One Step Ahead: A Composite Measure to Capture Critical Hospice and Palliative Care Processes

The Centers for Medicare and Medicaid Services (CMS) wants to empower consumers to make informed healthcare decisions. CMS also wants providers to improve the quality of care they provide. One step towards accomplishing both of these goals is by public reporting of quality measures (QM). However, with multiple quality measures focusing on different care processes–all of which provide valuable information–a key issue is how to report that information in an understandable and meaningful way.

Quality Measures in Hospice Care

CMS’s Hospice Quality Reporting Program (HQRP) currently reports seven quality measures, all developed by RTI International and endorsed by the National Quality Forum (NQF). These seven measures focus on care processes around the time of hospice admission and capture management of pain, shortness of breath, and bowel function, as well as patient preferences regarding life-sustaining treatments and spiritual  concerns.

Despite the valuable information each individual measure provides, it can be difficult to understand and use information from multiple individual measures. For example, what does it means if a hospice performs well on a pain screening measure but does not perform well on the dyspnea treatment measure? In Peters et al.’s Less Is More in Presenting Quality Information to Consumers, presenting less detailed and complicated interpretations of measure data, particularly data for the purposes of comparative decision-making, was found to benefit consumers with a diverse range of health information needs and health literacy skills.

Composite Measures: What They Are and How They Can Help

Composite measures strike a balance between what consumers want and what healthcare providers need from quality measures. They are a way to combine information from individual measures into a single measure with a single score.  According to Bilimoria and colleagues, composite measures simplify interpretation of data from multiple quality scores and facilitate consumer “understanding and decision-making.” Composite measures can be used alongside individual measures. Together, they provide both high-level and granular data to benefit both consumers and providers.

Composite measures set higher expectations for providers because of their emphasis on a comprehensive approach to care. Achieving comprehensive high-quality care, particularly in the hospice setting, can be difficult. In 2006, the NQF identified a set of preferred practices for palliative and hospice quality care, which included the care areas captured in the seven HQRP measures. However, according to a study published in Medical Care in 2011, comprehensive implementation of NQF preferred practices is rarely achieved.

Hospice and Palliative Care Composite Process Measure—Comprehensive Assessment at Admission

As part of our work to support the HQRP development and implementation, RTI International developed the Hospice and Palliative Care Composite Process Measure. This measure provides consumers with an overall picture of hospice care at admission by showing whether hospices complete all seven critical care processes. The figure below shows the seven component measures that collectively make up the Hospice and Palliative Care Composite Process Measure.


This composite quality measure provides consumers and providers with a single measure to easily and meaningfully compare quality across hospice providers.

The composite measure also sets a higher standard of care for hospices. Hospices perform well on the 7 individual HQRP measures — analyses conducted by RTI International [PDF] show that hospices average 90% or higher on all measures except for Pain Assessment. But we have also found that only 74% of patient records had all 7 processes documented at admission. The performance gap identified by the composite measure creates opportunities for quality improvement.

The Hospice and Palliative Care Composite Process Measure will be implemented on April 1, 2017. Future research will be needed to see if the new measure helps address the gap.

Ed. note: See also this related study, published ahead-of-print in Medical Care.

Franziska Rokoske

Franziska Rokoske

Director, End-of-Life, Palliative, and Hospice Care at RTI International
Franziska Rokoske is a researcher at RTI International and director of RTI's End-of-Life, Palliative, and Hospice Care research program. She has more than 20 years of experience as a clinician and researcher. Combining a clinical background in geriatric physical therapy with health services and policy research, she has been implementing and evaluating federally and state-funded projects and initiatives to improve health care for Medicare beneficiaries and vulnerable populations, especially patients nearing the end of life.
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Nan Tracy Zheng

Nan Tracy Zheng

Nan Tracy Zheng, PhD, a senior research analyst in RTI International’s End-of-Life, Palliative, and Hospice Care program, has 10 years of experience in health services research, health policies, and program evaluation regarding the elderly. Her current research focuses on (1) quality of care for the elderly across the spectrum of care such as post-acute care, long-term care, and end-of-life care; and (2) health services utilization and care processes. Dr. Zheng currently is the Associate Project Director of the Centers for Medicare & Medicaid Services (CMS) project to develop, implement, and maintain the Hospice Quality Reporting Program. She also leads the analyses under the evaluations of the CMS Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents and the Financial Alignment Initiative to evaluate the impact of the demonstrations on quality of care. Dr. Zheng was the lead analyst of the study conducted for the Medicaid and CHIP Payment and Access Commission on the effect of the gap between Medicare cost sharing amounts and Medicaid payments on use of primary care services among Medicare-Medicaid dually eligible beneficiaries.
Noha Sherif

Noha Sherif

Noha Sherif is a public health analyst in RTI’s eHealth, Quality and Analytics Division. Ms. Sherif’s work focuses on development, implementation, and maintenance of quality measures for federal quality reporting programs. She has experience in developing and testing quality measures for use in postacute and long-term care settings, including hospices, nursing homes, long-term care hospitals, and inpatient rehabilitation facilities. She is primarily engaged with the testing and validation of quality measures in the Hospice Quality Reporting Program. She received her undergraduate degree from Duke University in May 2014.
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Qinghua Li

Qinghua Li

Qinghua Li, Ph.D., is a health services researcher in the Quality Measurement and Health Policy program at RTI International. Her research focuses on quality of care in post-acute care, long-term care, and end-of-life care settings, measurement of health care processes and patients’ experiences. Dr. Li has extensive research experience in the study of health outcomes and health care utilization for individuals with dementia or mental illnesses, and people at end of life. At RTI, Dr. Li leads teams to develop, test, and implement quality measures for skilled nursing facility and hospice quality reporting programs.
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