Vital Signs Core Metrics for Health and Health Care Progress (2015) / Chapter Skim
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4 The Core Measure Set
4 The Core Measure Set
Pages 121-184
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From page 121... ...
Key considerations included ensuring that the core set would address the most critical issues and elements of the American health system, as well as meet the Committee's criteria for a core measure set presented in Chapter 3 (see Box 3-1) , and choosing best current measures to be used until the processes could be set in motion to refine the measures needed for application at every level.
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From page 122... ...
In addition to the evidence base for various candidate core measures, the Committee considered the potential utility of candidate measures as tools for motivating change, with particular attention to national health priorities, the face validity of measures, the strength of their linkage to progress, their capacity to promote broader change, their technical reliability, and their relevance at multiple levels of the health system. These and other considerations were operationalized through the development of criteria for the core set, described in Chapter 3 (see Box 3-1)
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Choosing a Best Current Measure The core measure set presented in Table 4-1 targets the most critical issues for making progress toward healthy people, better-quality care, lower costs, and engaged people. In many cases, these core measures will need to TABLE 4-1 Core Measure Set Current Key Best Current National Domain Element Core Measure Focus Measure Performancea Life 79-year life Length of Life LIFE expectancy at expectancy at life EXPECTANCY expectancy birth birth Quality of Self 66% report life WELL-BEING Well-being reported being healthy health 69% of adults Overweight Body mass OVERWEIGHT with BMI 25 & OBESITY and obesity index (BMI)
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From page 124... ...
be translated into specific, validated measures with associated data that can be applied at different levels for different groups, from the national or state level to the level of a single community or organization. Although the Committee recognizes the limitations of the data currently available for gauging multilevel performance on the issues addressed by the core measure set, it
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From page 125... ...
In the face of current limitations, and until specific measures can be further tested and made available at multiple levels or new measures and composites are developed that better capture the full intent of the measure foci, the Committee has identified best current measures that provide a near-term reflection of the target issues and their associated outcomes and can be used to help operationalize the measure set now. For example, the core measure focus for appropriate treatment is evidence-based care.
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c Life expectancy at birth 79-year life expectancy at birth CDC VSSd 2014 VSS state data Local data Self-reported health 66% report being healthye CDC NHISf 2013 CHR,g BRFSS Patient query Body mass index (BMI) 69% of adults with BMI of 25 or CDC NHANESi 2013 CHR, NCCDPHP Clinical records greaterh Addiction death rate 200 addiction deaths per 100,000 SG and VSSk 2014 VSS state data Clinical records people aged 15+j Teen pregnancy rate 27 per 1,000 females aged 15 to 19l CDC VSS 2014 CHR, NCHS Local birth data High school graduation 80% graduate in 4 yearsm DOEd NCESn 2014 CHR, NCES Local data rate Childhood 68% of children vaccinated by age CDC NISp 2012 Local PH Clinical records immunization rate 3o Unmet care need 5% report unmet medical needsq CDC NHIS 2014 State estimates State estimates reported Hospital-acquired 1,700 HAIs per 100,000 hospital CDC HAI and 2014 CDC state data Clinical records infection (HAI)
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Social support 21% inadequate social supportcc CDC BRFSS 2014 CHR, BRFSS Patient query a Rounded to nearest integer or nearest 1,000. b Year refers to year published.
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t Computed. HCUP reports 3.9 million preventable hospitalizations per year.
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From page 129... ...
For example, related priority measures could provide more actionable information for providers working in certain specialties, or for community activists who are focused on particular community health outcomes or issues. Given the broad nature of the core measure set, the related priority measures can increase the actionability of the set by providing a tool for different stakeholder groups to focus attention on particular areas.
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130 VITAL SIGNS TABLE 4-2 Core Measure Set with Related Priority Measures Core Measure Focus Best Current Measures Related Priority Measures Infant mortality Life LIFE Life expectancy at birth Maternal mortality EXPECTANCY expectancy Violence and injury mortality Multiple chronic conditions WELL-BEING Well-being Self-reported health Depression Overweight Activity levels OVERWEIGHT Body mass index & OBESITY and obesity Healthy eating patterns Tobacco use Addictive ADDICTIVE Addiction death rate Drug dependence/illicit use BEHAVIOR behavior Alcohol dependence/misuse Unintended Teen pregnancy rate Contraceptive use UNINTENDED PREGNANCY pregnancy Childhood poverty rate HEALTHY Healthy High school graduation Childhood asthma COMMUNITIES communities rate Air quality index Drinking water quality index Influenza immunizations Preventive Childhood PREVENTIVE Colorectal cancer screening SERVICES services immunization rate Breast cancer screening Usual source of care CARE ACCESS Care access Unmet care need Delay of needed care Wrong-site surgery Hospital-acquired infec PATIENT SAFETY Patient safety Pressure ulcers tion rate Medication reconciliation Cardiovascular risk reduction Hypertension control EVIDENCE Evidence- Preventable Diabetes control composite BASED CARE based care hospitalization rate Heart attack therapy protocol Stroke therapy protocol Unnecessary care composite Patient experience Care match Patient–clinician Shared decision making with patient communication CARE MATCH WITH PATIENT GOALS End-of-life/advanced care goals satisfaction planning Personal High spending relative to Health care–related INDIVIDUAL spending SPENDING BURDEN income bankruptcies burden continued
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From page 131... ...
A reversal in life expectancy for a group, or an intractable or increasing disparity, is a fundamental and strong failure alert. Improving life expectancy for any group requires the engagement of a broad range of stakeholders working individually and in coordination to address the causes of premature death in the population as whole, as well as in key demographic subpopulations.
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From page 132... ...
Additionally, because life expectancy includes infant mortality, these deaths may have a large effect on the average. While significant additional measure development is needed for the majority of the core measures, life expectancy at birth is an example of a best current measure that is sufficiently valid and reliable to represent the core measure concept.
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SOURCE: OECD, 2013. Related Priority Measures Alternative measures considered by the Committee include life expectancy at various ages, infant mortality, maternal mortality, quality-adjusted life years (QALYs)
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. WELL-BEING Well-being Importance Life expectancy and death rates from various diseases and injuries pro vide clear measures of health in a population group, but health and well-be ing in the population have many other components, including illness from chronic or acute diseases, injury, functional capacity, mental health, sense of security, and social networks.
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From page 135... ...
Improving well-being across the nation will require collective action, extending well beyond the care system to include such groups as employers, schools, community organizations, and others. Best Current Measure The Committee identified self-reported health status as the best current measure for well-being.
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While self-reported health status is a powerful tool for assessing wellbeing in terms of both its statistical validity and its conceptual simplicity, additional measure development may lead to improvements. For example, some survey structures may be superior to others for assessing well-being, so that improvements in the structure and wording of survey questions could lead to more accurate measures.
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Among them, the Committee selected two related priority measures for well-being: multiple chronic conditions and depression. These two measures provide information about well-being from two critical perspectives for the nation's health: chronic disease and mental health.
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Therefore, reducing the prevalence of overweight and obesity in the United States -- and, by 100 Percent of people who are obese 90 80 70 60 (30+ BMI) 50 40 30 20 10 0 United States OECD FIGURE 4-5 Obesity prevalence: United States versus OECD countries.
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, a relative number derived from an individual's weight and height, serves as a reliable indicator of overweight and obesity. The Committee therefore identified BMI as the best current measure for this core measure focus.
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Related Priority Measures Alternative measures considered by the Committee include caloric intake, fruit and vegetable consumption, sedentary lifestyles, and activity levels. Each of these measures provides important information about a key component of overweight and obesity.
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NOTE: BMI = body mass index.
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. Best Current Measure The Committee identified the addiction death rate as the best current measure for addictive behavior.
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mortality across these three addiction categories, the Committee selected three related priority measures that reflect these categories for use by stakeholder groups that may need a more detailed view of the behaviors associated with addictionrelated mortality: tobacco use, drug use, and excessive drinking. For example, some communities may have smoking rates that are lower than average but a significantly higher incidence of drug use.
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From page 144... ...
Best Current Measure The Committee identified teen pregnancy rate as the best current measure for unintended pregnancy. The number of live births to women aged 15 to 19 is readily countable, and it presents an accessible view of the extent to which births in the United States are planned and, by extension, the variety of social, cultural, educational, and health care factors related to the behaviors associated with unintended pregnancy.
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The children of teen mothers also experience poorer health outcomes relative to the children of older mothers. While teen pregnancy offers a look at unintended pregnancy in the population of women aged 15 to 19, better measures are needed to provide a full assessment of unintended pregnancy across age groups.
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While teen pregnancy highlights a critical outcome related to contraceptive use, it also is more narrowly focused as it considers only women aged 15 to 19. The related priority measure of contraceptive use considers unintended pregnancy at any age, and could be useful for stakeholder groups that work with older populations or with a broader focus on women's health and health care.
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From page 147... ...
Community health encompasses critical elements of health that fall outside of the care system but have a major impact on care and health outcomes, such as education, employment, housing, and environment. Best Current Measure The Committee identified high school graduation rate as the best current measure for healthy communities.
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From page 148... ...
Although unemployment and poverty might provide more immediate measures of community health, and effects on education are likely to occur over a longer time period, the Committee considered it important to highlight education as a critical factor in community health and socioeconomic well-being and a major determinant of health. This was due in part to the conclusion that elements of socioeconomic status linked to income are demonstrated in other areas of the core measure set, particularly within "personal spending burden." Findings in the literature suggest that the correlation between income and education is not strong enough to justify using one as a proxy for the other and that, in some cases, education may be the best single socioeconomic predictor of good health (Braveman et al., 2005; Winkleby et al., 1992)
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Related Priority Measures Alternative measures considered by the Committee include environ mental quality, poverty, quality of life, employment, and infrastructure. While many of these measures provide important information about a key aspect of community health, the Committee selected childhood poverty rate, childhood asthma, and air quality index as related priority measures.
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Best Current Measure The Committee identified childhood immunization rate as the best current measure for preventive services. According to the CDC's National
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Related Priority Measures Alternative measures considered by the Committee include the incidence of vaccine-preventable disease, colorectal cancer screening, aspirin for primary prevention of cardiovascular disease, breast cancer screening, tobacco cessation counseling, BMI screening and follow-up, and control of high blood pressure. While each of these measures provides important information about a key component of prevention, immunization status was selected as a proxy because it represents a particularly stable and long-lasting component of prevention and covers a large, non-diseasespecific population.
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. In 2012, recommended vaccines were received by 64 percent of children aged 19-35 months living below the federal poverty level, compared with 70 percent of children of this age in the U.S.
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Best Current Measure The Committee identified unmet care need as the best current measure for care access. Data on unmet care need are collected through a variety of measures and surveys, including the Agency for Healthcare Research and Quality's (AHRQ's)
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Related Priority Measures Alternative measures considered by the Committee include usual source of care, delay in initiation of needed care, lack of health insurance, and underinsurance. While each of these measures provides important information about aspects of care access, unmet need encompasses the broadest range of causes and consequences of lack of access to care.
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SOURCE: CDC, 2014c. PATIENT SAFETY Patient Safety Importance Avoiding harm is a primary obligation of the health care system, yet despite the steadily declining hospital mortality in the United States, one of every three hospitalized patients may be harmed during their stay, and one of five Medicare patients are rehospitalized within 30 days of admis sion (IOM, 2012a)
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From page 156... ...
Best Current Measure The Committee identified hospital-acquired infection rate as the best current measure for patient safety. Data on avoidable adverse events are available from many sources, with some studies suggesting that certain adverse events are underreported (Seiden and Barach, 2006)
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In addition to the best current measure of care-associated infections, the Committee identified a second priority measure: unnecessary care. This measure is a step removed from but closely related to the concept of patient safety.
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Best Current Measure The Committee identified preventable hospitalization rate as the best current measure for evidence-based care. The Committee found that an
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also administers the Hospital-Acquired Condition (HAC) Reduction Program, which was established by the ACA to promote improvement in patient safety in hospital settings by tying performance incentives to payment (CMS, 2014a)
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Related Priority Measures Alternative measures considered by the Committee include chronic disease management, readmissions, cardiovascular risk reduction, and elective delivery. While each of these measures provides important information about a key aspect of evidence-based care and appropriate treatment, preventable hospitalizations encompasses the broadest range of potential causes and conditions and also reflects such key health system performance issues as communication with patients, availability of ambulatory resources, care coordination, and social services.
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Examples include the Dartmouth CollaboRATE measure, the Patient Enablement Index, and the NCQA Patient-Centered Medical Home standards. Best Current Measure The Committee identified patient-clinician communication as the best current measure for care match with patient goals.
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From page 162... ...
Related Priority Measures Alternative measures considered by the Committee include use of shared decision making, patient ratings of providers, end-of-life care, and likelihood of recommending. While each of these measures provides important information about the extent to which health and health care align with patient goals, people's reports of satisfaction with their clinician's communication encompass a broad range of potential issues and concerns.
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From page 163... ...
End-of-life care represents a critical area in need of significant development in terms of both care and its measurement, and one in which patient and family views and perspectives play a critical role. Disparities The CAHPS composite measure on patient–clinician communication reveals disparities in health outcomes and responses, notably across geo graphic regions (see Figure 4-14)
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Protection from excess financial exposure is a key goal of the health care system. Best Current Measure The Committee identified high spending relative to income as the best current measure for personal spending burden.
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Data on health care affordability come from a variety of sources and are specified in a range of ways, including per capita spending on health care; rates of uninsured and underinsured; and more complex estimates that break down out-of-pocket spending according to payroll deductions, copays, coinsurance, and other cost sharing. These data have been collected for many years using standardized methods and are reported regularly through government agencies as well as by a variety of health organizations, including The Commonwealth Fund.
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consumers. POPULATION Population Spending Burden SPENDING BURDEN Importance In addition to its burden on individuals, health care spending consumes a large portion of the nation's gross domestic product (GDP)
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Best Current Measure In identifying the proportion of economic resources spent on health care as the best current measure for population spending burden, the Committee is underscoring the importance of considering the issue not only at the national level (health as a percentage of GDP for the nation) but also at the state and local levels and even at the institutional level.
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While these measures provide important information about the sustainability of health spending, proportion of GDP devoted to health care provides a simple, accessible estimate for the impact of health care spending on the nation's economy. In addition to proportion of economic resources spent on health care, the Committee identified three related priority measures for population spending burden: total cost of care, spending growth, and growth in health care spending versus GDP growth.
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From page 169... ...
This engagement includes choices about diet, exercise, lifestyle, and other behaviors that have well-known implications for the de velopment of chronic disease and other health consequences, as well as the extent to which people are prepared with the necessary knowledge, skills, and tools to play an active, meaningful role in the influence of community factors on their health and health care as well as that of others. Individual engagement means that individuals and families play an active role not only in their care but also in the range of factors that contribute to their health, including environment, community, economy, social well-being, and more.
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Example elements could include health literacy; involvement in personal, family, and community health; and working actively to improve the health of oneself and others, as well as active involvement in promoting a health-oriented
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Related Priority Measures Alternative measures considered by the Committee include self-care, actively trying to lose weight, use of emerging m-health tools (see Chapter 2) that help move care to where the patient is, and family health.
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. Community engagement also has significant linkages with other core measure foci, including well-being, healthy communities, and individual engagement.
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Enabling and encouraging communities to take an active role in improving their health presents a significant opportunity for improving health and health care and brings together a broad range of stakeholder groups. Best Current Measure The Committee identified social support as the best current measure for community engagement.
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Development and pilot testing of composite measures in this and other areas is a key priority for the implementation of core measures. Related Priority Measures Alternative measures considered by the Committee include healthrelated community activities, availability of healthy food, green space, walkability, public transportation, and political involvement.
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From page 175... ...
For many of the core measure foci, significant research and development are needed to build measures and data streams that are true reflections of the most critical facets of American health. For example, the preventable hospitalizations measure takes a narrow, limited view of evidence-based care, the core measure focus it is intended to represent.
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From page 176... ...
The Committee identified best current measures for each core measure to illustrate how the core measures could be applied in the short term, with the expectation that over the long term, improved measures would be developed, validated, and incorporated into the nation's vital signs. Establishing an Ongoing Process The health and health care field is constantly evolving and, accordingly, the nation's vital signs cannot be implemented statically.
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From page 177... ...
By reexamining the range of measures in use today through the lens of quality, sensitive outcomes, and system-impact protocols, it is possible to reduce this panoply of measures of patient safety -- as with each other measurement area identified -- to a patient safety composite, as illustrated in the far right column, that works cooperatively with the full measure set to provide actionable, consistent information about health performance. Figure 4-19 also illustrates, in a schematic sense, the growing measurement burden, how it might be reduced, and the role that core metrics would play in such a process, using the example of patient safety.
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others ... future fall risk POPULATION HEALTH - Atrial fibrillation and HS: life expectancy atrial flutter: chronic anti HS: perceived health coagulation therapy HS: days with physical or mental illness - Maternity care: elective Beh: fruit/vegetable consumption delivery or early induc Beh: activity levels tion without medical Soc: income/child proverty indication at greater than or equal to 37 weeks and Soc: neighborhood crime less than 39 weeks Env: air particulate matter And many more...
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From page 179... ...
Life expectancy at birth Infant mortality Maternal mortality Violence and injury mortality Co-occurring chronic conditions Self-reported health Health-adjusted life expectancy Body mass index Life expectancy Activity levels Well-being Healthy eating patterns Tobacco use Overweight and Drug dependence/illicit use obesity Alcohol dependence/misuse Addiction deaths Addictive Adolescent pregnancy Contraceptive use behavior Unmet need or delayed care Unintended Patient experience Patient-clinician pregnancy IMPACT communication Healthy ASSESSMENT High blood pressure therapy • Quality-sensitive protocol communities outcomes Acute heart attack therapy Preventive protocol • System-impact Stroke therapy protocol services protocols Diabetes therapy protocol Breast cancer therapy protocol Care access Pain management protocol Patient safety Asthma management protocol Childhood immunization Evidence-based Influenza immunization care USPSTF recommended services Care match with Depression screening and patient goals treatment Colorectal cancer screening Personal Breast cancer screening Advanced care planning spending burden Wrong site surgery Population Hospital acquired infection Pressure ulcers spending burden Medication reconciliation Individual Preventable hospitalizations Spending relative to income engagement Per capita health care spending Community Spending growth categories Childhood poverty engagement Health literacy Use of personal health tools High school graduation Air quality index Drinking water quality index Social support availability Availability of healthy food Community walkability Community health benefit agenda NOTES: Beh: behavior; Can: cancer; Com: community engagement levels; CVD: heart disease and stroke; DM: diabetes mellitus; Env: environmental; HS: health status; ID: infectious disease; Ind: individual; MCH: maternal and child health; MH: mental health; OGQ: other and general quality; PC: personal cost; Pexp: patient experience; Prev: preventive services; Resp: pulmonary disease, including asthma; RR: relative resource use; Safe: safety; Soc: social; Surg: surgery; UN: unnecessary services.
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2014. Vital signs: Disability and physical activity -- United States, 2009-2012.
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. CDC Vital Statistics Cooperative Program.
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2006. The health literacy of America's adults: Results from the 2003 National Assessment of Adult Literacy.
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2006a. Racial and ethnic disparities in hospital patient safety events, 2005.
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2008. Racial disparities in patient safety indicator (PSI)
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