Quality and Outcome Measures for Medical Rehabilitation

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Chapter 8 Quality and Outcome Measures for Medical Rehabilitation

Karen L. Andrews, Heather S. Ohl, Mary F. Kessler, Dexanne B. Clohan

Quality health care can be defined as providing the best possible outcomes, safety, and service. Quality patient care should be the first priority of every rehabilitation professional. Turning this priority into practice can be difficult for many reasons. For example, sometimes scientific clarity on what constitutes quality is lacking. Financial incentives such as fee-for-service arrangements that reward activity rather than outcomes can also hamper quality efforts and lead to overuse of a broad variety of health care services.²² Where health services are concerned, more is not necessarily better. To help determine what constitutes quality and how health professionals should measure it, this chapter discusses quality improvement, evidence-based outcome measures, practice improvement, safety, and accreditation.

As this chapter goes to press, the United States is involved in a passionate national health care reform debate. Health care reform efforts under consideration range from payment reform to efforts to promote implementation of health information technology. Some advocate public, government-run insurance to provide cost containment from private insurance. Others believe a “public option” would create a government-run, government–price-controlled, Medicare-like insurance plan and advocate instead for health insurance and Medicare payment reform. Others support changes that would require all Americans to purchase health insurance. In his address to a joint session of Congress on September 9, 2009, President Obama stated, “Our health care problem is our deficit problem.”

A large number of outcomes scales are now available for rehabilitation and for health care in general. One can anticipate that consumer-driven care will increase the demand for information about health plans, specialty components of health care, and the quality of plans and providers. Initiatives to improve health care quality include reporting on performance (often described as “report cards” or “transparency”) and paying extra for services deemed to be of high quality (“pay for performance” [P4P]). Effective techniques of quality measurement are essential for either of these initiatives to work.

Efforts to measure and reward quality care have grown exponentially over the last decade. In 2007, more than 100 million Americans were enrolled in health plans that measure and report quality of care. In 2008, 240 preferred provider organizations, covering more than 42 million members, joined their health maintenance organization counterparts and reported audited Healthcare Effectiveness Data and Information Set (HEDIS) data to the National Committee for Quality Assurance (NCQA). The total number of Americans included in quality reporting increased 29% in 2008 and has more than doubled since 2000.²²

Quality Improvement

Quality assurance (QA) refers to planned and systematic production processes that provide confidence in a product’s suitability for its intended purpose. QA has long been part of the medical culture. It was customary for a negative medical event to trigger an investigation to identify why it occurred and who was at fault. In 1991, The Joint Commission formulated a plan to move hospital quality programs away from QA toward continuous quality improvement (CQI). CQI is a method of quality control that is widely accepted in the manufacturing industry to analyze and improve production processes. CQI programs focus on both outcome and process of care. In her inaugural health care “success story” report of July 13, 2009, Secretary Kathleen Sebelius stated, “We know there are tremendous examples of efficient, high-quality health care in America today. Our challenge is spreading these good examples across the country.” CQI is the ongoing, organization-wide framework in which employees are committed to and involved in monitoring all aspects of their organization’s activities to continuously improve them. Quality improvement includes a critical evaluation of current practice to develop process improvements, reduce practice variation, and optimize resource consumption. A process is broken down into a series of steps and then analyzed to decide what approach might work better. The effect of any change—often called an intervention—is examined in terms of specific clinical and economic outcomes. CQI focuses on process or system improvement rather than placing blame on individuals.

A general principle behind CQI is that 85% of errors occur because of a suboptimal system, and only 15% of errors are attributable to individuals.¹ CQI attempts to determine “what is wrong with this system and why did an error occur.” (The system failed the employee rather than the reverse.) The evidence suggesting that quality problems are largely caused by systes failures has led to an emerging focus on the organizational factors necessary to improve the quality of health care. Adapting these principles to medicine presents unique challenges. Physicians often resist standardizing care, fearing a loss of autonomy or loss of their ability to provide individualized care. A work environment with needless variation increases the likelihood of medical errors by the health care personnel involved. There is frequently an inherent tension between standardization to excellence and physician autonomy that needs to be understood and confronted.

For two decades, health care workers have had varying degrees of success using the principles of CQI to improve the quality of patient care.⁸ Experts using CQI in health care believe it is possible to improve quality and save money at the same time. The objectives of quality improvement are to ensure access to new technology, good procedural outcomes, and patient satisfaction while simultaneously identifying opportunities for expense reduction. Integrated quality-improvement initiatives help ensure that the research of today becomes the practice of tomorrow.

Quality Outcomes/Practice Measures

Clinicians have greater credibility with payers and policymakers if they collect and share outcomes that demonstrate the economic benefits of an intervention as well as the impact on health, function, and quality of life.²⁶ For patients and their families struggling to come to terms with a newly acquired disability, it can be hard to think of the “cost” part. The key for them is generally to achieve the best possible outcome “whatever the cost.” As clinicians respond to the public demand for person-centered care, we must recognize the current financial pressure on health care systems and the need to share a scarce resource equitably among a large group of patients.

The traditional medical model focuses on diagnosis and treatment of acute disease. For many medical decisions, it is not always clear that treatment is the best option. For instance, there is growing evidence that the amount of surgery that can be justified on the basis of traditional practice guidelines actually exceeds the amount of surgery that patients want when fully informed.³⁴ Shared decision making allows patients and care providers to determine whether the patient should undergo diagnostic testing or receive therapy. In contrast to acute diseases, chronic conditions are usually not cured. As a result, patients must adapt to these problems. Because diagnosis and treatment might detect and address an aspect of a disease without extending life expectancy or improving quality of life, patients and physicians need to have candid discussions to equip patients to make informed decisions about what combination of treatment and adaptation best fits their needs. To use a surgical analogy, although clinicians can detect and attempt to “fix” prostate cancer, the real challenge is deciding whether diagnosis and treatment are valuable. Crahn et al.¹³ discovered that screening 70-year-old men for prostate cancer reduced quality-adjusted life days. The reason for this negative impact is that screening identifies prostate cancer in many men who would have died of other causes. These men, once identified, are likely to engage in a series of treatments that can significantly reduce their quality of life. The treatment causes harm without producing substantial benefits. Clinicians in physical medicine and rehabilitation also need to be alert to the balance of burden and benefit of treatment in helping patients reach personal choices about their care. Creating an outcome measure at the individual patient level (e.g., to walk two blocks, to manage grooming independently, to cycle without hip pain) is a way of incorporating principles from the overall quality movement to benefit individual patients.

Pay for Performance

One way that insurers and the Centers for Medicare & Medicaid Services (CMS) are trying to improve quality is by developing pay for performance (P4P) programs. P4P is an emerging movement in health insurance to pay providers for higher-quality care as measured by selected evidence-based standards and procedures. P4P relies on a combination of quality measures that include clinical outcomes, clinical processes, and patient satisfaction. All of the data are collected and then “measured” by comparing them with a standard. Incentives are paid based on how one does compared with the standard or measure defined. Incentives include bonus payments and feedback reports.

There are currently more than 100 P4P projects nationally.¹¹ Employers, private payers, Congress, and CMS are all moving forward with P4P programs or variations of it. The measures used to assess quality and cost-effectiveness in P4P programs vary greatly. Many of the measurements used in P4P initiatives look at process data. If someone should have received a type of care, did that patient in fact receive it? The “percentage compliance” measures are well suited to outcomes measures.

The HEDIS is a tool used by more than 90% of Americans with managed health care plans and a growing number of preferred provider organization plans to measure performance on important dimensions of care and service. By providing objective clinical performance data, HEDIS provides purchasers and consumers the means to make informed comparison among health plans on the basis of performance. HEDIS includes performance measures related to dozens of important health care issues including comprehensive diabetes care (yearly foot examinations); the use of imaging studies and recommendations for exercise in patients with low back pain; the use of high-risk medications in the elderly; and other strategic safety initiatives. National Quality Forum–endorsed measures can be found at http://www.ncqa.org.

Since 1996, the NCQA has reported to the nation on the state of health care quality. One in three Americans is enrolled in a health plan that is transparent regarding the measurement of the quality of its care and services. For the ninth consecutive year, health care delivered by plans that measure and report performance data continues to improve despite rising costs and a slowing national economy.²³

Patient Safety

The Institute of Medicine report, To Err Is Human: Building a Safer Health System, highlighted the opportunity to reduce preventable medical errors. Since its release, patient safety has become a preeminent issue for health care.¹⁶ Wrong-site, wrong-procedure, or wrong-person surgery suggests problems with the accuracy and completeness of the information brought to the point of care, the quality of communication, and the degree of teamwork among the members of the team. To Err Is Human found that the knowledge about error reduction was easily accessible, but the implementation of the knowledge was lacking. After this report, patients and payers began demanding a higher standard of care. The public, hospital leaders, and health care professionals want to reduce the risk of similar system failures occurring in the future.

During acute rehabilitation, persons with disabilities are transferred across care settings (e.g., from an emergency trauma department to the hospital’s neurology unit, to a postacute rehabilitation hospital), increasing the chances for miscommunication, information loss, and errors. Providers today are caring for more patients, who are more acutely ill, in shorter periods of time than in the past. These workload demands can contribute to adverse events and act as a barrier to implementing patient safety innovations. Payers and patients are primarily interested in excellent care as defined by measured outcomes (e.g., decreased infections, readmissions, mortality). Good processes of care (evidence-based guidelines) should lead to good outcomes. Vigilance is required to make sure rehabilitation safety goals are not sacrificed in favor of goals related to productivity and cost containment.

The 2001 Committee on the Quality of Healthcare report, Crossing the Quality Chasm: A New Health System for the 21st Century, states that there is a need to approach health care in a different way, one that focuses more directly on providing care that is safe, effective, patient-centered, efficient, and equitable.¹⁰ The report identifies these as specific aims for quality measurement and reporting. The Institute of Medicine’s seminal 2002 report, Health Professions Education: A Bridge to Quality, outlines that health professionals must “cooperate, communicate, and integrate care in teams to ensure that care is continuous and reliable.”¹⁶ Formal quality improvement and outcomes monitoring systems aim to improve the effectiveness of care, reduce errors, and improve function and quality of life. These systems enable patients, families, referral sources, and payers to make better choices regarding level and type of rehabilitation needed.

Measures Development

Many quality measures were developed early in the quality improvement movement. For these early initiatives, the risks and rewards from measures were nominal. The goal was for local improvement. The results were not publicly reported. Many different private and public sector groups have attempted to design models to measure performance and report data. While progress has been made, the proliferation of multiple, uncoordinated, and sometimes conflicting initiatives has consequences for stakeholders. Without a uniform approach to select performance measures, conflicting initiatives divert limited resources away from quality measures and reporting. Although public statements of lives saved or errors prevented abound, consumers lack the tools to evaluate the validity of such statements. Hospital Compare was created through the efforts of the CMS, the Department of Health and Human Services, and other members of the Hospital Quality Alliance: Improving Care Through Information. Hospital Compare is a quality tool provided by Medicare to help patients compare the quality of care hospitals provide. The CMS Hospital Compare website can be found at http://www.hhs.gov.

Evidence-based practice requires that clinicians use objective outcomes measures to compare alternative approaches. Evidence-based practice has become the mantra of our modern health care system. Evidence-based practice implies that care is up-to-date, based on the best evidence, and “proven effective.” It is seen as adhering to a rigorous standard and likely to be associated with better overall care.²⁵ Evidence-based guidelines need to be developed to establish standards for quality rehabilitative care.

Physician Consortium for Performance Improvement

The mission of the Physician Consortium for Performance Improvement (PCPI or the Consortium) is to improve patient health and safety by (1) identifying and developing evidence-based clinical performance measures, (2) promoting the implementation of clinical performance improvement activities, and (3) advancing the science of clinical performance measurement and improvement. The Consortium uses cross-specialty workgroups to develop performance measures from evidence-based clinical guidelines.

PCPI measures are designed for physicians managing the care of patients with a particular condition. Measures focus on the patient and the care or procedures they receive. The Consortium develops patient-centered performance measures that are evidence based, statistically valid, and reliable (Box 8-1).

BOX 8-1 Quality Is a Journey, Not a Destination

Establishing performance measures based on the best available clinical evidence requires precise thinking and wording. An effective measure specifically describes a denominator (the universe of patients whose care qualifies to be evaluated by the measure) and a numerator (the number of patients whose care meets the standard).

But progress never stops; so performance measures need to be reviewed periodically to ensure they truly reflect the best practice. As an example, CMS retired a measure on April 1, 2009, that had been collected since 2005. The measure, “acute myocardial infarction patients without beta-blocker contraindications who received a beta-blocker within 24 hours after hospital arrival,” was withdrawn based on new evidence assembled by the American College of Cardiology and the American Heart Association that shows that while beta-blockers reduced the risk of death from arrhythmia and reinfarction, they also can significantly increase the risk of cardiogenic shock within the first 24 hours of admission in some patients with a previous history of heart failure. So while performance measures are a strong tool for improving clinical care, constant vigilance is necessary to build and use the tools wisely.

Rehabilitation Quality Outcome Measures

Physical medicine and rehabilitation professionals attempt to maximize patients’ function after a traumatic injury or other medical condition. Traditional outcome measures focus on functional ability. Classification systems like the World Health Organization’s International Classification of Impairments, Disabilities, and Handicaps ³⁷ and Nagi’s scheme of disablement²² have become standard ways to describe and conceptualize an individual’s disability.

Measures of functional ability like the FIM instrument ²⁷ have become core outcome instruments in rehabilitation medicine. FIM can be used as a clinical assessment tool as well as a risk adjuster in payment systems. Medical rehabilitation has developed systems for monitoring patient gains and basic functional activities, but more work is needed to translate these systems into performance measures that can be used to evaluate the work of specific rehabilitation physicians or hospitals. Because the FIM system focuses on the patient’s actual outcome, rather than just measuring a process step taken by the physician, it could serve as the basis for improved performance measurement.

The FIM instrument is composed of 18 items (13 motor, 5 cognitive) (Box 8-2) and uses a seven-level ordinal scale to measure major gradations of function. The FIM instrument documents a patient’s need for assistance from another person, a device, or both, taking into account the amount of time needed to complete the task.²⁹ Functional status at admission and discharge is assessed by the FIM.²⁷ Demographic, medical, and other variables were added to form the Uniform Data Set for Medical Rehabilitation.³¹ The FIM instrument is used by inpatient rehabilitation hospitals and some other facilities to track patients’ progress from admission through discharge and follow-up.²⁸ To maintain data reliability, facilities must administer an FIM instrument credentialing test created by Uniform Data System for Medical Rehabilitation (UDS_MR) to clinicians every 2 years.³¹

BOX 8-2 FIM Instrument