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The Workshop
.
BACKGROUND AND CONDUCT
To provide a context and some background materials for the committee,
TOM and HCFA staff compiled a set of readings Hat was forwarded before
the meeting. TOM staff developed a brief exercise, completed before He
workshop, to identify a large set of clinical conditions grouped by major
organ systems and disease categories and then to provide a means of
narrowing the sets to be discussed at the workshop to a manageable few.
HCFA staff compiled a large array of data tables on most of the conditions
to be discussed, some of which were distributed before He meeting and
some of which was made available the day of the workshop.
The workshop began win presentations on the effectiveness research
initiative by William L. Roper and Henry I. Krakauer (HCFA) and a general
discussion of He criteria by which He clinical conditions should be selected.
Kathleen N. Lohr (IOM) reviewed He homework exercise. The committee
then discussed the preliminary list of conditions, selected an interim group
of conditions, discussed that group in greater depth, and chose the final set
to be recommended to HCEA. We also briefly discussed patient manage-
ment options for He key conditions Hat we judged would be important to
the Effectiveness Initiative. The executive session focused on the final
recommendations to be made to HCFA.
Homework Exercise
The homework exercise was conducted as a modified Delphi process, in
which committee members completed two questionnaire sheets to classify
and Hen rate potential clinical conditions as to Heir probable importance
for the Effectiveness Initiative. IOM staff generated a list of 42 diagnoses
4
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s
judged to represent He primary conditions that should be considered (see
Table 1~. We were then asked to assign each condition to one of three
categories: (1) must be included in the workshop discussion, (2) probably
important to the HCFA program, and (3) can be dropped from further
discussion. The exercise restricted us from classifying more than 10 con-
ditions in the first (highest priority) category. The third step was to take the
10 (or fewer) conditions we classified as highest priority and rate them on
an "importance scale" ranging from 1 (highest importance to the Effective-
ness Initiative) to 5 (lowest importance). We returned these sheets to IOM
staff, who compiled the results and reported on them at the meeting.
Of the 14 members of the committee, 13 resumed the classification and
rating sheets. In our initial response, we collectively nominated 31 condi-
tions as "must be included," including a 43rd condition (urinary incon-
tinence). Based on a simple count of votes, we found that 10 conditions had
been so classified by at least six of the committee: angina, breast cancer,
acute myocardial infarction (10 votes each); prostatic hypertrophy (9 each);
hip fracture and peripheral vascular disease (7 each); end transientischemic
attack (TIA) without occlusion, Alzheimer's disease, cataracts, and oc-
clusion/stenosis of precerebral arteries (6 each).
When the importance ratings were analyzed, we determined with some
simple scoring rules that 14 conditions had clearly higher importance than
the others. They included all those listed above plus cardiovascular accident
and stroke without TIA, depressive disorders, degenerative joint disease,
and gastrointestinal bleeding. These conditions roughly one-~ird of He
original list formed a core set on which initial discussions at He workshop
were focused. A second round of voting on an intermediate listing was also
conducted during the workshop.
HCFA Data
Additional background materials were made available by staff of the
Health Standards and Quality Bureau (HSQB) of HCFA, both before and
at the meeting, in the form of two sets of data Hat reflect the present
capabilities of the HSQB/HCFA files.
The first set of data concerned monitoring of outcomes of medical
interventions. Specific topics examined for a number of disease categories
are listed on Page 8:
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6
TABLE 1 Potential List of Clinical Conditions to Consider for HCFA Effectiveness
Iniiiadve
This list of clinical conditions to be considered at the Clinicians' Workshop for the Health
Care Financing Administration's Effectiveness Initiative is based on the work already
being done internally by HCFA or externally by researchers sponsored by HCFA or by
the National Center for Health Services Research. The listing is organized by major diag-
nosis or disease classes and, within those, more specific clinical condition areas. (No
priority order should be inferred.) Specific procedures related to one or another of these
diagnoses are not listed.
DIAGNOSTIC CLASS
I. CardiovasculartCirculatory Disease
CLINICAL CONDITION
2.
3.
4.
5.
6.
7.
8.
1. Angina (stable and unstable)
Acute myocardial infarction
Valvular heart disease
Congestive heart failure
Hypertension
Bradycardia and conduction defects
Tachycardia
Aortic Aneurysm
8.a Abdominal
8.b Thoracic
9. Peripheral vascular disease
10. Deep vein thrombophlebitis
II. Cerebrovascular Disease
11. Cerebrovascular accident/stroke other than TIAs
12. Transient ischemia attack without occlusion
13. Occlusion/stenosis of precerebral arteries
III. Disorders of Nervous System and Sense Organs
14. Pa~inson's disease
15. Alzheimer's disease
16. Cataracts
17. Glaucoma
18. Hearing loss
IV. Diseases of the Respiratory System
19. Chronic obstructive pulmonary disease
20. Pneumonias
21. Respiratory failure
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7
TABLE 1 (Continued)
V. Diseases of the Gastrointestinal/Digestive System
22. Gastrointestinal bleeding
23. Peptic ulcer disease
24. Diverticular disease
25. Cholecystitis
26. Cholelithiasis
27. Hernia (inguinal)
28. Hiatal hernia
VI. Disorders of the Endocrine System
VII. Musculoskeletal Disease
VIII. Genitourinary Diseases
IX. Neoplastic Disease (Primary)
29. Diabetes mellitus
30. Osteoporosis
31. Degenerative joint disease
(osteoarthritis/osteoarthrosis)
32. Hip fracture
33. Kidney/urinary tract infection
(pyelonephritis, cystitis)
34. Kidney stones
35. Prostatic hyperplasia/trophy
Breast cancer
Uterine cancer
Colorectal cancer
Stomach cancer
40. Leukemia/lymphoma
X. Psychological and Psychiatric Disorders
41. Anxiety states
42. Depressive states
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8
1. demographics and mortality rates;
2. patterns of morbidity: time to first readmission within 12 months
(e.g., readmissions and relative risk of readmissions);
3. patterns of morbidity: prior admissions within 12 months;
4. patterns of morbidity: readm~ssions within 30 days of first discharge
(e.g., percentage of persons at risk; readmissions for specific causes; length
of stay and charges in readmissions);
5. patterns of morbidity: readmissions within 31-180 days of first
discharge (e.g., percentage of persons at risk; readmissions for specific
causes; length of stay and charges in readmission);
6. patterns of morbidity: readmissions within 181-360 days of first
discharge (e.g., percentage of persons at risk; readmissions for specific
causes; length of stay and charges in readmissions);
7. charges for medical care (e.g., total, hospital charges, and charges
for various other providers or settings);
8. cumulative mortality rates;
9. population-based mortality rates,
10. year-to-year relative risks of dying after hospitalization; and
11. time trends in mortality rates and use of coronary revascularization.
The second set of data illustrated HCFA's efforts to acquire and analyze
data from hospital medical records in special studies being done Trough
the Medicare PROB. It focused specifically on coronary artery bypass graft
surgery and balloon angioplasty, win special emphasis on risk factors
predictive of dead or of rehospitalization.
PREMISES OF THE CLINICAL WORKSHOP
In discharging its responsibilities, the committee based its deliberations
on several premises and understandings Mat form the context for our
specific recommendations.
1. The workshop marks tile beginning of a planning and implementa-
tion process blat will involve other clinical and research experts.
2. Many different points of view will be involved in the planning and
implementation of He Effectiveness Initiative. These will include the major
units of HCFA, over federal agencies, and all appropriate private sector
constituencies, such as the physician and other provider communizes,
insurance carriers, and academic and other research teams.
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9
3. The development of information on ambulatory care, long-term care,
and quality of care Trough He Medicare PROs and Trough external
investigator-initiated research is crucial to He effort to expand He relevant
data bases and to address He issues that tine Effectiveness Initiative is
intended to examine. We assume existing HCFA data alone cannot answer
all questions that might arise from the Initiative; Hey can, however, identify
many problems warranting greater investigation. Thus, we expect that
HCFA will undertake to gamer information on outpatient encounters on a
diagnosis-speci~c basis.
4. Data will need to be managed in a careful and responsible way. This
includes He publication of findings in peer-reviewed journals and He
avoidance of premature release of information. We assume that external
review groups will be used extensively at all stages planning, implemen-
tation, and review-of He Effectiveness Initiative program.
Representative terms from entire chapter:
clinical conditions
