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Show Quality of Medical Care Delivered to Medicare Beneficiaries: Improvement Trends in Utah (1998-2000) Michael P. Silver, MPH & Kevin Kennedy, MHA The Medicare clinical performance monitoring system provides the nation and states with broad indicators of health care system quality and effectiveness. This article describes this system and its use by the Centers for Medicare and Medicaid Services (CMS) in the evaluation of the Medicare Quality Improvement Organization contractor performance. Improvement trends in Utah observed in the first remeasurement cycle, comparing quality indicators rates from 1998 to 2000, are reviewed for inpatient and outpatient clinical topic areas. In the fall of 2000, the Health Care Financing Administration (now the Centers for Medicare & Medicaid Services or CMS) announced the creation of a nationwide clinical performance monitoring system (Jencks, et al., 2000). This system provides CMS with information on national trends in indicators of health care quality and, from state-specific estimates, an objective basis for evaluating the performance of Medicare Quality Improvement Organizations (QIOs). The initial version of this system profiled care provided in hospitals and preventive services provided in outpatient settings. Through periodic review, data from this system can be used by local health care providers, policy makers, and the public to identify statewide health care quality issues and trends in this vulnerable population. Performance evaluation for Medicare QIOs for the 1999 through 2002 contract cycle (the 6th Scope of Work-SOW) began with a baseline sample of performance indicators reflecting quality of health care prior to the beginning of the contract in 1998. Remeasurement, using data from the year 2000 has recently been completed (Jencks, Huff, & Cuerdon, 2003). This report reviews the results of this evaluation for Utah and implications for further improvement initiatives. QUALITY OF CARE MEASURES CMS developed 22 quality of care indicators from 7 broad clinical topic areas. The clinical topic areas were selected based on review of disease prevalence, scientific evidence of potential for improvement, measurement reliability, evidence of a meaningful gap between actual and optimal performance, and evidence that QIOs could effectively intervene to improve performance. To eliminate the need for risk adjustment and to provide useful data for improvement efforts, the quality indicators focused on processes of care, rather than health care outcomes. Quality indicators were defined to exclude patients with documented contraindications to the elements of care assessed. The clinical topic areas were: • Inpatient • Heart failure-1 indicator • Stroke prevention and treatment - 3 indicators • Acute myocardial infarction - 7 indicators • Pneumonia - 5 indicators • Outpatient • Diabetes treatment - 3 indicators • Cancer screening - 1 indicator Immunization - 2 indicators Taken together, these indicators have significant direct impact on health care outcomes. In addition, they provide a window into the functioning of some critical aspects of the health care system, including chronic care, disease prevention, prevention of secondary complications, screening, acute/emergency treatment, prescribing, and coordination of treatment. Inpatient indicators were derived through medical record review of a random sample of between 750 and 800 discharges from the Medicare fee-for-service population from each state with the principal diagnosis for each clinical topic area (except for the atrial fibrillation stroke prevention indicator, which included either principal or secondary diagnoses). The medical record review was condvicted for all states by one of two CMS-contracted data abstraction centers. Outpatient indicators for diabetes and mammography were measured utilizing Medicare claims for screening and testing services. Immunization indicators were derived from random telephone surveys of those over age 65. Baseline data were established via the 1999 Behavioral Risk Factor Surveillance System (BRFSS), and a BRFSS-like telephone survey was performed by CMS during spring of 2001 to provide remeasurement data. HEALTHINSIGHT 6* ACTIVITIES SCOPE OF WORK (SOW) At the beginning of the 6th SOW, Healthlnsight, the Medicare QIO for the State of Utah, realigned operational staff according to the major areas of focus for the contract. Two internal teams, inpatient and outpatient, were formed. Variation in the demands of quality improvement in the inpatient and outpatient settings, in Healthlnsight's experience working with providers in different settings, and in the nature of the quality indicators themselves produced different strategies for facilitating improvement activities in these settings. Inpatient Quality Improvement Activities The design and conduct of Healthlnsight 's inpatient quality improvement activities took advantage of long-standing relationships with hospital quality improvement personnel statewide. Interactions concentrated, although not exclusively, on the 17 hospitals with the largest volumes of Medicare discharges. Taken together, these hospitals account for approximately 85% of the Medicare discharges in Utah. At the beginning of the 6th SOW, customer knowledge gathering focused on identifying common and overlapping priorities and interests with individual 133 Utah's Health: An Annual Review Volume DC |