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Long-Term Care Survey Alert

Quality Measures - Special Report:

Don't Trip Over Risk-Adjustment Pitfalls To New Pressure Ulcer Quality Measures

Published on Wed Feb 11, 2004

The pressure is on with implementation of the new set of publicly reported quality measures, especially for facilities' pressure ulcer scores.

The Centers for Medicare & Medicaid Services posted facilities' performance on the new set of QMs in late January (see chart for a list comparing the former QMs to the new round). And during a follow-up CMS-sponsored Open Door Forum on the new QMs, nursing home providers laid out their case for how the pressure ulcer scores could mislead consumers about their quality of care. For example, due to the lack of a facility-adjusted profile, the new QMs "skewer" the very centers of wound care excellence that CMS is trying to promote, an ODF participant pointed out.

CMS representatives Mary Pratt and Jean Scott agreed with many of providers' concerns and promised to make some changes moving forward. Here's a rundown of nursing homes' top concerns:

  •  Too little time to heal pressure ulcers for the post-acute measure. The QM reports the percentage of short-stay residents whose pressure ulcers remained the same or worsened from the 5-day to the 14-day assessment. Yet the assessment reference dates for these two assessments can be as little as three days apart, one provider pointed out. "The lookback periods are almost entirely the same," the ODF participant noted. "And you can have a stage 4 or stage 3 ulcer get better but not change in its staging, so what the QM is telling the public isn't necessarily true."

  •  No way to differentiate pressure ulcers present at admission and those that developed in-house. Here's the rub, as one provider put it: Facilities that admit high numbers of residents with wounds that require more than 90 days to heal look bad on the chronic-care QM. "Yet if the QM reported an acquired pressure ulcer rate for the facility, a lot of the industry's issues [with the public reporting] would dissipate," one provider noted.

    Pratt and Scott agreed, but noted that the MDS 2.0 version doesn't capture information about whether pressure ulcers were present at admission. CMS is, in fact, trying to figure out how to correct that shortfall with the MDS 3.0. Scott also promised to look into highlighting information on the Nursing Home Compare Web site indicating that wound care centers would be expected to have higher numbers of pressure ulcers because of whom they admit - and that 90 days may not be enough time to heal bad ulcers.

  •  Inclusion of residents in the low-risk chronic care pressure ulcer QM who are really at high risk of skin breakdown. The low-risk group simply includes chronic-care residents with pressure ulcers who don't have any of the three conditions included in the high-risk pressure ulcer measure (impaired transfer or bed mobility, comatose or malnutrition). "And that's a very limited definition of risk," observes Ruta Kadonoff, senior health policy analyst for the American Association of Homes & Services for the Aging. AAHSA had, in fact, suggested CMS use the term "average risk" in lieu of low risk, but CMS believed that term was too confusing to the public.

    The good news is that the QMs are a work in progress, and CMS does appear intent on addressing providers' concerns, emphasizes Kadonoff.

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