Future Directions for the National Healthcare Quality and Disparities Reports (2010) / Chapter Skim
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Appendix F The Expected Population Value of Quality Indicator Reporting (EPV-QIR) : A Framework for Prioritizing Healthcare Performance Measurement David O
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176 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS quality and disparities, quality and disparities reporting is more often targeted at variability in the implementation of available information. Recently, value of research approaches have been adapted to address issues of imperfect implementation (Fenwick et al., 2008; Hoomans et al., 2009)
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APPENDIX F 177 S can be written as De = eS – eO. The incremental cost of S is the difference between the cost of the standard of care (cS)
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178 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS is the total net health benefits that can be gained by improving implementation from current rates to 100%. MaxPVQI is simply the difference between PVPI and PVCI, or MaxPVQIS = PVPIS – PVCIS = NS × (1 – rSC)
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APPENDIX F 179 Change in Quality Population Indicator Health Benefits/ Reporting Cost Savings Probability that information will lead to QI is variable Quality Change in Rates Improvement of Performing Action to Change Standard of Provider Effectiveness of QI in Care Behavior changing provider behavior is variable FIGURE 1 Conceptual Model for the Expected Population Value of Quality Indicator Reporting NOTE: Patients may also change behavior based on quality indicator reporting, for example by selecting high-quality providers, causing changes in the rates at which care delivered meets standards of care. Figure F-1 R01677 This equation provides our fundamental framework for developing estimates of the value of quality reporting efforts.
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180 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS III. USING THE EPV-QIR FRAMEWORK TO PRIORITIZE MEASURES Using the EPV-QIR framework to prioritize measures ideally requires data on all the elements included in Eq.
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APPENDIX F 181 Expected Quality Improvements. To develop more precise estimates of the EPV-QIR, it is necessary to know the probability of quality improvement (pQ)
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182 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS TABLE 1 EPV-QIR Calculations for 18 NHQR Measures Denominator Pop.
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APPENDIX F 183 TABLE 1 Continued Denominator Pop.
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184 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS TABLE 2 14 NHQR Measures Ranked in Descending Order of Value of Perfect Implementation Denominator VPI Share of Cumulative Mnemonic NHQR Measure Population (QALYs) Total VQI % VQI NHQR_DMHTN Percent of adults with diagnosed diabetes with most recent 17,268,973 7,021,537 39.33% 39.33% blood pressure <140/80 mm/Hg NHQR_DMFOOT Adults age 40+ with diagnosed diabetes who had their feet 17,268,973 2,326,165 13.03% 52.36% checked for sores or irritation in the calendar year NHQR_PAP3YR Percent of women (age 18 and over)
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APPENDIX F 185 TABLE 3 14 NHQR Measures Ranked in Descending Order of Value of Quality Improvement Denominator VQI Share of Cumulative Mnemonic NHQR Measure Population (QALYs) Total VQI % VQI NHQR_DMHTN Percent of adults with diagnosed diabetes with most recent 17,268,973 2,913,938 46.62% 46.62% blood pressure <140/80 mm/Hg NHQR_DMCHOL Adults age 40 and over with diagnosed diabetes with total 17,268,973 824,453 13.19% 59.81% cholesterol <200 mg/dL NHQR_DMFOOT Adults age 40+ with diagnosed diabetes who had their feet 17,268,973 681,566 10.90% 70.71% checked for sores or irritation in the calendar year NHQR_DMHBA1C Percent of adults with diagnosed diabetes with HbA1c level 17,268,973 669,375 10.71% 81.42% >9.5% (poor control)
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186 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS munication will itself depend on the expected value of perfect information in a specific decision-making context, or what Basu and Meltzer (2007) term the expected value of individualized care (EVIC)
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APPENDIX F 187 using this framework must be routinely assessed across a range of estimates of the value of health appropriate to the setting (e.g., at least $50,000 to $200,000 per QALY in the United States)
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188 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS at a single point in time will alter the quality of care for succeeding cohorts. A more elaborate model can be constructed that estimates the expected value of quality improvement based on discounted streams of net health benefits that may be realized over a specific time horizon.
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APPENDIX F 189 National Healthcare Quality Report, 2003. Agency for Healthcare Research and Quality, Rockville, MD.
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190 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS APPENDIX A Incorporating Inappropriate Use into the EPV-QIR Framework Incorporating inappropriate use or overuse into the EPV-QIR framework requires adjustments to the framework. If overuse is defined as excessive use of an intervention in a measure population, the primary adjustment is that the NHB of current use can be negative compared to no use.
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APPENDIX F 191 VCI2 = 322,221 × 0.1795LY = 57,839LY VCI3 = 118,148 × 0.189LY = 22,330LY The total value of current implementation is the sum of these values: 293,351LY. The maximum value of quality improvement in this cohort is equal to 405,999LY – 293,351LY = 112,648LY.
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192 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS APPENDIX B Sample EPV-QIR Calculations CALCULATION 1. A Basic Example. Percent of Individuals Age 65+ Who Ever Received a Pneumococcal Vaccination [NHQR CAPVACC65EVER]
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APPENDIX F 193 in Column 5, and is calculated by multiplying the NHB in Column 2 by the number of persons in Column 4. The sum of PVPI ("Total")
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194 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS As specified, women receiving annual mammography or biennial mammography are said to be in compliance with the standard of care in the NHQR measure. Number of Women Receiving Standard of Care and Non-Standard Care.
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APPENDIX F 195 NHB of mammography ranges from 0.005 QALYs per woman following a 5-year screening strategy, to 0.02039 QALYs per woman following an annual screening strategy. Indeed, the NHB accruing to annual screening is 1.25 times larger than the NHB accruing to biennial screening, and both annual and biennial screening are considered to be compliant with BRCA2YRMAMM.
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196 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS As shown in Column 5, the value of perfect implementation (VPI) is the total possible number of QALYs that can be gained by moving all women who are not currently receiving the standards of care, to biennial or annual screening.
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APPENDIX F 197 [NHQR_DMCHOL] Adults age 40 and over with diagnosed diabetes with total cholesterol <200 mg/dL.
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198 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS • Table 1: Annual Estimates of the Resident Population by Sex and Five-Year Age Groups for the United States: April 1, 2000 to July 1, 2008 (NC-EST2008-01)
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APPENDIX F 199 Population • Table 1: Annual Estimates of the Resident Population by Sex and Five-Year Age Groups for the United States: April 1, 2000 to July 1, 2008 (NC-EST2008-01)
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200 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS • Note -- this study evaluated two types of FOBT -- rehydrated FOBT (RFOBT) and unrehydrated FOBT (UFOBT)
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APPENDIX F 201 [NHQR_HFACE] Percent of hospital patients with heart failure and left ventricular systolic dysfunction who were prescribed ACE inhibitor or ARB at discharge.
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202 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS sold in the U.S. each year from Maki et al.
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APPENDIX F 203 avoided, can also be viewed as the net health benefit lost for every infection that occurred. Thus, Column 2 presents the NHBs lost per infection under different catheter "regimes." Column 3 reports the NHB lost per infection under perfect implementation.
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204 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS TABLE A.4.1 Number of Individuals Receiving Standard and Non-standard Care: AMIACE Parameter Source Base Population -- Age < 60 51,054 NHDS 2005 (AMI Discharges, age < 60) , 27% LVSD Base Population -- 60 ≤ Age < 70 39,171 NHDS 2005 (AMI Discharges, 60 ≤ age < 70)
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APPENDIX F 205 TABLE A.4.3 The Value of Perfect and Current Implementation, and Quality Improvement: AMIACE Net Health NHB under Population Value of Population Value of Maximum Population Benefit Perfect Imp. N Perfect Implement'n Current Implement'n Value of Quality Care Type QALYs QALYs Persons (VPI)
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