A new approach for measuring quality of care for women with hypertension.

BACKGROUND: Guidelines for care of hypertensive patients have proliferated recently, yet quality assessment remains difficult in the absence of well-defined measurement systems. Existing systems have not always linked process measures to blood pressure outcomes. METHODS: A quality measurement system was developed and tested on hypertensive women in a West Coast health plan. An expert panel selected clinically detailed, evidence-explicit indicators using a modified Delphi method. Thirteen indicators (1 screening, 5 diagnostic, 5 treatment, and 2 follow-up indicators) were selected by this process. Trained nurses used a laptop-based tool to abstract data from medical records for the most recent 2 years of care. RESULTS: Of 15 004 eligible patients with hypertensive and other chronic disease codes, 613 patients were sampled, all eligible for the screening indicator. Of these, 234 women with an average blood pressure of 140/90 mm Hg or more, or a documented diagnosis of hypertension, were studied for the remaining indicators. The average woman received 64% of the recommended care. Most patients did not receive adequate initial history, physical examination, or laboratory tests. Only 37% of hypertensive women with persistent elevations to more than 160/90 mm Hg had changes in therapy or lifestyle recommended. The average adherence proportion to all indicators was lower in patients with uncontrolled blood pressure (>140/90 mm Hg) than in those with controlled blood pressure (54% vs 73%; P<.001). CONCLUSIONS: Quality of hypertensive care falls short of indicators based on randomized controlled trials and national guidelines. Poor performance in essential care processes is associated with poor blood pressure control.

The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior.

CONTEXT: Despite growing concern over the escalating antimicrobial resistance problem, physicians continue to inappropriately prescribe. It has been suggested that a major determinant of pediatrician antimicrobial prescribing behavior is the parental expectation that a prescription will be provided. OBJECTIVES: To explore the extent to which parental previsit expectations and physician perceptions of those expectations are associated with inappropriate antimicrobial prescribing; and to explore the relationship between fulfillment of expectations and parental visit-specific satisfaction. DESIGN: Previsit and postvisit survey of parents and postvisit survey of physicians. SETTING: Two private pediatric practices, one community based and one university based. PARTICIPANTS: Ten physicians (response rate = 77%), and a consecutive sample of 306 eligible parents (response rate = 86%) who were attending sick visits for their children between October 1996 and March 1997. Parents were screened for eligibility in the waiting rooms of the two practices and were invited to participate if they spoke and read English and their child was 2 to 10 years old, had a presenting complaint of ear pain, throat pain, cough, or congestion, was off antimicrobial therapy for the past 2 weeks, and was seeing one of the participating physicians. MAIN OUTCOME MEASURES: Antimicrobial prescribing decision, probability of assigning a bacterial diagnosis, and parental visit-specific satisfaction. RESULTS: Based on multivariate analysis, physicians' perceptions of parental expectations for antimicrobials was the only significant predictor of prescribing antimicrobials for conditions of presumed viral etiology; when physicians thought a parent wanted an antimicrobial, they prescribed them 62% of the time versus 7% of the time when they did not think the parent wanted antimicrobials. However, physician antimicrobial prescribing behavior was not associated with actual parental expectations for receiving antimicrobials. In addition, when physicians thought the parent wanted an antimicrobial, they were also significantly more likely to give a bacterial diagnosis (70% of the time versus 31% of the time). Failure to meet parental expectations regarding communication events during the visit was the only significant predictor of parental satisfaction. Failure to provide expected antimicrobials did not affect satisfaction. CONCLUSIONS: The antibiotic resistance epidemic should lead to immediate replication of this study in a larger more generalizable population. If inaccurate physician perceptions of parent desires for antimicrobials for viral infections are confirmed, then an intervention to change the way physicians acquire this set of perceptions should be undertaken.

Assessing the quality of care for children. Prospects under health reform.

The failure to pass federal health reform legislation this year does not mean that the health care crisis has been solved. As we look forward to predictably more incremental efforts to reduce costs, increase access, and improve quality, key issues from the most recent round of deliberations will undoubtedly reemerge. In the last session of Congress, private and public policymakers sent a clear signal that the era of accountability had arrived. In the health reform bills that Congress considered last year, a range of "measurement" strategies were put forth as essential elements for achieving accountability in a reformed health care system. For example, routine monitoring of the quality of care delivered by health plans and health providers was viewed as necessary to balance the impact of policies to control the cost of health care. Each of the major bills that were introduced this past year--Gephardt/Mitchell (S 1757/HR 3600), Cooper/Grandy (HR 3222), Breaux/Durenburger (S 1579), Nickles (S 1743), Chafee/Thomas (S 1770/HR 3704), and Wellstone/McDermott (S 491/HR 1200)--and the mark-up bills that have emerged from Senate and House committees have placed considerable emphasis on evaluating changes in access to health care and quality of care. Although the bills addressed issues related to financing, coverage, and the structure of the delivery system quite differently, they demonstrated much more consensus with regard to quality monitoring.

Screening for chlamydia in adolescents and young women.

OBJECTIVE: To measure the proportion of sexually active females aged 15 to 25 years who received a screening test for Chlamydia trachomatis infection during the previous year. DESIGN: Administrative data were used to identify females in the target age range who were likely to be sexually active. Medical record data were reviewed for a sample to determine whether the administrative algorithm was acceptable. Laboratory claims data and medical record data were used to identify females who had had a screening test for chlamydia. SETTING: Four geographically dispersed US managed health care plans. PATIENTS: We studied 19,214 sexually active females aged 15 to 25 years continuously enrolled for calendar year 1997 in 1 of 4 major US health plans who had a visit to their health care provider during that year. Sexual activity was determined using an algorithm designed for use with administrative data. MAIN OUTCOME MEASURE: Rates of chlamydia screening among sexually active females aged 15 to 25 years. RESULTS: The proportion of females aged 15 to 25 years identified as sexually active by the administrative data algorithm in the 4 health plans was similar (43%-54%; P =.79). However, substantial variation was found in rates of chlamydia screening for eligible females in these 4 health plans (2%-42%; P<. 001). Plans varied considerably in the types of visits (eg, sexually transmitted disease screening or pregnancy) that determined eligibility for the measure. CONCLUSIONS: A measure of health plan performance on screening for chlamydia in young females using administrative data is feasible and provides useful results despite some flaws in estimation. There is room for improvement in rates of chlamydia screening in sexually active females aged 15 to 25 years.

Development of a quality of care measurement system for children and adolescents. Methodological considerations and comparisons with a system for adult women.

OBJECTIVES: To describe the development of a pediatric quality of care measurement system designed to cover multiple clinical topics that could be applied to enrollees in managed care organizations and to compare the development of this system with the concurrent development of a similar system for adult women. DESIGN: Indicators were developed for 21 pediatric (ages 0-18 years) clinical topics and 20 adult (ages 17-50 years) women's clinical topics. Indicators were classified by the strength of evidence supporting them. A modified Delphi method was used to obtain validity and feasibility ratings from a pediatric expert panel and an adult women's expert panel. Indicators were categorized by type of care (preventive, acute, or chronic), function (screening, diagnosis, treatment, or follow up), and modality (history, physical examination, laboratory/radiology study, medication, other intervention, or other contact). RESULTS: Of 557 pediatric and 391 adult women's proposed indicators, 453 (81%) and 340 (87%), respectively, were retained by the 2 expert panels. A lower percentage of final pediatric indicators than adult indicators were based on randomized, controlled trials and other rigorous studies (18% vs 40%, P < .001). The expert panels were more likely to retain indicators based on rigorous studies (93% retained) than on descriptive studies and expert opinion (81% retained, P < .001). A higher percentage of pediatric indicators than women's indicators were for preventive care (30% vs 11%, P < .001) and a lower percentage were for acute care (36% vs 49%, P < .001) or chronic care (34% vs 41%, P = .06). CONCLUSIONS: This study contributes to the field of pediatric quality of care assessment by providing many more indicators than have been available previously and by documenting the strength of evidence supporting these indicators. Formal consensus methods are essential for the development of pediatric quality measures because the evidence base for pediatric care is more limited than for adult care.

Parent expectations for antibiotics, physician-parent communication, and satisfaction.

OBJECTIVES: To explore how parents communicate their preferences for antibiotics to their child's physician and to examine whether physicians can communicate why antibiotics are not being prescribed in a way that maintains satisfaction with the visit. DESIGN: Previsit survey of parents, audiotaping of the study encounters, and a postvisit survey of parents and physicians. SETTING: Two private pediatric practices. PARTICIPANTS: Ten physicians (response rate = 77%) and a consecutive sample of 295 eligible parents (response rate = 86%) who attended acute care visits for their children between October 1996 and March 1997. MAIN OUTCOME MEASURES: Physician-perceived pressure to prescribe antibiotics and parental visit-specific satisfaction. RESULTS: Fifty percent of parents expressed a previsit expectation for antibiotics. Among these parents, only 1% made a direct verbal request for them. Even when no direct requests for antibiotics were made, physicians still perceived an expectation for antibiotics 34% of the time. Among parents who did not receive expected antibiotics, those offered a contingency plan from the physician (i.e., the possibility of receiving antibiotics in the future if their child did not get better) had a higher mean satisfaction score than parents not receiving a contingency plan (76 vs. 58.9; P<.05). CONCLUSION: Physicians should consider providing a contingency plan to parents who expect antibiotics for their children when there is no clinical indication. Further study is needed to determine how parents indirectly communicate their desire for antibiotics and what additional communication techniques physicians can use to resist the overprescribing of antibiotics.

Six challenges in measuring the quality of health care.

Quality monitoring is becoming an accepted method for purchasers, patients, and providers to evaluate the value of health care expenditures. Important advances in the science of quality measurement have occurred over the past decade, but many challenges remain to be addressed so that quality monitoring may realize its potential as a counterforce to the demands of cost containment. This paper describes six such challenges (balancing perspectives, defining accountability, establishing criteria, identifying reporting requirements, minimizing conflict between financial and quality goals, and developing information systems) and proposes some ways in which the public and private sectors might collaborate to respond effectively.

Keeping quality on the policy agenda.

Quality of care in the United States and elsewhere consistently fails to meet established standards. These failures subject patients to premature death and needless suffering. Yet, unlike the experience with other threats to life (tire failures or airplane rudders), public and private policymakers have been unable to maintain sufficient interest in identifying and solving problems with quality to change the way in which care is delivered. We discuss why it is hard to keep quality on the policy agenda and suggest short-term steps that are necessary if quality is to improve here and in the rest of the world.

Developing a clinical performance measure.

BACKGROUND: Clinical performance measurement is an increasingly important way for public and private purchasers alike to compare the value of health services provided by competing health delivery systems. The widespread use of performance measures has increased the demand for development of new measures that cover previously unevaluated aspects of care. METHODS: Four steps required to develop a clinical performance measure that is suitable for making comparisons among health delivery systems are discussed: (1) choosing clinical areas to measure, (2) selecting performance indicators within each area, (3) designing specifications for consistent implementation of a measure, and (4) evaluating the scientific strength of a measure. RESULTS: The application of these steps to developing measures of quality for hypertension is provided, with an emphasis on a measure of adequacy of control of blood pressure. CONCLUSIONS: Developing useful clinical performance measures requires careful attention to methodologic issues. Following the steps outlined in this paper should enhance the quality of future measurement development.

Physicians' characteristics influence patients' adherence to medical treatment: results from the Medical Outcomes Study.

The influence of physicians' attributes and practice style on patients' adherence to treatment was examined in a 2-year longitudinal study of 186 physicians and their diabetes, hypertension, and heart disease patients. A physician-level analysis was conducted, controlling for baseline patient adherence rates and for patient characteristics predictive of adherence in previous analyses. General adherence and adherence to medication, exercise, and diet recommendations were examined. Baseline adherence rates were associated with adherence rates 2 years later. Other predictors were physician job satisfaction (general adherence), number of patients seen per week (medication), scheduling a follow-up appointment (medication), tendency to answer patients' questions (exercise), number of tests ordered (diet), seriousness of illness (diet), physician specialty (medication, diet), and patient health distress (medication, exercise).

Can health care quality indicators be transferred between countries?

OBJECTIVE: To evaluate the transferability of primary care quality indicators by comparing indicators for common clinical problems developed using the same method in the UK and the USA. METHOD: Quality indicators developed in the USA for a range of common conditions using the RAND-UCLA appropriateness method were applied to 19 common primary care conditions in the UK. The US indicators for the selected conditions were used as a starting point, but the literature reviews were updated and panels of UK primary care practitioners were convened to develop quality indicators applicable to British general practice. RESULTS: Of 174 indicators covering 18 conditions in the US set for which a direct comparison could be made, 98 (56.3%) had indicators in the UK set which were exactly or nearly equivalent. Some of the differences may have related to differences in the process of developing the indicators, but many appeared to relate to differences in clinical practice or norms of professional behaviour in the two countries. There was a small but non-significant relationship between the strength of evidence for an indicator and the probability of it appearing in both sets of indicators. CONCLUSION: There are considerable benefits in using work from other settings in developing measures of quality of care. However, indicators cannot simply be transferred directly between countries without an intermediate process to allow for variation in professional culture or clinical practice.

Pew Memorial Trust policy synthesis: 5. State coverage for organ transplantation: a framework for decision making.

Transplantation of hearts and livers for both adults and children is increasingly viewed as therapeutic and lifesaving, but access to these procedures is impeded by their high cost as well as by a limited supply of organs. In the absence of comprehensive federal coverage, pressure is being brought to bear on states to provide broader access to these procedures. This synthesis provides a framework for the consideration of coverage decisions at the state level. While there are no "right" answers about whether a state should support such coverage, the analytic tools of cost analysis, demand estimation, and assessment of capacity described in this synthesis can better inform the decision-making process.

Overview of issues in improving quality of care for children.

OBJECTIVE: To provide a framework for a research agenda-setting conference on quality of care for children. DATA SOURCES/STUDY SETTING: Literature review. CONCLUSIONS: Research on quality of care for children has lagged behind its counterpart for adults. Defining key issues and questions in seven topic areas-the health of children; the efficacy and effectiveness of health services for children; assessing quality of care; improving quality of care within health services delivery systems; assessing and improving quality at the community level; getting financial incentives right; and disseminating information about the results of research investigations-will facilitate the development of an effective research strategy. Ultimately, enhanced information in these areas will lead to improvements in the processes and outcomes of care for children.

Assessing the quality of healthcare provided to children.

OBJECTIVE: To present a conceptual framework for evaluating quality of care for children and adolescents, summarize the key issues related to developing measures to assess pediatric quality of care, examine some existing measures, and present evidence about their current level of performance. PRINCIPAL FINDINGS: Assessing the quality of care for children poses many challenges not encountered when making these measurements in the adult population. Children and adolescents (from this point forward referred to collectively as children unless differentiation is necessary) differ from adults in two clinically important ways (Jameson and Wehr 1993): (1) their normal developmental trajectory is characterized by change, and (2) they have differential morbidity. These factors contribute to the limitations encountered when developing measures to assess the quality of care for children. The movement of a child through the various stages of development makes it difficult to establish what constitutes a "normal" outcome and by extension what constitutes a poor outcome. Additionally, salient developmental outcomes that result from poor quality of care may not be observed for several years. This implies that poor outcomes may be observed when the child is receiving care from a delivery system other than the one that provided the low-quality care. Attributing the suboptimal outcome to the new delivery system would be inappropriate. Differential morbidity refers to the fact that the type, prevalence, and severity of illness experienced by children is measurably different from that observed in adults. Most children experience numerous self-limited illness of mild severity. A minority of children suffer from markedly more severe diseases. Thus, condition-specific measures in children are problematic to implement for routine assessments because of the extremely low incidence and prevalence of most severe pediatric diseases (Halfon 1996). However, children with these conditions are potentially the segment of the pediatric population that can be most affected by variations in the quality of care. Improving the care provided to these children is likely to have the largest impact on quality of life and longevity. The low prevalence of most severe pediatric diseases also makes it difficult to evaluate the effectiveness of new treatment modalities; multi-center trials or long enrollment periods are usually required to obtain a large enough patient sample to conduct the necessary randomized controlled trials or cohort studies. Another challenge encountered when measuring quality of care for children is that, in most cases, they depend on adults to both obtain care and to report on the outcomes of that care. Parents and their children may have different perceptions of what defines health or have different levels of satisfaction with the care they receive. Children, particularly those with special needs, also depend on a broad range of services including the medical system, community intervention programs, social programs, and school-based services. Dependency on these various services adds to the difficulty of measuring and appropriately attributing health outcomes observed in children to a particular service delivery entity. Adolescents also depend on adults for access to some of their care; however, they have special needs related to confidentiality and parent-child information sharing. Adolescents commonly seek care at facilities, such as school-based clinics, that allow them to obtain confidential care. These facilities usually provide out-of-health plan care for these children, which raises special issues related to information availability for quality assessments and for assessing utilization patterns in this population. If the source of poor health outcomes is not known, quality improvement is not possible. The many challenges faced when constructing pediatric (this term will be used to refer to both children and adolescents) quality of care measures have resulted in few of these instruments being developed specifically for children. Most of the measures developed to date have either a very limited pediatric component or still require the process or outcome validation step. Although several practice guidelines and indicators of quality have been constructed, a conceptual framework to guide the development of such tools for quality assessment in the pediatric population is lacking. CONCLUSIONS: Pediatric health services researchers and the organizations that fund this work need to focus on developing a set of quality assessment tools that will address several challenging issues. Working within the context of the conceptual framework presented, we draw several conclusions related to issues that should be considered in developing quality of care measures for children.

Choosing quality of care measures based on the expected impact of improved care on health.

Consumers, payers, and policymakers are demanding to know more about the quality of the services they are purchasing or might purchase. The information provided, however, is often driven by data availability rather than by epidemiologic and clinical considerations. In this article, we present an approach for selecting topics for measuring technical quality of care, based on the expected impact on health of improved quality. This approach employs data or estimates on disease burden, efficacy of available treatments, and the current quality of care being provided. We use this model to select measures that could be used to measure the quality of care in health plans, but the proposed framework could also be used to select quality of care measures for other purposes or in other contexts (for example, to select measures for hospitals). Given the limited resources available for quality assessment and the policy consequences of better information on provider quality, priorities for assessment efforts should focus on those areas where better quality translates into improved health.

Coronary angiography and revascularization: defining procedural indications through formal group processes. The Canadian Revascularization Panel, the Canadian Coronary Angiography Panel.

OBJECTIVES: To summarize the process and extent of interphysician agreement within two panels convened to derive indications for the appropriate use of coronary angiography and for coronary revascularization procedures. PARTICIPANTS: Two panels, each with nine practitioners. METHODS: Panelists rated the appropriateness of intervention for a comprehensive set of indications for each procedure. Indications were brief profiles created by combining and permuting clinical characteristics pertinent to case selection for intervention. Ratings were first made at home, with a second round at the panel meeting following open discussion. Final rankings of indications as 'appropriate', 'uncertain' or 'inappropriate' were based on the pattern of panelists' responses on a nine-point scale, including the median rating and extent of agreement among panelists. Agreement was defined as at least seven panelists' ratings within the three-point region containing the median rating. Panelists were later mailed a much-reduced list of indications for which there was agreement on appropriateness. These were re-rated on a necessity scale. A procedure was rated 'necessary' only if a physician was ethically obligated to recommend it as the preferred treatment option. RESULTS: For appropriateness of angiography, agreement occurred in 38.2% of indications in round 1 and 64.4% in round 2 (P < 0.0001). For coronary artery bypass graft (CABG) versus medical therapy, the corresponding increase was from 43.5 to 54.0% (P < 0.0001). Agreement on necessity of angiography occurred for 44.3% of scenarios. For indications where CABG alone was appropriate, agreement on necessity was 56%. However, for indications where percutaneous transluminal coronary angioplasty (PTCA) could be regarded as the first-line intervention, agreement on necessity was only 5%. CONCLUSIONS: A two-step panel process permitted considerable convergence of panelists' ratings, highlighting the importance of formal panel methods in setting utilization management criteria. However, the extent of continuing disagreement on ratings underscores the need to avoid a forced consensus; instead, divergent opinions should be taken as indicative of uncertainty about the appropriateness of intervention. Interpanelist agreement on necessity ratings was modest, but may help in setting benchmarks to assess possible underprovision of invasive cardiac services in Canada.

An experimental evaluation of residential and nonresidential treatment for dually diagnosed homeless adults.

Homeless adults with both a serious mental illness and substance dependence (N = 276) were randomly assigned to: (1) a social model residential program providing integrated mental health and substance abuse treatment; (2) a community-based nonresidential program using the same social model approach; or (3) a control group receiving no intervention but free to access other community services. Interventions were designed to provide 3 months of intensive treatment, followed by 3 months of nonresidential maintenance. Subjects completed baseline interviews prior to randomization and reinterviews 3, 6, and 9 months later. Results showed that, while substance use, mental health, and housing outcomes improved from baseline, subjects assigned to treatment conditions differed little from control subjects. Examination of the relationship between length of treatment exposure and outcomes suggested that residential treatment had positive effects on outcomes at 3 months, but that these effects were eroded by 6 months.

Quality-of-care research in mental health: responding to the challenge.

Quality-of-care research in mental health is in the developmental stages, which affords an opportunity to take an integrative approach, building on principles from efficacy, effectiveness, quality assessment, and quality assurance research. We propose an analytic strategy for designing research on the quality of mental health services using an adaptation of the structure, process, and outcome classification scheme. As a concrete illustration of our approach, we discuss research on a particular target population-patients with chronic schizophrenia. Future research should focus on developing models of treatment, establishing criteria and standards for outcomes and processes, and gathering data on community practices.