department of health and human services measuring clinical lab ordering quality: theory and practice...
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Department of Health and Human Services
Measuring Clinical Lab Ordering Quality: Theory and Practice
Measuring Clinical Lab Ordering Quality: Theory and PracticeSteven M. Asch MD MPH
VA, RAND, UCLAApril 29, 2005
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INSTITUTE OF MEDICINEDEFINITION OF QUALITY The degree to which health services for individuals and populations * increase the likelihood of desired health outcomes and * are consistent with current professional knowledge
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Lundberg , 1981
Were results used properly to improve care?
Has the right testbeen ordered?
Action
The 9 steps in the performance of any laboratorytest. The brain-to-brain turnaround time loop.
Interpretation
Reporting
Analysis
PreparationTransportation
Identification
Collection
Ordering
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WHAT IS POOR QUALITY?WHAT IS POOR QUALITY?
• Too little care – underuse– Failure to provide an effective service when
it could have produced a good outcome
• Too much care – overuse– Providing care when its risks of harm
greater than potential benefit
• The wrong care – misuse– Avoidable complications of appropriate care
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CONCEPTUAL FRAMEWORK
STRUCTURE PROCESS OUTCOMES
Technical Excellence
• Right choices
• Effective/skillful
Interpersonal Excellence
• Patient-centered
• Responsive
Functional Status
Satisfaction
Mortality
Biological Status
Health CareOrganization
Characteristics
ProviderCharacteristics
CommunityCharacteristics
PopulationCharacteristics
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EXAMPLES OF STRUCTURAL MEASURESEXAMPLES OF STRUCTURAL MEASURES
• Health care organization characteristics- Weekend and night hours and
convenient locations of laboratories- Volume
• Provider characteristics– Number of pathologists– Training of laboratory staff
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CONCEPTUAL FRAMEWORK
STRUCTURE PROCESS OUTCOMES
Technical Excellence
• Right choices
• Effective/skillful
Interpersonal Excellence
• Patient-centered
• Responsive
Functional Status
Satisfaction
Mortality
Biological Status
Health CareOrganization
Characteristics
ProviderCharacteristics
CommunityCharacteristics
PopulationCharacteristics
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4%
30%33%
29%33%
86%
60%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
All U/A Glu K Cr Chol Trig
% Adherence
HTN NEW DIAGNOSIS LABSHTN NEW DIAGNOSIS LABS
Asch et. al. BMC CV, 2005
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QATOOL SCORES BY MODEQATOOL SCORES BY MODE
Visit 73%
Medication 69%
Immunization 66%
Physical Exam 63%
Laboratory/Radiology 62%
Surgery 57%
History 43%
Education 18%McGlynn, Asch et. al. NEJM 2003
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CONCEPTUAL FRAMEWORK
STRUCTURE PROCESS OUTCOMES
Technical Excellence
• Right choices
• Effective/skillful
Interpersonal Excellence
• Patient-centered
• Responsive
Functional Status
Satisfaction
Mortality
Biological Status
Health CareOrganization
Characteristics
ProviderCharacteristics
CommunityCharacteristics
PopulationCharacteristics
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WHY MEASURE OUTCOMES?WHY MEASURE OUTCOMES?
– Allow innovation in process
– People care about outcomes directly
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SAMPLE SIZE PROBLEMSSAMPLE SIZE PROBLEMS
– For mortality, need huge samples:• CHF patients: 12% vs 16%, need 957
patients at each hospital.
– Rarer outcomes• People care, but statistical comparison is
impossible.
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DOES SICKNESS OR QUALITY DETERMINE CHF MORTALITY?Sickness at Process
Admission Poor Medium Good Total
Least Sick 1/4 4 7 4 5Middle 1/2 11 8 8 9Most Sick 1/4 37 32 26 32Total 16 14 12 14
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ACCOUNTABILITY: IS PROVIDER RESPONSIBLE FOR PROBLEM?
ACCOUNTABILITY: IS PROVIDER RESPONSIBLE FOR PROBLEM?
– Current treatment must have big impact relative to other factors.
– Do not want providers avoiding those who:• have a bigger chance of problems• are less likely to adhere to treatment
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CHOOSING MEASURES:PRACTICAL CONSIDERATIONS
– Choosing areas to measure
– Selecting indicators
– Designing specifications
– Testing the measure
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CHOOSING AREAS:ASSESSING HEALTH IMPORTANCE
– Mortality
– Morbidity
– Utilization
– Cost
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PREVALENCE OF SELECTED ACUTE CONDITIONS AMONG WORKING ADULTS
Condition Work Loss Days/100 Persons
Injuries
Influenza
Infections and parasitic disease
Common cold
Digestive system conditions
Other upper respiratory
Acute ear infections
85.5
53.1
20.6
15.4
12.3
9.3
3.2
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CHOOSING AREAS: POTENTIAL FOR IMPROVEMENT
CHOOSING AREAS: POTENTIAL FOR IMPROVEMENT
– What are the key outcomes of interest?
– What processes produce those outcomes?
– How well are key elements of care delivered today?
– How variable is care delivery?
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CHOOSING MEASURES: DEGREE OF PROVIDER CONTROL
CHOOSING MEASURES: DEGREE OF PROVIDER CONTROL
– How might the measure be affected by characteristics of the enrolled population?
– What actions can providers or clinical laboratories take to improve performance?
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STRENGTH OF SCIENTIFIC EVIDENCESTRENGTH OF SCIENTIFIC EVIDENCE
I: Randomized controlled trialII-1: Nonrandomized controlled trialI-2: Cohort or case control studiesII-3: Multiple time seriesIII: Opinions or descriptive studies
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COST-EFFECTIVENESS OF PROCESS
MMR Immunization $14 saved/$1 spent
Cervical cancer screening $21,000 spent/year (ages 20-28)
Cervical cancer screening $11,000 spent/year (ages 29-50)
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DESIGNING MEASURE SPECIFICATIONSDESIGNING MEASURE SPECIFICATIONS
– Define indicator– Identify target population– Define eligible population– Determine need for risk adjustment– Identify data sources– Write data collection instructions– Develop scoring rules
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Example measureExample measure
• Men with a new diagnosis of prostate cancer, who have not had a serum PSA in the prior three months, should have serum PSA checked within one month after diagnosis or prior to any treatment, whichever comes first.
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EVALUATING DATA SOURCES
DATA SOURCE STRENGTHS WEAKNESSES
Medical Record Clinical Detail Expense Missing links
Administrative Use of services Clinical detail
Patient Surveys General Health Expense
Interpersonal Clinical detail
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TESTING THE MEASURETESTING THE MEASURE
– Reliability: The proportion of times that repeated use of measure in same population gives the same result
– Validity: The extent to which the measure accurately represents the concept being assessed
– Interpretability: Ease with which target audience can understand and use information generated by measure
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WHY SHOULD CLINICIANS CARE ABOUT MEASURING QUALITY?
WHY SHOULD CLINICIANS CARE ABOUT MEASURING QUALITY?
– Internal quality improvement
– External monitoring and evaluation
– Consumer/purchaser decision-making
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ADEQUACY OF CASE-MIX CONTROLADEQUACY OF CASE-MIX CONTROL
– Severity of disease– Incidence and prevalence by
demographics•age•race•gender