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.