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Long-Term Care Survey Alert

Quality Assurance:

CMS CONTINUES QUEST FOR VALID QUALITY MEASURES

Published on Sun Sep 01, 2002

Wanted: quality measures that truly tell if a nursing facility is providing good care.

The Centers for Medicare & Medicaid Services took another step toward that goal last month when it released findings of a study performed on its behalf by Abt Associates Inc. titled "Validation of Long-Term and Post-Acute Care Quality Indicators" (http://cms.hhs.gov/providers/nursinghomes/nhi/).

The study examined 45 quality indicators derived from the minimum data set that are commonly used to assess resident outcomes and care in long-term care facilities. CMS already uses many of the indicators and measures in its quality monitoring and survey process. The study also looked at various risk adjustment methods.

"Some of the quality indicators tested very well and appeared to be very valid," reports Sandra Fitzler, director of clinical services for the American Health Care Association. "Others worked well for acute care or chronic care populations and others were not recommended."

The study found the following chronic care measures to be invalid and recommended rejecting them for further use:

  • Behavioral symptoms ( high and low risk);

  • Weight loss;

  • Antipsychotic use (high risk and low risk);

  • Worsening behavior; and

  • Worsening pressure ulcers.

    Of the current measures used in CMS' pilot Nursing Home Quality Initiative in six states, only the weight loss measure was found invalid and won't be used in the national initiative this fall.

    The Abt study also recommended a facility-level adjustment for some quality measures based upon patient characteristics upon admission (known as the FAP or facility admission profile).

    In AHCA's view, CMS' efforts can be viewed as a start on measuring and reporting quality.

    "It's the best available science even though it's not completely there," says Fitzler. "For example, pain and infection are evolving areas because they are new quality measures."

    CMS has further risk-adjusted the infection QM by excluding patients with end-stage disease or those receiving hospice services, as recorded on the MDS. The adjustment helped, but the measure includes a broad spectrum of infections, including respiratory, urinary tract and even fever. (By comparison, the quality indicator used by surveyors only focuses on urinary tract infections.) "Yet a high prevalence of a certain type of infection in a facility can signal very different clinical issues or shortcomings," says James Marx, an infection control specialist and principal of Broad Street Solutions in San Diego.

    In some cases, tinkering with the risk adjustment might not make as big of a difference as providers think, according to David Gifford, clinical coordinator for the Rhode Island Quality Partners, one of the state-run quality improvement organizations supporting nursing facilities in the pilot and national quality initiative.

    "For example, some providers have suggested that amputees should be excluded from the post-acute measure that looks at improvement in walking [from the 5-day to the 14-day assessment]," Gifford notes. "But some amputees walk again with assistive devices, which is the rationale for including them in the quality measure," he explains.

    Gifford points out, however, that most facilities don't care for enough patients with leg amputations to alter their score on the quality measure.

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