involved in admission and assignment planning.

[The electronic use of the NANDA-, NOC- and NIC- classifications and implications for nursing practice]. / Die elektronische Anwendung der NANDA-, NOC- und NIC-Klassifikationen und Folgerungen für die Pflegepraxis.

The data model developed on behalf of the Nursing Service Commission of the Canton of Zurich (Pflegedienstkommission des Kantons Zürich) is based on the NANDA nursing diagnoses, the Nursing Outcome Classification, and the Nursing Intervention Classification (NNN Classifications). It also includes integrated functions for cost-centered accounting, service recording, and the Swiss Nursing Minimum Data Set. The data model uses the NNN classifications to map a possible form of the nursing process in the electronic patient health record, where the nurse can choose nursing diagnoses, outcomes, and interventions relevant to the patient situation. The nurses' choice is guided both by the different classifications and their linkages, and the use of specific text components pre-defined for each classification and accessible through the respective linkages. This article describes the developed data model and illustrates its clinical application in a specific patient's situation. Preparatory work required for the implementation of NNN classifications in practical nursing such as content filtering and the creation of linkages between the NNN classifications are described. Against the background of documentation of the nursing process based on the DAPEP(1) data model, possible changes and requirements are deduced. The article provides a contribution to the discussion of a change in documentation of the nursing process by implementing nursing classifications in electronic patient records.

Work complexity assessment, nursing interventions classification, and nursing outcomes classification: making connections.

When nurses understand what interventions are needed to achieve desired patient outcomes, they can more easily define their practice. Work Complexity Assessment (WCA) is a process that helps nurses to identify interventions performed on a routine basis for their specific patient population. This article describes the WCA process and links it to the Nursing Interventions Classification (NIC) and the Nursing Outcomes Classification (NOC). WCA, NIC, and NOC are all tools that help nurses understand the work they do and the outcomes they achieve, and that thereby acknowledge and validate nursing's contribution to patient care.

[Lithuanian version of the Nursing Outcomes Classification Use Survey: development and psychometric evaluation]. / Slaugos rezultatu klasifikacijos lietuviskos anketos parengimas ir psichometrinis ivertinimas.

UNLABELLED: Cross-cultural tests and research instruments are broadly used to adapt questionnaires developed in different countries and cultures. The Nursing Outcomes Classification (NOC)--a comprehensive, standardized classification of patient outcomes--can be used to evaluate the results of nursing interventions. OBJECTIVE: To develop and test psychometrically the Lithuanian version of the Nursing Outcomes Classification Use Survey. MATERIAL AND METHODS: A Lithuanian version of the Nursing Outcomes Classification Use Survey was developed following traditional methodological procedures of research instrument translation and adaptation. The newly developed instrument was tested with a sample of 70 staff nurses from nursing and supportive care hospitals. The content and practical feasibility of the Lithuanian version of NOC was measured for its reliability and validity. Psychometric analysis was conducted with the statistical package SPSS 13.0 for Windows. Results revealed a successful translation of NOC from English to Lithuanian with validity and acceptability of a shortened Lithuanian version (244 items instead of the original 330 items). Satisfactory internal consistency (Cronbach alpha >0.80 in 18 classes and in 6 classes out of 28 Cronbach alpha between 0.70 and 0.80) was defined, and stability in time was very good with a 7-day break between repeated translations (Spearman-Brown coefficient for the whole instrument was 0.806, ranging from 0.707 to 0.970). The majority of items in the Lithuanian version correlated with measurement class (correlation coefficients >0.40). CONCLUSIONS: The Lithuanian version of Nursing Outcomes Classification Use Survey is a reliable, valid, and applicable to outcome identification in clinical practice and nursing research. Future research and further evaluation of the newly developed Lithuanian version of NOC is suggested.

Gestión por procesos en Radiología / Process management in Radiology

La gestión por procesos es un método actual con origen en la industria. Inicialmente se aplicaba para controlar la calidad de un producto o servicio, así como asegurar dicha calidad con el fin de obtener una respuesta eficiente en cuanto a las especificaciones previamente definidas. En anidad, este tipo de gestión persigue la identificación y mejora de procesos organizativos siempre con vistas a beneficial al paciente, según una secuencia ordenada y coordinada de acciones (AU)

Process management is a current method which originated in industry. Initially it was applied to control the quality of a product or service, as well as ensuring quality in order to obtain an effective response with regard to the previously defined specifications. In the Health sector, this type of management seeks to identify and improve organizational processes in order to benefit the patient, according to an ordered and coordinated (AU)

Evaluación del riesgo materno neonatal durante el embarazo / Evaluation of Maternal Neonatal Risks During Pregnancy

El país no cuenta con un instrumento validado para la identificación del riesgo obstétrico. El control prenatal es un programa de tamizaje multifásico, en el que se identifica el riesgo obstétrico de la paciente, con el fin de generar la atención específica que ésta necesite con base en el riesgo identificado. El control prenatal es la prueba tamiz para detectar el alto riesgo obstétrico durante el embarazo. No se ha validado con criterio científico la consulta prenatal como herramienta de tamizaje del riesgo obstétrico. El contenido de las consultas prenatales parece ser más ritualista que el producto de un programa de control de salud racional. Para complicar aún más la evaluación del control prenatal, hay un efecto variable según las poblaciones. No existe ninguna duda sobre la amplia aceptación que tiene el control prenatal en el país. Aunque existe un consenso general sobre muchos factores prenatales y perinatales que aumentan el riesgo obstétrico, no se encuentra en la literatura un acuerdo que permita calcular tal grado de riesgo. Algunos de los registros disponibles comercialmente se han incorporado a los sistemas de puntuación de alto riesgo con el fin de clasificar a las pacientes en categorías de alto y bajo riesgo.

Evaluación del programa centinelas de la salud área naval Nº 2 de la fuerza naval en Santa Cruz septiembre-noviembre 2004

Es un estudio prospectivo de tipo evaluativo sobre le funcionamiento del Programa Centinela de la Salud del Area Naval Nº 2 de la fuerza área en Santa Cruz de la Sierra en el periódo septimbre a noviembre 2004. Se investigo en 6 grupos focales, los participantes fueron reclutadas que asistieron al curso de capacitación. Se entrevisto cinco instructores y un coordinador del programa. Para los grupos focales se aplicó guía temática y para la entrevista informadores claves se utilizo un cuestionario con preguntas abiertas. Los resultados fueron: cumplimiento de la instrucción avance de contenidos, teóricos prácticos, conocimientos satisfactorios, adquisición de concentización sensibilización frente a los problemas de salud, existencia de cierto grado de coordinación entre los diversos actores que participan del programa con algunas dificultades

CCORT/CCS quality indicators for congestive heart failure care.

BACKGROUND: Quality indicators are measurement tools for assessing the structure, processes and outcomes of care. Although quality indicators have been developed in other countries, Canadian cardiovascular disease indicators do not exist. OBJECTIVE: To develop quality indicators for measuring and improving congestive heart failure (CHF) care in Canada. METHODS: An 11-member multidisciplinary national expert panel was selected from nominees from national medical organizations. Potential quality indicators were identified by a detailed search of published guidelines, randomized trials and outcomes studies. A two-step modified Delphi process was employed with an initial screening round of indicator ratings, followed by a national quality indicator panel meeting, where definitions of the indicators were developed using consensus methods. Indicators were designed to be measurable, using retrospective chart review and linking existing administrative databases. RESULTS: The case definition criterion was developed based on a discharge diagnosis of CHF (International Classification of Diseases, 9th revision [ICD-9] code 428.x), with diagnostic confirmation using clinical criteria. In total, 29 indicators and five test indicators were recommended. Process indicators included prescription for angiotensin-converting enzyme inhibitors, beta-blockers or warfarin (for atrial fibrillation) at hospital discharge. Nonpharmacological in hospital process indicators included evaluation of left ventricular function, weight measurement and selected patient education counselling instructions. Process indicators in the ambulatory setting included prescription and adherence to drug therapies and physician follow-up. Outcome indicators included mortality, readmissions and emergency visits. CONCLUSIONS: A set of Canadian quality indicators for CHF care encompassing organizational attributes, pharmacotherapy, investigations, counselling, continuity of care and disease outcomes has been developed. These quality indicators will serve as a foundation for future studies evaluating the quality of CHF care in Canada.

Modelo de gestión integral multidisciplinario de unidad de mama / Integral management model in a multidisciplinary breast unit

La demanda asistencial de patología mamaria ha aumentado en los últimos años, con la consiguiente saturación de consultas Hospitalarias y ocupación de quirófanos. En nuestra Unidad hemos desarrollado un sistema innovador de Gestión Integral Multidisciplinario dirigido a adaptar la demanda a nuestros recursos reales. Los objetivos que planteamos son los siguientes: Optimizar la utilización de la consulta externa y garantizar la continuidad Internivel, Optimizar la indicación quirúrgica e integrar de forma racional las derivaciones procedentes del Programa de Detección Precoz de nuestra Comunidad Autónoma. Método: el Modelo de Gestión se puso en marcha en la Unidad de mama del Hospital Costa del Sol en Mayo del 94. En el rediseño del proceso, se han desarrollado las siguientes herramientas: Optimización de la utilización de consulta externa y continuidad internivel- Definición de criterios de derivación y establecimiento de protocolos de patología benigna frecuente con Atención Primaria, clasificación y priorización de derivaciones, diseño de circuitos diagnósticos ágiles basados en el Acto Único diagnóstico como puerta de entrada al hospital y manejo extrahospitalario de lesiones de baja sospecha, con gestión interna de seguimientos por técnicas de imagen. Optimización de la Indicación Quirúrgica - Utilización de técnicas de punción percutánea para reducir la tasa de intervenciones diagnósticas y planificar el tratamiento de carcinomas, aplicación de un modelo de congruencia radiopatológico en la selección de indicaciones quirúrgicas y promoción del uso de Hospital de Día. Integración racional de las derivaciones procedentes del Programa de Detección Precoz - Gestión de derivaciones conjunta con el Distrito Sanitario, con el Acto Único diagnóstico como puerta de entrada al hospital; definición de criterios de derivación a consulta tras el Acto Único y utilización de técnicas de punción percutánea para reducir morbilidad en el proceso diagnóstico de mujeres asintomáticas. Resultados: con la mejora continua de estas herramientas, hemos reducido las primeras visitas en consulta en un 64 por ciento en 1997 y en un 77 por ciento en 1998, con diagnóstico radiopatológico completo en el 79 por ciento de las mismas y reducción de la lista de espera media en consulta de 31,6 días en 1995 a 17 en 1998. En la optimización quirúrgica se han evitado el 89 por ciento de intervenciones diagnósticas, el 93 por ciento de los carcinomas se sometieron a una única cirugía planificada y el 50 por ciento de las intervenciones se realizaron en Hospital de Día. La gestión de derivaciones del Programa de Detección Precoz, con el Acto Único como puerta de entrada, ha limitado las derivaciones a consulta a un 13 por ciento del total de mujeres con criterio de estudio hospitalario, lo que ha supuesto un incremento de 0,6 primeras visitas por consulta, sin repercusión en la lista de espera. Con la utilización de técnicas de punción percutánea se ha evitado 65 intervenciones diagnósticas en este grupo de pacientes, con un Valor Predictivo Positivo de la cirugía de 0,82. Conclusiones: el rediseño de procesos llevado a cabo en el Modelo de gestión Integral Multidisciplinario, ha dado respuesta a nuestras necesidades asistenciales y es una alternativa válida a la gestión clásica de Unidades de Mama en un entorno de recursos limitados ante una patología en demanda creciente (AU)

The future of home and hospice care. Linking interventions to outcomes.

The pressure on home care and hospice nurses to reach successful outcomes in a cost-effective manner mandates that they become well versed in how to analyze data. The goal of outcome research is to relate patient outcomes to the interventions provided. This article discusses the challenges of outcomes research and how it differs from and relates to performance improvement, and it explores solutions to common problems.

Toward an unequivocal definition and classification of patient outcomes.

PURPOSE: To determine the extent possible of developing an unequivocal formulation of a conceptual, structural, and contextual definition of "patient outcomes," and the possibility of coming to an agreement on the criteria for classification of patient outcomes. METHODS: An international Delphi survey of 33 experts. FINDINGS: A conceptual, structural, and contextual definition of patient outcomes and priorities for the characteristics of patient outcome classification. CONCLUSIONS: The authors recommend the unequivocalness of nursing terminology, not only for reasons of effectiveness and efficiency, but also to clarify the nursing vocabulary for epistemological reasons.

Efficacy, effectiveness and efficiency in mental health service delivery.

OBJECTIVE: The aim of this paper is to review the status of treatments in psychiatry. METHOD: The criteria for good treatment are defined and then treatments in psychiatry are examined for efficacy, effectiveness and efficiency. RESULTS: A large number of treatments were listed by Nathan and Gorman as having satisfied the criteria for efficacy: that is, they had been shown to be superior to placebo in randomised controlled trials. The problem of effectiveness (does the treatment still work when used by the average clinician with the average patient?) is a general one in medicine, but the evidence in psychiatry is not outstanding. The problem of efficiency (what level of resources are required to produce benefit?) is being addressed in a piecemeal fashion, and again this is no different to the situation in general medicine. CONCLUSIONS: A considerable number of treatments have been shown to satisfy the criteria for efficacy. Effectiveness requires that psychiatrists apply such proven treatments and demonstrate benefit through the use of outcome measurement. A system that separated the health budget into segments for prevention, cure and care might ensure that these three goals were pursued equitably and efficiently.

Improving client outcomes through differentiated practice: a rural nursing center model.

The TriCounty Community Health Center (the Center) was created in 1994 with federal grant monies to increase access and to provide outreach and primary health care services for rural residents. The Center employs a differentiated practice model of nursing care in which all nurses use the nursing process targeted to client systems that match the nurse's level of educational preparation and competence. The model allows nurses to intervene with various client systems, including the individual, family, aggregate, and community. Program outcomes for the Center suggest that using a differentiated nursing practice model for outreach and primary care services appears to have a positive impact on the health of individuals, families, and aggregates in rural settings, using the Omaha Classification System as a framework for evaluation.

Outcomes for home and community nursing in integrated delivery systems.

In these tumultuous times in health care, nursing providers are under pressure to capture data that demonstrate the effectiveness of nursing interventions on client health. At the University of Iowa, researchers are attempting to develop a client outcome classification system that uses a standardized language across different health care settings to capture this vital information.

Who needs clinical audit?

Clinical audit focuses on self--and, more importantly, peer assessments of the performance of practitioners and the service they provide to patients. Some practitioners may feel threatened by audit; however, when conducted as intended and viewed as a form of education, it may become recognised as an integral, cost-effective element of everyday clinical practice. This article highlights ways in which practitioners may increasingly appreciate the need to understand and apply clinical audit processes in their practice environments.

Sistema de residencias y relación costo/beneficio con respecto a otros sistemas de atención médica / Residence system and cost/benefit related to other medical assistance systems

Ante el planteo del problema de si la residencia es un adecuado sistema de asistencia, y frente al desconocimiento de la relación costo/beneficio en la atención médica por residentes, y con el objetivo de comparar un grupo de variables (número de diagnósticos, uso de exámenes de laboratorio, mortalidad global y días de estadía) entre pacientes asistidos por la Residencia (1990-1991) y por la Planta (1986-1987), se estudiaron retrospectivamente 609 pacientes, en quienes se registraron sexo, edad, diagnósticos efectuados, días de estadía, uso de métodos complementarios y condiciones de alta. Los resultados arrojaron una estadía por paciente más corta, un mayor número de diagnósticos, mayor índice de sobrevida y menor índice de mortalidad en pacientes asistidos por la Residencia, con un mayor costo en el uso de métodos de laboratorio