Performance Measurement in Pediatric Emergency Care Evie Alessandrini, MD, MSCE Center for Health Care Quality Division of Emergency Medicine p Medical Center Cincinnati Children’s Hospital

Di l Disclosure I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. y I do not intend to discuss an unapproved or i investigative ti ti use off a commercial i l product/device in my presentation.

Performance Measurement Learning Objectives • Delineate the different purposes of performance measurement • Become familiar with existing endorsed performance measures of emergency care • Develop a framework for organizing pediatric emergency care performance measures for your ED

Measurement Motivators • Health Care System – Growing complexity and costs – Transparency initiatives

• Institute of Medicine Reports – To Err is Human, 1999 – Crossing the Quality Chasm, 2001 – Performance Measurement: Accelerating I Improvement, t 2005 – The Future of Emergency Care, 2006 • Develop national standards for emergency care performance measurement

Performance Measurement: Accelerating Improvement 2005 IOM Report • The ultimate purpose of performance measurement is to improve the health of everyone in the United States • Performance measures are yardsticks by which all health care providers and organizations can determine how successful they are in delivering recommended care and d iimproving i patient ti t outcomes t • Public reporting of performance data holds health providers accountable to both consumers and purchasers of care; transparency builds trust • Patients can also learn what the expected professional standards sta da ds o of ca care ea are ea and d where e e tthey ey ca can go to receive ece e itt

Outcomes Quality

Why Measure Performance? • Improvement – Within one ED or with one practitioner – Within networks of EDs or health systems

• Discrimination – Transparency, consumer decision-making decision making – Regionalization of care

• Incentives – Pay for performance – National rankings

Performance Measurement Learning Objectives • Delineate the different purposes of performance measurement • Become familiar with existing endorsed performance measures of emergency care • Develop a framework for organizing pediatric emergency care performance measures for your ED

National Quality Forum Existing Measures Hospital-based p Emergency g y Care • Median time from ED arrival to ED departure for admitted patients* • Median time from ED arrival to ED departure for discharged patients* • Admit Decision Time to ED Departure Time for Admitted P ti t * Patients* • Door to provider • Left without being seen * Measures stratified by – Psychiatric P hi i di diagnoses, observation b i patients, i transfers, f allll others h www.qualityforum.org

National Quality Forum Existing Measures Hospital-based Emergency Care (cont.) • Severe Sepsis and Septic Shock: Management Bundle • Confirmation of endotracheal tube placement • Percentage of patients with Chest Pain Symptoms in ED receiving Early Therapy including IV, Oxygen, Nitrogl cerin Morphine and Che Nitroglycerin, Chewable able Aspirin on Arri Arrival al • Pregnancy test for female abdominal pain patients • Anticoagulation g for Acute Pulmonary y Embolus Patients • Pediatric Weight documented in kilograms

www.qualityforum.org

Children’s Health Corporation of America Existing Measures Whole System Measures • ED Left Without Being g Seen • ED Length of Stay

www.chca.com

Other Existing Measures and M Measurement O Organizations i i • Joint Commission – ORYX performance measures • Children’s Asthma Care measures (inpatient) • http://www.jointcommission.org/PerformanceMeasurement // / f

• AHRQ Pediatric Quality Indicators (PDIs) – 18 risk-adjusted measures – Obtained from inpatient administrative data – www.qualityindicators.ahrq.gov/pdi_overview.htm

• Alliance for Pediatric Quality – AAP, American Board of Pediatrics, CHCA, NACHRI – www.kidsquality.org

Other Existing Measures and M Measurement O Organizations i i ACEP National Report Card on the State of Emergency Medicine • Access to Emergency Care • Quality and Patient Safety Environment • Medical Liability Environment • Public P bli Health H lth and d IInjury j P Prevention ti • Disaster Preparedness http://www.emreportcard.org

Performance Measurement Learning Objectives • Delineate the different purposes of performance measurement • Become familiar with existing endorsed performance measures of emergency care • Develop a framework for organizing pediatric emergency care performance measures for your ED

Rationale for Framework Limitations of p prior work – Single centers or geographic locales – Focus on condition-specific indicators – Preponderance of process-oriented measures – Benchmarks very focused on • Timeliness (through put) • Satisfaction (ceiling effect)

– Lack of comprehensiveness regarding spectrum of ED care • Lindsay et. al., AEM, 2002 • Guttmann et. et al., al Pediatrics, Pediatrics 2006

Performance Measure Framework Quality indicator set development process • Adapted dapted from o AHRQ Q • “Defining Quality Performance Measures for Pediatric Emergency Care” Care – EMSC Targeted Issues Grant

Performance Measure Framework Measure development dimensions • IOM Quality Domains • Donabedian’s frame framework ork for q quality alit • PEM disease frequency and severity Measure evaluation dimensions • National Quality Forum criteria

Institute of Medicine Quality Domains Built around the core need for health care to be • Safe • Effective • Efficient • Timely • Patient-centered • Equitable

Institute of Medicine Quality Domains Safe • Health care avoids injuries to patients f from th the care that th t is i intended i t d d to t help h l them

Effective • Health care provides services based on scientific knowledge to all who could benefit, and refrains from providing services to those not likely to benefit

Institute of Medicine Quality Domains Efficient • H Health lth care avoids id waste, t including i l di waste t of equipment, supplies, ideas and energy

Timely • Health care reduces waits and sometimes harmful delays for both those who receive and those who give care

Institute of Medicine Quality Domains Patient - centered • Health care provides care that is respectful of and responsive to individual patient preferences, need and values, and ensures that patient values guide all clinical decisions

Equitable • Health care provides care that does not vary because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status

Donabedian’s Donabedian s Framework Structure • Indirect quality-of-care measures related to a physical setting and resources: Staff, space, supplies, equipment and financial reso resources rces

Process • Measures evaluate the method or process by which care is delivered, including both technical and interpersonal components

O t Outcome • Outcome elements describe valued results related to g g life, relieving gp pain, reducing g disabilities and lengthening satisfying the consumer

PEM Disease Frequency & Severity • Condition-specific – Proportion of patients with croup receiving corticosteroids ti t id

• General – Proportion of patients returning to the ED within 72 hours of an initial ED visit

• Cross-cutting Cross cutting – Proportion of patients with pain who receive an analgesic

Choosing Condition-Specific Measures 30.00

25.00

24 59 24.59

% of Diagnosis

20.00

19.22

16.18

15.33

NHAMC S PC DP

15.00 12.80 11.91 9.97

10.00

11 48 11.48 9.65

9.64

5.00

0.00 Trauma

ENT, Dental & Mouth Diseases

Gastrointestinal Diseases

Respiratory Diseases

Systemic States

Major Group

Alessandrini et.al., Academic Emerg Med; February 2010

Choosing Condition-Specific Measures 8.00%

www.pecarn.org/tools 7.00%

6.00%

% of diagnosis

5 00% 5.00%

NHAMC S PC DP

4.00%

3.00%

2.00%

1.00%

0 00% 0.00% I n f e c t i o us N oseLa c e r a t i on s, I nf e c t i ou s Ea r C on t u si on s & Vi r a l I l l n e sse s & S i nu s D i sor d e r s,

A m p ut a t i o ns & D i sor de r s U n i nf e c t e d

i nc l ud i ng U R F I or e i gn B o di e s

Fe v e r

I nf e c t i ou s

I n f e c t i o us

S t r a i n s & Ga st r o e n t e r i t i sFr a c t ur e s & S pr a i ns

D i sl oc a t i o ns

( e x t r e m i t i e s)

( e x t r e m e t i e s)

R e sp i r a t or yM ou t h & Th r o a t

A br a si o ns

D i se a se s

( e x t e r n a l , of a n y b od y pa r t )

( e x t e r na l )

Subgroup

D i sor d e r s

Choosing g Measures of Disease Severity y Severity Classification System • Apnea, respiratory arrest • Anaphylaxis p y – various etiologies

• Severe head injury • Sepsis and meningitis – various etiologies

• Cardiac arrest • Status epilepticus

www.pecarn.org/tools

Measure Evaluation Dimensions Importance • The measure reflects a priority or high i impact t aspectt off healthcare h lth • The measure addresses outcomes or is strongly linked to improving outcomes • The measure addresses an area of considerable variation or poor performance across providers or population groups

Measure Evaluation Dimensions Scientific Acceptability • There is strong evidence for the specific measure focus, f such h as evidence id b based d guidelines • The measure is reliable, reproducible and accurately represents quality of care

Measure Evaluation Dimensions Usability • The measure provides information that is actionable ti bl and d can b be used d tto make k decisions that improve the quality of care • The measure is meaningful f and understandable

Measure Evaluation Dimensions Feasibility • Data for the measure is generated during care delivery d li and d iis available il bl iin th the EHR or other electronic sources • Data collection for f the measure can be implemented • The information provided outweighs the costs/burdens of collecting the data

Steps in Measure Specification • • • • • • • •

Numerator statement Denominator statement Denominator exclusions ata source sou ce a and d co collection ect o methods et ods Data Sampling Risk adjustment Stratification to detect disparities Level of measurement / analysis

Steps in Measure Specification Risk Adjustment • Accounts for patient-associated factors before comparing outcomes across settings • “Levels “L l th the playing l i fifield” ld” • Would be unnecessary if patients were randomly assigned to treatments, settings etc.

Further Considerations • Measures valuable to patients – Not minimum level of competency

• Composite C Measures – Conceptual and analytic issues

• Measures crossing sites of care • Balancing measures – Are we improving parts of our system at the expense of others?

References • AAP Policy Statement: Principles for the Development and Use of Quality Measures – Pediatrics 121 (2) (2), February 2008 2008, pp 411 411-418 418

• Pediatric Clinics of North America “Pediatric Quality”:: Quality Measures in Pediatrics Quality – Volume 56 (4), August 2009, pp 816-829

References • Institute of Medicine Report: Performance Measurement, Accelerating Improvement – December 2005 – www.iom.edu/Reports/2005/PerformanceMeasurement-Accelerating-Improvement Measurement Accelerating Improvement.aspx aspx

• Joint Policy Statement—Guidelines for Care of Children in the Emergency Department – Pediatrics 2009;124:1233–1243