Using Core Measure Data to Improve Quality of Health Care 

The concept of evidence-based medicine is demonstrated throughout the CMS core measures.  For example:

·       The acute myocardial infarction measure of aspirin on arrival and discharge in an acute myocardial infarction hospital inpatient is supported by evidence that aspirin in this patient population reduces adverse events and mortality with an additive effect when used in combination with thrombolytic therapy. 

·       There is convincing evidence that the use of angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in patients with heart failure and left ventricular systolic dysfunction will reduce morbidity and mortality.  Thus, heart failure measures look at processes of care for assessing left ventricular systolic function and for prescribing ACE inhibitors or ARBs upon hospital discharge in patients with heart failure and left ventricular systolic dysfunction. 

·       The administration of appropriate antibiotic therapy within six to eight hours of hospital arrival in patients with community acquired pneumonia has been shown to reduce mortality by 15 to 30 percent.  Implementation of this care is evaluated in the pneumonia measure of initial antibiotic received within six hours of hospital arrival. 

·       Venous thromboembolism (VTE) is one of the most common postoperative complications, and VTE prophylaxis is the most effective strategy to reduce morbidity and mortality.  However, VTE prophylaxis is often underused.  The Surgical Care Improvement Project (SCIP) measure of surgery patients with recommended VTE prophylaxis ordered and those who receive appropriate venous VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery monitors the hospital’s use of proper VTE prophylaxis.   

CMS continues to promote higher quality and more efficient health care for Medicare beneficiaries.  Therefore, in the final rule for general acute care hospitals paid under the Inpatient Prospective Payment System (IPPS) issued on July 31, 2009, four new measures were added to the RHQDAPU program.   

The new measures, required for discharges as of October 1, 2009, include two chart-abstracted measures for surgical care improvement and two structural measures.   The new SCIP measures are additions to the SCIP measure set already being collected and submitted to CMS.   CMS believes the two structural measures will promote hospital participation in nursing-sensitive care and stroke care registries that collect quality data.  The new measures are as follows:

In addition to these new measures, CMS is retiring the Acute Myocardial Infarction (AMI)-6 measure – beta-blocker at arrival.  This action was based on the evolving evidence for care of acute myocardial infarction patients and changes in the American College of Cardiology/American Heart Association practice guidelines.   New guidelines recommend early beta-blockers should be avoided in certain patient populations due to increased mortality risk.  Therefore the measure was retired based on evidence that revision of the measure would be impractical and may result in unintended consequences, including harm to certain acute myocardial infarction patients.  

In addition to providing quality-of-care information to consumers, there is a financial aspect to the RHQDAPU initiative.  Although a voluntary program, hospitals that do not participate in the initiative will receive a reduction of 2.0 percent in their Medicare Annual Payment Update for fiscal year 2010.  

Although practicing evidence-based medicine has been proven to improve the quality of health care, budgetary constraints leading to limited resources are making it more difficult for hospitals to devote adequate time and resources to CMS core measure abstraction.  Experienced, well-trained staff is necessary to assure accurate data collection.  Inaccurate data can result in the hospital’s failure to receive the full Medicare Annual Payment Update, inhibit root cause analysis of underlying issues, and may ultimately affect future quality improvement efforts.   

Each core measure contains multiple elements that often involve complex specifications such as date/time of admission/discharge, acceptable data sources within the medical record, and lengthy inclusion/exclusion terms.  Abstraction staff must be fully aware of the instructions in the Specifications Manual for National Hospital Inpatient Quality Measures and remain abreast of updates and changes as they occur.  Complex issues may require additional research of information in Quality Net’s Quest database.  In addition, timely abstraction facilitates early recognition of potential issues leading to prompt process improvement.  Improved patient care will be reflected by increased measure success rates, thus raising consumer confidence in services.   

For facilities performing their own abstraction, staffing issues, vacations, and extended leaves can affect timely and accurate data collection.  In addition, financial budgets must include not only the initial cost of training but funding for ongoing continuing education for all core measure staff.  Outsourcing the task of abstraction may be an option to address these concerns.  An experienced outside vendor can provide consistent, dedicated, and knowledgeable staff.  Consistent staffing will result in increased efficiency, fewer errors, and more reliable data.  Through the use of a vendor’s centralized abstraction staff, hospitals can be assured data abstraction is performed by well-trained, qualified staff in a timely manner.  A third-party abstractor can also provide an objective opinion into potential issues that may be difficult to recognize by those engaged in the daily tasks and processes.  Outsourcing core measure abstraction enables the hospital to devote nursing resources to the provision of patient care.  Not only will this enhance staff satisfaction, but will likely lead to increased patient satisfaction as well.

Loretta Herfel , RN, CCS, CPHQ
Kristine Hoffman, RN, CPHQ
Orest Kostelyna, MD