Methods for Developing Patient-Reported Outcome-Based Performance Measures (PRO-PMs).

OBJECTIVE: To recommend methods for assessing quality of care via patient-reported outcome-based performance measures (PRO-PMs) of symptoms, functional status, and quality of life. METHODS: A Technical Expert Panel was assembled by the American Medical Association-convened Physician Consortium for Performance Improvement. An environmental scan and structured literature review were conducted to identify quality programs that integrate PRO-PMs. Key methodological considerations in the design, implementation, and analysis of these PRO-PM data were systematically identified. Recommended methods for addressing each identified consideration were developed on the basis of published patient-reported outcome (PRO) standards and refined through public comment. Literature review focused on programs using PROs to assess performance and on PRO guidance documents. RESULTS: Thirteen PRO programs and 10 guidance documents were identified. Nine best practices were developed, including the following: provide a rationale for measuring the outcome and for using a PRO-PM; describe the context of use; select a measure that is meaningful to patients with adequate psychometric properties; provide evidence of the measure's sensitivity to differences in care; address missing data and risk adjustment; and provide a framework for implementation, interpretation, dissemination, and continuous refinement. CONCLUSION: Methods for integrating PROs into performance measurement are available.

Addressing electronic clinical information in the construction of quality measures.

Electronic health records (EHR) and registries play a central role in health care and provide access to detailed clinical information at the individual, institutional, and population level. Use of these data for clinical quality/performance improvement and cost management has been a focus of policy initiatives over the past decade. The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA)-mandated Pediatric Quality Measurement Program supports development and testing of quality measures for children on the basis of electronic clinical information, including de novo measures and respecification of existing measures designed for other data sources. Drawing on the experience of Centers of Excellence, we review both structural and pragmatic considerations in e-measurement. The presence of primary observations in EHR-derived data make it possible to measure outcomes in ways that are difficult with administrative data alone. However, relevant information may be located in narrative text, making it difficult to interpret. EHR systems are collecting more discrete data, but the structure, semantics, and adoption of data elements vary across vendors and sites. EHR systems also differ in ability to incorporate pediatric concepts such as variable dosing and growth percentiles. This variability complicates quality measurement, as do limitations in established measure formats, such as the Quality Data Model, to e-measurement. Addressing these challenges will require investment by vendors, researchers, and clinicians alike in developing better pediatric content for standard terminologies and data models, encouraging wider adoption of technical standards that support reliable quality measurement, better harmonizing data collection with clinical work flow in EHRs, and better understanding the behavior and potential of e-measures.

Electronic quality measurement predicts outcomes in community acquired pneumonia.

Using electronic medical data, we calculated emergency department physician performance and subsequent outcomes on a measure used in the Centers for Medicare & Medicaid Services' Physician Quality Reporting System. The measure assesses use of guideline recommended antibiotics for community acquired pneumonia. Physicians met measure criteria in 70.6% of cases at one institution. Among patients admitted to the hospital, measure compliant cases had a significantly shorter length of stay, lower costs and lower intensive care utilization than measure failures. For measure failures admitted to the hospital, antibiotic treatment was adjusted to be measure compliant within 48 hours in 57.1% of cases. Use of electronic performance measurement for antibiotic treatment of community acquired pneumonia identified variations in physician performance. Measure compliance correlated with significantly improved patient outcomes and lower costs.

Nutrient compensatory foraging in a free-living social insect.

The geometric framework model predicts that animal foraging decisions are influenced by their dietary history, with animals targeting a combination of essential nutrients through compensatory foraging. We provide experimental confirmation of nutrient-specific compensatory foraging in a natural, free-living population of social insects by supplementing their diet with sources of protein- or carbohydrate-rich food. Colonies of the ant Iridomyrmex suchieri were provided with feeders containing food rich in either carbohydrate or protein for 6 days, and were then provided with a feeder containing the same or different diet. The patterns of recruitment were consistent with the geometric framework: while feeders with a carbohydrate diet typically attracted more workers than did feeders with protein diet, the difference in recruitment between the two nutrients was smaller if the colonies had had prior access to carbohydrate than protein. Further, fewer ants visited feeders if the colony had had prior access to protein than to carbohydrates, suggesting that the larvae play a role in worker foraging behaviour.

Use of physician education and computer alert to improve targeted use of gastroprotection among NSAID users.

BACKGROUND: Gastrointestinal (GI) hemorrhage accounts for 200-400,000 admissions in the United States annually. Around 50% of patients with bleeding ulcer have used aspirin and/or nonsteroidal anti-inflammatory drugs (NSAIDs). Misoprostol and proton pump inhibitors (PPIs) may reduce NSAID-related upper GI tract complications in high-risk patients, but their targeted use may be suboptimal. AIM: To determine the impact of physician education, a computer alert, or both on the targeted use of GI prophylaxis in high-risk patients discharged from hospital. METHODS: To target high-risk patients, we studied cardiology telemetry and coronary care unit (CCU) services. Every 4th wk, 8 different residents managed these patients. Over a 32-wk period, residents were assigned to one of the four 8-wk groups sequentially: Group I: control; Group II: physician education, consisting of a 10-min tutorial on risk factors for NSAID-related GI complications; Group III: computer alert; and Group IV: combination of tutorial and computer alert. We reviewed all patients admitted to these cardiology services during the study period. Exclusion criteria included discharge on no ulcerogenic medications, incomplete discharge data, and inpatient death. Patients readmitted during the study period were not re-counted. Medical records were reviewed for discharge medications, past medical history, demographics, admission and discharge diagnoses, hospital days, and the Charlson comorbidity index. Other indications for acid suppression were documented. A chi(2) test was used to determine independence among all four groups. RESULTS: We enrolled 721 patients, of whom 120 (16.7%) were excluded. The remaining 601 were divided by physician intervention group and risk for NSAID-related GI complications. In total, 270 of 601 (45%) patients were discharged home on appropriate gastroprotection. The overall use of gastroprotection increased from 43 to 61% with the combination of an electronic alert and physician education (P < 0.001); among PPI-naïve patients, the rate increased from 26% to 55% (P < 0.0001). When stratified by known risk factors for GI complications of NSAIDs, the odds of receiving a gastroprotective prescription among PPI-naïve patients was 1.6 with education alone, 1.8 with electronic alert alone, and 2.9 with the combination (P < 0.0001). CONCLUSION: The combination of a computer alert and brief physician education led to an increase in the use of gastroprotection among NSAID users at the time of discharge from hospital. This effect was most evident among high-risk, PPI-naïve patients. Combining physician education and a computer alert appears to have an additive effect.

Clinical decision support to avoid adverse drug events with anticoagulants.

Unintentional duplication or timing of anticoagulant orders leaves patients at high risk for serious adverse events. Alerts at the point of electronic order entry have the potential to mitigate this risk; however poor specificity with a high frequency of interruptions may decrease the ability of a clinician to recognize specific hazards. This poster will depict custom clinical decision support designed to prevent specific misadventures with this high risk class of medications.