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Appendixes

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A Supporting Tables 363

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364 APPENDIX A TABLE A.1 Literature Review on Impact of Quality Improvementa Reference Data Source, Sample Size, and Time Frame Barr J, et al. "A Randomized Intervention 1,908 women aged 5075 enrolled in a to Improve Ongoing Participation in northeast HMO who had a mammogram Mammography." The American Journal of with no subsequent visits for next 1821 Managed Care. 2001. months 19941996 Berner, et al. "Do Local Opinion Leaders Unit of analysis: acute care hospitals in Augment Hospital Quality Improvement Alabama with more than 100 patients with Efforts?" Medical Care. 2003. unstable angina (UA) as the primary or secondary diagnosis; 22 hospitals were willing to participate Baseline: 19971998 Follow-up: 19992000 Bradley E, et al. "A Qualitative Study of Interviews with hospital staff Increasing Beta-blocker Use After 45 respondents of various disciplines, staff Myocardial Infarction." JAMA. 2001. levels, and hospitals October 1996September 1999

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APPENDIX A 365 Study Purpose, Methodological Approach, and Outcome Measures Findings Effectiveness of various interventions for breast Telephone with option to schedule cancer screening guidelines appointment was the most effective Randomized control trial with three groups: intervention (relative risk = 1.39) (1) received mailings, (2) telephone call with option Researchers suspect that its success to schedule appointment, and (3) regular publicity was due to convenience of scheduling campaign and personal aspect The number of mammograms received after the Mailings were not found to be intervention period and within 2 years of the initial useful mammogram Limitations: this group of women may have been hard to motivate or had mammograms outside of the health plan Assess whether or not physician opinion leaders Use of OLs results in small, (OL) helped implementation of CMS's HCQIP inconsistent effects Three-armed randomized control trial (no Use of OLs resulted in significant intervention, HCQIP-CMS's quality improvement improvement only with the plan only, and OL-HCQIP plus addition of intervention of antiplatelet physician OL); HCQIP and OL administered medication within 24 hours change through education of guidelines, Many caveats and reasons why the presentation of hospital-specific data, and clinical OLs did not show more influence reminders were presented: Measured adherence to five of AHRQ's UA Study was limited guidelines (electrocardiography within 20 minutes, to chart review data antiplatelet medication at discharge, antiplatelet A physician leader may have medication within 24 hours, use of heparin, and stepped up in no-intervention and use of beta-blockers) HCQIP groups Outcome measure: percent change in compliance Hospital type may lead to bias with guidelines before and after the intervention Hospital may concurrently for all five interventions participate in other QI projects The quality-of-care indicators chosen Identify factors that may improve beta-blocker Importance of physician leadership use (i.e., hospital size, geographic region, and Similar initiatives were used to changes in beta-blocker use rates). Develop method enhance use among hospitals with for classifying it various MI volumes Qualitative study based on interviews with No factors were found to directly hospital staff, data analyzed via qualitative coding correlate to higher performance techniques Methods to improve care, coded qualitative data continues

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366 APPENDIX A TABLE A.1 Continued Reference Data Source, Sample Size, and Time Frame Bradley E, et al. "From Adversary to Primary data in the form of interviews Partner: Have Quality Improvement 105 randomly selected hospital quality Organizations Made the Transition?" management directors Health Services Research. 2005. 2002 Burwen D. "National and State Trends in Medicare patients with AMI without Quality of Care for Acute Myocardial contraindications per state guidelines Infarction Between 19941995 and 1998 19941995: 234,754 patients 1999." Archives of Internal Medicine. 2003. 19981999: 35,713 patients Baseline: 19941995 Follow-up: 19981999

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APPENDIX A 367 Study Purpose, Methodological Approach, and Outcome Measures Findings Describe impact of QIOs on AMI quality of care Interviews generally found the Created survey instrument asking about the QIOs' quality improvement efforts to following: amount of contact between hospital be useful (more than 60% of quality departments and QIO, number of AMI- interviewees rated interventions as related QIO-supported or -led interventions, and helpful or very helpful) whether QIO interventions had affected AMI Many thought the impact of QIOs quality was low in that quality of care would not be different in the absence of QIO efforts (only 25% thought care would be worse without QIOs) QIOs are seen more as collaborative partners than as adversaries, as they were stigmatized in the past Many believed that QIOs could be more effective at attaining more support from physicians and senior management of hospitals Determine improvement in quality of care for Quality improved overall between AMI the two periods Analyzed data from CCP. Quality indicators In practice, some types of quality studied: early administration of aspirin, aspirin indicators are more readily improved prescribed at discharge, early administration of than others (i.e., reperfusion therapy beta-blockers, beta-blocker prescribed at discharge, and smoking cessation counseling) ACE prescribed at discharge, and smoking due to challenges in implementation cessation counseling. Used r2 and chi-squared (e.g., improvements in an indicator analyses cannot always be accomplished Probability of patients studied for whom quality through behavioral changes initiated indicators were documented by a single physician) Improvement was not due to geographic or regional differences or patient characteristics Diffusion of evidence-based therapies into practice is not optimal continues

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368 APPENDIX A TABLE A.1 Continued Reference Data Source, Sample Size, and Time Frame Centor R. "Diffusion of Troponin Testing Medicare patients with suspected cardiac in Unstable Angina Patients: Adoption Prior ischemia in 22 volunteer Alabama hospitals to Guideline Release." Journal of Clinical Baseline: 1,272 patients Epidemiology. 2003. Follow-up: 1,302 patients Baseline: March 1997February 1998 Follow-up: January 1999December 1999 Chu L, et al. "Improving the Quality of Medical record abstraction Care for Patients with Pneumonia in Very 36 hospitals, mostly rural community Small Hospitals." Archives of Internal hospitals, in Oklahoma Medicine. 2003. Cycle 1: April 1995June 1995 Cycle 2: November 1996March 1997

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APPENDIX A 369 Study Purpose, Methodological Approach, and Outcome Measures Findings Determine status of quality indicators before Guidelines released in 2000 implementation of guidelines reflected already accepted practice Examined changes in troponin use before and not dissemination of new implementation of ACC/AHA presented their knowledge clinical guidelines in 2000; quality measures: Troponin tended to be ordered for receipt of aspirin within 24 hours of admission, higher-risk patients, which may have receipt of aspirin at discharge, receipt of beta- been an indicator for more aggressive blocker during hospitalization, receipt of heparin clinical management during hospitalization for patients at moderate to high risk of AMI or death, performance of EKG within 20 min after arrival, and admission to hospital bed with cardiac monitoring; logistic regression analyses were used to determine appropriateness of troponin use Troponin ordered, troponin positive when ordered, previously developed quality measures for unstable angina, use of ACE inhibitors, and procedure rates Demonstrate that QIO can be effective external Intervention versus control groups change agent driving improvement of pneumonia (Cycle 1): treatment guidelines Intervention group found to be Hospitals split into two groups. Two intervention more likely to show statistical cycles. Interventions consisted of QIO providing improvement in process measures hospitals feedback via face-to-face meetings with than control group medical staff and individual hospital profiles; No statistically significant hospitals had to provide QIO with quality differences in outcomes measures improvement plans. (unadjusted mortality, p = 0.39; Cycle 1: first group of hospitals received length of stay, p = 0.47) intervention, results were compared with those for During Cycle 1, no significant a control (Group 2) differences from results in control Cycle 2: second group (control group in Cycle 1) group found, maintaining that received intervention differences in process measures not Chi-squared test for proportions, two-tailed due to external confounders related t-tests, ANOVA, regression coefficients; p < 0.05 to the condition Intervention in control group (Cycle 2): Statistically significant improvement made in four of five measures after intervention Results may not be duplicated in large hospitals CMS policy did not allow randomization of hospitals continues

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370 APPENDIX A TABLE A.1 Continued Reference Data Source, Sample Size, and Time Frame Coleman E, et al. "Preparing Patients and Colorado integrated delivery system Caregivers to Participate in Care Delivered Patients age 65+ with at least one of nine Across Settings: The Care Transitions conditions Intervention." Journal of the American Control: 1,235 patients Geriatrics Society. 2004. Intervention: 158 patients July 2001September 2002 Cortes L. "The Impact of Quality MDS reports of restraint use Improvement Programs in Long Term Population statewide in LTC facilities, Care." Texas Department of Human 69,59070,814 patients Services. 2004. 20022003 Daniel D, et al. "A State-Level Application 47 teams (representing public health of the Chronic Illness Breakthrough Series: delivery system, community care, large Results from Two Collaboratives on clinics, hospitals systems, and private Diabetes in Washington State." Joint practices) Commission Journal on Quality and Safety. Collaborative I: October 1999November 2004. 2000 Collaborative II: February 2001March 2002

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APPENDIX A 371 Study Purpose, Methodological Approach, and Outcome Measures Findings Determine if transitions between health care Use of transition coach and settings can be enhanced by more active roles of personal health record is promising patients and caregivers to reduce rehospitalization rates Intervention: designate a transition coach to postdischarge work with patient and caregiver via visits and OR at 30 days: 0.52 phone calls; coaches also teach patients about OR at 90 days: 0.43 personal health records; patient records are tracked OR at 180 days: 0.57 for rehospitalizations 6 months after discharge Actual cost of transition coach over Postdischarge hospital use rates at 30, 90, and 8 months: $47,133 180 days (rehospitalization and emergency room) Determine the extent to which the Texas Dept. of Facilities receiving both DHS and Human Services (DHS) program and QIO program QIO assistance showed a 55.1% each contributed to reduced use of restraints reduction in restraint use among LTC residents Facilities receiving only DHS Attributable fraction: 139 facilities enrolled in assistance showed a 35.3% reduction QIO TA program, all 1,050 facilities in state in restraint use received TA from DHS. The difference in observed Estimated excess fraction of improvement between the QIO subgroup and the improvement attributable to the QIO remaining facilities is the fraction attributable to program: 19.8% the QIO intervention Statewide, 90% of improvement is Change in restraint prevalence among facilities attributable to the DHS program; receiving QIO TA and those receiving DHS TA 10% is attributable to QIO because only QIO served only 13% of facilities statewide Conclusion: state and QIO programs are not redundant and the programs are complementary Assess effect of collaboratives at state level; test State-level collaboratives effective what efforts may be associated with quality Provided more technical support improvement Increased participation Teams independently collected data on process Higher absolute improvement and outcomes of clinical indicators of diabetes associated with teams with lower care; over 13-month test period, teams congregated baseline levels at four conferences, sharing lessons learned Process measures had greater Indicators of success: absolute improvement absolute improvement, perhaps due (from baseline to remeasurement) and to behavioral changes, which are improvement in remeasurement values necessary by both providers and patients continues

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424 APPENDIX A TABLE A.6 Continued Dimension of Task Setting Performance Performance Measures 1d1 Physician Clinical performance Statewide support for Physician practice measure results Voluntary Reporting Programg Statewide quality improvement by working with public health, provider groups, and others to support prevention and disease-based care processes Assistance to Medicare Advantage plans Assistance to End-Stage Renal Disease Networks Medicare Management Demonstration Project Clinical performance Export data measurement and reportingm Process improvementm Care management process to meet individual's health needs through the practice site systems survey Systems improvementm Production and use of information from electronic systems Satisfaction and knowledge/perceptionb

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APPENDIX A 425 Statewide Improvement Identified Participant Improvement Scoring Weights Scoring Weights Targets (17% of totall) Targets (83% of totall) Improvement, as 0.1 evaluated by project 8.3% of total score officer Report on at least one 0.2 DOQ measure: 0.2 Preexisting electronic systems (10% of sites did not have them; 20% of sites did) Adoption of care 0.2 management 0.2 process: Electronic clinical information systems (30% of sites did not have them; 75% sites did) Produce and use 0.2 electronic clinical 17% of total score information for 75% of sites without preexisting electronic clinical information systemsb At least 80% score on 0.1 satisfaction and 8.3% of total score knowledge/ perception surveys continues

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426 APPENDIX A TABLE A.6 Continued Dimension of Task Setting Performance Performance Measures 1d2 Underserved Clinical performance Claims-based clinical measuresg populations measure results Clinical performance Task 1d1 activities measurement and reporting Systems improvement Promotion of culturally and linguistically appropriate service (CLAS) standards Process improvement Cultural competency education Satisfaction and knowledge/perceptionb

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APPENDIX A 427 Statewide Improvement Identified Participant Improvement Scoring Weights Scoring Weights Targets (35% of totaln) Targets (65% of totaln) 4% absolute 0.25 improvement for all 25% of total score underserved populations for diabetes, mammography, and adult immunization measures Promote improvement Select underserved in rates for populations that at applicable least equal the underserved underserved populations population in the state to complete Task 1d1 activities Use Office of 0.25 Minority Health 25% of total score Theme 3 tool with 80% completion rate to promote adoption of CLAS standardsb 80% primary care 0.4 physicians complete 40% of total score both Themes 1 and 2 of Office of Minority Health toolb At least 80% score on 0.1 satisfaction and 10% of total score knowledge/ perception surveys continues

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428 APPENDIX A TABLE A.6 Continued Dimension of Task Setting Performance Performance Measures 1d3 Part D Clinical performance prescription measure results drug Benefit NOTE: RFR = Reduction in failure rate; IPG = identified participant group; QIO = Quality Improvement Organization; OASIS = Outcome and Assessment Information Set; CMS = Cen- ters for Medicare and Medicaid Services; CPOE = Computerized Provider Order Entry; CAHPS = Consumer Assessment of Healthcare Providers and Systems. aThe Task 1a score is equal to (0.5 clinical performance measure scores) + (0.5 organization culture change scores) + (0.1 satisfaction and knowledge/perception score) + (0.2 extra credit); total score = 1.1; total possible score = 1.3. bCore activities. If a QIO does not complete these specific activities, its contract may be subject to reevaluation by a Centers for Medicare and Medicaid Services panel. cThe Task 1b score is equal to (0.65 clinical performance measure score) + (0.05 systems improvement score) + (0.14 process improvement score) + (0.06 organization culture change score) + (0.1 satisfaction and knowledge/perception score) + (0.27 extra credit); total score = 1.0; total possible score = 1.27. dThe total points for these measures are scaled on the basis of percent improvement above or below the target RFR. Extra credit is available for scoring above the target RFR, indicated here by (max). eExcept acute care hospitalization and emergent care; see Table A.3 for measures. fThe Task 1c1 score is equal to (0.3 clinical performance measure score) + (0.2 clinical performance measurement and reporting scores) + (0.3 process improvement score) + (0.2 systems improvement score) + (0.1 satisfaction and knowledge/perception score); total score = 1.1; total possible score = 1.3.

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APPENDIX A 429 Statewide Improvement Identified Participant Improvement Targets Scoring Weightso Targets Scoring Weightso Measures to be Implementation of a To be determined by developed by quality improve- Government Task consensus review ment project Leader process CAHPS For QIOs electing to work on self- management of medication therapy gSee Table A.3 for measures. hExtra credit for the Appropriate Care Measure Identified Participant Group is based on recruitment of hospitals. iPartial credit is also given. QIOs achieving at least 25% RFR on three measures will receive 0.05 point; QIOs achieving at least 25% RFR on four measures will receive the full 0.1 point. jThe Task 1c2 score is equal to (0.6 clinical performance measure score and clinical perfor- mance measurement and reporting score) + (0.4 organization culture change) + (0.1 satisfac- tion and knowledge/perception score); total possible score = 1.35. kExtra credit for these activities are scaled on the basis of the percentage of critical access hospitals achieving the target RFR. lThe Task 1d1 score is equal to (0.1 clinical performance measure score) + (0.4 clinical performance measurement and reporting score) + (0.4 process improvement score) + (0.2 sys- tems improvement score) + (0.1 satisfaction and knowledge/perception score); total score = 1.2. m The total points for these activities are scaled on the basis of the ability of participants without electronic clinical information systems to produce clinical information. nThe Task 1d2 score is equal to (0.25 clinical performance measure score) + (0.25 systems improvement score) + (0.4 process improvement score) + (0.1 satisfaction and knowledge/ perception score); total score = 1.0. o"Passing" for Task 1d3 is to be determined by the Task 1d government task leader.

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430 APPENDIX A TABLE A.7 Comparison of Deliverables for the 7th and 8th Scopes of Work 7th SOW Deliverables 8th SOW Deliverables Task 1a: Nursing Homes Development and implementation of a Development of alternative Task 1a criteria quality improvement plan in which 3 to 5 of (applicable to WY, AK, DC, and PR) the 10 nursing home quality-of-care measures were targeted for statewide improvement Development and implementation of a plan Lists of the identified participants for groups to partner with nursing home stakeholders 1 and 2 List of the identified participants Indicate whether QIO will work on process improvement measures and which nursing homes will submit data for these measures Contact name for each identified participant Set targets for the measures for high-risk pressure ulcers and measures for physical restraints (management of depressive symptoms and management of pain in patients with chronic pain are optional) with the help of nursing homes at the statewide level Submit statewide targets for the measures of high-risk pressure ulcers and for physical restraints; submissions for measures of management of depressive symptoms and management of pain in chronic pain are optional Documentation of PARTner activity codes Documentation of baseline and annual remeasurement rates for resident satisfaction Documentation of baseline and annual remeasurement rates for staff satisfaction Documentation of annual certified nursing assistant or nursing aids turnover rate Quarterly submission of mandatory process of care data (optional) Task 1b: Home Health QIO training of home health agencies on Lists of the clinical performance of identified OBQI participant group and their plans of action List of identified participants Lists of the systems improvement and organization culture change identified participant group

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APPENDIX A 431 TABLE A.7 Continued 7th SOW Deliverables 8th SOW Deliverables List of contact information for each Selected statewide OASIS measure participant Acute care hospitalization strategic plan Acute care hospitalization strategic plan final report Systems improvement and organization culture change identified participant group survey results Systems improvement and organizational culture change identified participant group plans of action Statewide survey results of statewide immunization practices Documentation of PARTner activity codes Task 1c1: Hospitals List of contact information for every Update data on Provider Reporting System hospital in the state List of identified participants for acute care measure, surgical care improvement project, and systems improvement and organization culture change identified participant groups Documentation of contact with local American College of Surgeons president Results of baseline readiness/adoption tool for CPOE, bar coding, or telehealth Results of remeasurement readiness/adoption tool for CPOE, bar coding, or telehealth Systems improvement and organizational culture change hospitals' plans for CPOE, barcoding, and telehealth implementation plans Task 1c2: Critical Access Hospitals N/A Submission of critical access hospital measure set Report of quality improvement activities on at least one critical access hospital measure List of participants for identified participant group Final report of quality improvement activities with all reporting critical access hospitals continues

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432 APPENDIX A TABLE A.7 Continued 7th SOW Deliverables 8th SOW Deliverables Submission of the Rural Organizational Safety Culture Change interventions and change models tested/implemented Baseline results and methods of safety culture survey Report of Rural Organizational Safety Culture Change intervention and change models implemented Remeasurement results of safety culture survey Task 1d1: Physician Practice List including each identified participant Assistance given to Medicare Advantage along with his or her Unique Physician plans Identification Number via PARTner List of contact information for each Assistance provided to support Physician participating physician office Voluntary Reporting Program and other statewide work Recruitment plan Work plan indicating the technical assistance activities offered to identified participant physician practice sites, including those sites in Task 1d2 List of physician practices sites receiving QIO assistance Strategy and assistance for electronic submission of DOQ measures Office System Survey assessing status of identified participant group for electronic clinical information production and use Updated environmental scan List of physician practice sites with applications of interest for QIO assistance List of physician practice sites using EHR due to work of QIO Information depicting QIO efficiencies Office System Survey of identified participant groups Task 1d2: Physician Practice: Underserved Populations N/A Identify Task 1d1 underserved identified participants Identify CLAS identified participants Report efforts to reach underserved populations Report CLAS results

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APPENDIX A 433 TABLE A.7 Continued 7th SOW Deliverables 8th SOW Deliverables Task 1d3: Physician Practice/Pharmacy: Part D Prescription Drug Benefit N/A Assessment of environment for electronic prescribing and continuous quality improvement QIO staff/training plan Baseline levels of performance Submission of two concept papers for quality projects to be developed with Medicare Advantage and other prescription drug plans Submission of one project proposal for a quality project to be developed with Medicare Advantage and other prescription drug plans Plan interventions and develop interventional materials Identify annual quality measure targets Report required information on providers involved in projects Directory of contacts within each prescription drug plan Task 1e: Underserved and Rural Beneficiaries Submission of approved 6th SOW plans N/A targeting an underserved population Submission of plan if new project was chosen Report of final results Task 1f: Medicare Advantage Plan of action to invite Medicare+Choice N/A organizations to participate in Tasks 1a to 1e Submit list of contacts for all Medicare+ Choice organizations NOTE: SOW = scope of work; QIO = Quality Improvement Organization; PARTner = Pro- gram Activity Reporting Tool; OBQI = Outcome-Based Quality Improvement; OASIS = Out- comes and Assessment Information Set; CPOE = computerized provider order entry; N/A = not applicable; DOQ = Doctor's Office Quality; EHR = Electronic Health Record; CLAS = culturally and linguistically appropriate service.

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