Vital Signs Core Metrics for Health and Health Care Progress (2015) / Chapter Skim
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Pages 3-34
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From page 3... ...
. Identifying and prioritizing the most powerful among these myriad measures at each level of activity -- establishing core measures -- can enable the health system to work in a coordinated fashion with many stakeholders, most importantly with patients, citizens, and communities, toward a shared vision of America's health future.
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The Committee's work was made possible by the financial support of three sponsors: Blue Shield of California Foundation, the California HealthCare Foundation, and the Robert Wood Johnson Foundation. The charge to the Committee was to "conduct a study and prepare a report directed at exploring measurement of individual and population health outcomes and costs, identifying fragilities and gaps in available systems, and considering approaches and priorities for developing the measures necessary for a continuously learning and improving health system." Specifically, the Committee was directed to • "consider candidate measures suggested as reliable and representa tive reflections of health status, care quality, people's engagement and experience, and care costs for individuals and populations; • identify current reporting requirements related to progress in health status, health care access and quality, people's engagement and experience, costs of health care, and public health; • identify data systems currently used to monitor progress on these parameters at national, state, local, organizational, and individual levels; • establish criteria to guide the development and selection of the measures most important to guide current and future-oriented action; • propose a basic, minimum slate of core metrics for use as sentinel indices of performance at various levels with respect to the key elements of health and health care progress: people's engagement and experience, quality, cost, and health;
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Two full surveys were developed and administered to the Committee members, soliciting their insights on the relative merits of and alternatives to candidate measures, their opinions on priorities, and any issues that may not have received adequate attention. This summary describes the key context for this study, including the challenge of the burden of measurement, and then presents the Committee's approach to selecting core measures.
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. The emerging health information technology infrastructure could support a real-time measurement system for the routine collection of information about care processes, patient needs, progress toward health goals, and individual and population health outcomes.
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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 8... ...
Consequently, unless a process measure, or composite process measure set, offered the prospect of a broader impact on system performance, the Committee tended to give outcome measures priority over process measures. Many of the individual measures in use today were developed and implemented for a particular purpose and circumstance, without attention to the broader context.
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APPROACH TO THE SELECTION OF CORE MEASURES Starting Point: Domains of Influence The Committee's starting point in identifying the foci for core measures was assessment of the key domains of influence -- that is, those with the greatest potential to have a positive effect on the health and well-being of the population and each individual within it, now and in the years to come. The domains identified in the Committee's charge include healthy people,
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. To help improve population health, a core measure set must provide solid indicators of progress toward that goal.
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Care Costs The health care system is characterized by inefficiencies in spending and resource use, such that, according to the 2013 IOM report Best Care at Lower Cost (IOM, 2012a) , an estimated 30 percent of health care spending is wasted.
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As defined in Box S-1, core measures, for present purposes, represent a parsimonious set of measures that provide a
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Rather, the Committee's approach helped identify ways in which a core measure set might help channel and transform the effectiveness of the many otherwise siloed efforts aimed at engaging the various potentially controllable determinants of health. Identification of candidate core measures involved an assessment of the most important elements for each of the four domains identified above: for healthy people, these were length of life, quality of life, healthy behaviors, and healthy social circumstances; for care quality, they were prevention, access to care, safe care, appropriate treatment, and person-centered care; for care costs, they were affordability and sustainability; and for people's engagement in health and health care, they were individual engagement and community engagement.
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THE CORE MEASURE SET Applying the above criteria, the Committee arrived at the core measure set presented in Table S-1. In this table, the domains represent the highest level of organization of the core measures, serving as a guiding framework for their selection and application; the key elements represent the broadest conceptually discrete components of the respective domains; the core measure foci express the most representative and specific focus for measurement for each key element, translating the conceptual key element into something measurable; and the best current measures are measures selected by the Committee from among those now in use in various settings as most representative of the foci of the specified core measures.
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rate admissions 10,000 Preventable avoidable per Appropriate Evidence EVIDENCE- hospitalization 100,000 treatment BASED CARE based care rate hospital admissions Patient– Care match 92% satisfied Person- clinician com CARE MATCH WITH with patient with provider centered care PATIENT GOALS munication goals communication satisfaction continued
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Standardized measurement approaches exist for life expectancy and overweight and obesity, but such widely accepted standardized measures are absent for most of the other foci, including well-being, addictive behavior, healthy communities, evidence-based care, spending burden, and individual and community engagement. Additionally, many of the core measures will need to be adapted when used at different levels of the health system.
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This measure set, while imperfect, represents in the Committee's view a powerful starting set of "vital signs" for tracking progress toward improved health and health care in the United States. The Committee believes further that the core measure set recommended herein comprises the vital signs on the status and progress of the nation's health and health care, that a single measure can be chosen or developed for each of the core measure foci within each domain of influence, and that the development of a standardized measure is essential for each focus.
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High-quality care is a function of the interplay among access to care, prevention, and appropriate treatment. The interplay among and the reinforcing nature of these elements was a factor in the identification and consideration of core measures.
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Preventive services: Preventive services -- immunization, screening, counseling, and chemo prophylaxis -- present a valuable opportunity for both improving health and adding value. Based on rigorous evidence standards, the U.S.
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Evidence-based care: One of the central challenges for the American health system is ensuring that care delivered is based on the best available scientific evidence of appropriateness and effectiveness. While advances in medicine and health care have led to substantial gains in life expectancy and quality of life over time, a variety of estimates suggest that many people still fail to receive recommended care or they receive care not based on scientific evidence.
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To begin to accommodate this challenge, the Committee also identified 39 "related priority measures" for consideration, presented in Table S-2. These measures, together with the core measures, give a more detailed view of the
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22 VITAL SIGNS TABLE S-2 Core Measure Set with Related Priority Measures Core Measure Focus Related Priority Measures Infant mortality LIFE EXPECTANCY Life expectancy Maternal mortality Violence and injury mortality Multiple chronic conditions WELL-BEING Well-being Depression Activity levels OVERWEIGHT Overweight and obesity & OBESITY Healthy eating patterns Tobacco use ADDICTIVE Addictive behavior Drug dependence/illicit use BEHAVIOR Alcohol dependence/misuse UNINTENDED Unintended pregnancy Contraceptive use PREGNANCY Childhood poverty rate Childhood asthma HEALTHY Healthy communities COMMUNITIES Air quality index Drinking water quality index Influenza immunizations PREVENTIVE SERVICES Preventive services Colorectal cancer screening Breast cancer screening Usual source of care CARE ACCESS Care access Delay of needed care Wrong-site surgery PATIENT SAFETY Patient safety Pressure ulcers Medication reconciliation Cardiovascular risk reduction Hypertension control Diabetes control composite EVIDENCE- Evidence-based care BASED CARE Heart attack therapy protocol Stroke therapy protocol Unnecessary care composite Patient experience CARE MATCH WITH Care match with patient goals Shared decision making PATIENT GOALS End-of-life/advanced care planning INDIVIDUAL Personal spending burden Health care–related bankruptcies SPENDING BURDEN Total cost of care POPULATION Population spending burden SPENDING BURDEN Health care spending growth
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Prominent examples of such existing programs, stakeholders, and activities include the Meaningful Use Program, the Medicare Shared Savings Program, payers and purchasers, state Medicaid waivers, categorical grants, community health planning, community benefit requirements, and related health care reform provisions. Table S-3 highlights some of the ways in which the core measure set can help streamline and improve the measurement and operational efficiencies of these entities.
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It is the HHS Secretary who directs the agencies most involved in the collection and use of health data; who signs off on reporting requirements and responsibilities; who is centrally positioned to convene and work with the key stakeholders; and who, as the leader most responsible for the nation's effectiveness and efficiency in delivering better health at lower cost, has the greatest potential to unlock the capabilities of the core measure set. A first-order implementation leadership opportunity lies in the Secretary's ability to embed the use of the core measure set in the programs
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As a member of the cabinet, the HHS Secretary also has the opportunity to facilitate cross-sectoral approaches to improving health by working with housing, transportation, environment, education, agriculture, and labor authorities. Similarly, the HHS Secretary is the appropriate person to steward the eventual process of amending the core measure set.
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These perspectives touch on the key conceptual and practical elements engaged by the core measures and their implementation, and they underpin the Committee's recommendations. Because those recommendations are grounded in the basic notion that achieving the potential of core measures will require broad leadership from stakeholders throughout the nation, they are targeted to, and organized around, stakeholder opportunities and responsibilities.
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Composite measures. Certain core measures are intended to be composites developed from individual elements collected discretely and reported in the ag gregate to express how a family of condition-specific measures better reflects systemic performance than the individual measures.
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All People -- as Individuals, Family Members, Neighbors, Citizens, and Leaders Recommendation 2: All people should work to understand and use the core measure set to assist in taking an active role in shaping their own health prospects and those of their families, their communities, and the nation. The Federal Government Recommendation 3: With the engagement and involvement of the Executive Of fice of the President, the Secretary of the U.S.
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Recommendation 5: The Secretary of HHS should establish and implement a mechanism for involving multiple expert stakeholder organizations in efforts to develop as necessary, maintain, and improve each of the core measures and the core measure set as a whole over time. The Secretary's role should encompass stewardship of work on • ational standardization of the best current measures and related priority n measures detailed in this report; • evelopment of the longer-term measures necessary to improve the utility d and generalizability of the core measures; • ational standardization of reporting on health disparities for each of the n core measures, including disparities based on race, ethnicity, gender, and socioeconomic status; • eriodic review and revision of the individual measures in response to p changing circumstances; and continued
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Clinicians and Health Care Delivery Organizations Recommendation 7: Clinicians and the health care organizations in which they work should routinely assess their contributions to performance on the core mea sures and identify opportunities to work collaboratively with community and public health stakeholders to realize improvements in population health. Employers and Other Community Leaders Recommendation 8: Employers and other community leaders should use the core measures to shape, guide, and assess their incentive programs, their pur chasing decisions, and their own health care interventions, including initiatives aimed at achieving transparency in health costs and outcomes and at fostering seamless interfaces between clinical care and supportive community resources.
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From page 31... ...
Moreover, core measures could be used to help better align the incentives and actions of multiple organizations at multiple levels: if they were striving for the same results, their activities would be more likely to align, or if they differed, would create natural experiments with which to assess the value of alternative routes to the same goals. But this opportunity for alignment must start with the existence of well-accepted, sound core measures of commonly sought outcomes.
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Therefore, a continuous learning approach to implementation, emphasizing the dynamic nature of the measures and the implementation process, can ensure that the core measures will serve as a sustained and reliable guide to and prompt for improvement and progress through decades to come. REFERENCES Agaku, I
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2008. Drug abuse costs the United States economy hundreds of billions of dollars in increased health care costs, crime, and lost productivity.
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USPSTF (U.S. Preventive Services Task Force)
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