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The American Journal of Managed Care October 2013
Dispensing Channel and Medication Adherence: Evidence Across 3 Therapy Classes
Reethi Iyengar, PhD, MBA, MHM; Rochelle Henderson, PhD, MPA; Jay Visaria, PhD, MPH; and Sharon Glave Frazee, PhD, MPH
Utilization of Lymph Node Dissection, Race/Ethnicity, and Breast Cancer Outcomes
Zhannat Z. Nurgalieva, MD, PhD; Luisa Franzini, PhD; Robert O. Morgan, PhD; Sally W. Vernon, PhD; and Xianglin L. Du, MD, PhD
The Mis-Measure of Physician Performance
Seth W. Glickman, MD, MBA; and Kevin A. Schulman, MD
Inefficiencies in Osteoarthritis and Chronic Low Back Pain Management
Margaret K. Pasquale, PhD; Robert Dufour, PhD; Ashish V. Joshi, PhD; Andrew T. Reiners, MD; David Schaaf, MD; Jack Mardekian, PhD; George A. Andrews, MD, MBA, CPE; Nick C. Patel, PharmD, PhD, BCPP; and James Harnett, PharmD, MS
Empirical Analysis of Domestic Medical Travel for Elective Cardiovascular Procedures
Jacob D. Langley, MS-HSM; Tricia J. Johnson, PhD; Samuel F. Hohmann, PhD, MS-HSM; Steve J. Meurer, PhD, MBA, MHS; and Andy N. Garman, PsyD
Physician Capability to Electronically Exchange Clinical Information, 2011
Vaishali Patel, PhD, MPH; Matthew J. Swain, MPH; Jennifer King, PhD; and Michael F. Furukawa, PhD
Physician Assistants in American Medicine: The Half-Century Mark
James F. Cawley, MPH, PA-C; and Roderick S. Hooker, PhD, PA
How Do Providers Prioritize Prevention? A Qualitative Study
Jeffrey L. Solomon, PhD; Allen L. Gifford, MD; Steven M. Asch, MD; Nora Mueller, MAA; Colin M. Thomas, MD; John M. Stevens, MD; and Barbara G. Bokhour, PhD
Outcomes Among Chronically Ill Adults in a Medical Home Prototype
David T. Liss, PhD; Paul A. Fishman, PhD; Carolyn M. Rutter, PhD; David Grembowski, PhD; Tyler R. Ross, MA; Eric A. Johnson, MS; and Robert J. Reid, MD, PhD
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Performance Measurement for People With Multiple Chronic Conditions: Conceptual Model
Erin R. Giovannetti, PhD; Sydney Dy, MD; Bruce Leff, MD; Christine Weston, PhD; Karen Adams, PhD, MT; Tom B. Valuck, MD, JD; Aisha T. Pittman, MPH; Caroline S. Blaum, MD; Barbara A. McCann, MSW; and Cynthia M. Boyd, MD, MPH

Performance Measurement for People With Multiple Chronic Conditions: Conceptual Model

Erin R. Giovannetti, PhD; Sydney Dy, MD; Bruce Leff, MD; Christine Weston, PhD; Karen Adams, PhD, MT; Tom B. Valuck, MD, JD; Aisha T. Pittman, MPH; Caroline S. Blaum, MD; Barbara A. McCann, MSW; and Cynthia M. Boyd, MD, MPH
The Performance Measurement for People with Multiple Chronic Conditions conceptual model can facilitate development and refinement of quality measures for a medically complex population.
Background: Improving quality of care for people with multiple chronic conditions (MCCs) requires performance measures reflecting the heterogeneity and scope of their care. Since most existing measures are disease specific, performance measures must be refined and new measures must be developed to address the complexity of care for those with MCCs.

Objectives: To describe development of the Performance Measurement for People with Multiple Chronic Conditions (PM-MCC) conceptual model.

Study Design: Framework development and a national stakeholder panel.

Methods: We used reviews of existing conceptual frameworks of performance measurement, review of the literature on MCCs, input from experts in the multistakeholder Steering Committee, and public comment.

Results: The resulting model centers on the patient and family goals and preferences for care in the context of multiple care sites and providers, the type of care they are receiving, and the national priority domains for healthcare quality measurement.

Conclusions: This model organizes measures into a comprehensive framework and identifies areas where measures are lacking. In this context, performance measures can be prioritized and implemented at different levels, in the context of patients’ overall healthcare needs.

Am J Manag Care. 2013;19(10):e359-e366
Improving the quality of care for people with multiple chronic conditions (MCCs) requires performance measures reflecting the heterogeneity of, and scope of care required by, these people.
  • The Performance Measurement for People with Multiple Chronic Conditions conceptualmodel is designed to facilitate development and refinement of performance measures to address the complexity and dynamic nature of care for those with MCCs.
  • The model centers on patient and family goals and preferences for care in the context of multiple care sites and providers, the type of care they are receiving, and the national priority domains for healthcare quality measurement.
One-fourth of Americans have 2 or more chronic conditions, yet this population accounts for more than half of overall healthcare expenditures.1 Having multiple chronic conditions (MCCs) can negatively affect quality of life,2 ability to work,3 disability,4 and mortality.5 Despite the high prevalence of MCCs and corresponding negative consequences, care for people with MCCs is often fragmented, incomplete, inefficient, and ineffective,4,6,7 resulting in potentially avoidable inpatient admissions,8,9 adverse  consequences of therapeutic interactions,10 and postoperative complications. The Department of Health and Human Services has identified “fostering healthcare and public health system changes to improve the health of individuals with multiple chronic conditions” as one of 4 goals in an overall strategic framework to improve the health of individuals with MCCs.1 Various  agencies, including the Centers for Medicare & Medicaid Innovation Center, Centers for Disease Control and Prevention, and     Administration on Aging, are funding projects centered around healthcare quality improvement for individuals with MCCs.  However, existing healthcare quality measures used in many of these projects are inadequate for measuring quality improvement for this population.1

Existing quality performance measures are often limited by a disease-specific focus,7,11 do not account for patient and family  preferences and goals,12,13 and often focus on a single setting such as hospitals. Performance measurement has been largely guided by a single disease heuristic that does not address challenges common to MCCs such as disease interactions and treatment interactions, and little evidence exists to support development or adaptation of performance measures for people with MCCs.14 To improve quality and efficiency of care for people with MCCs, performance measures need to address the  heterogeneity and scope of care, individuals’ priorities and care preferences, the high risk of uncoordinated care across settings, and the high risk for adverse health outcomes in the presence of comorbidities. Currently, few measures meet these criteria, and those that exist require further development.7,15

There is a need to develop new performance measures and refine existing measures to address the complexity of care experienced by patients with MCCs and their families over time. Such development efforts would be facilitated by an appropriate conceptual model. Existing conceptual models of quality of care address some of these issues but do not address the broader perspective of people with MCCs.16,17 To help advance development of new performance measures and implementation of existing measures in this area, the Department of Health and Human Services requested that the National Quality Forum convene a multistakeholder steering committee to develop a measurement framework for individuals with MCCs. As part of this effort we developed the Performance Measurement for People with Multiple Chronic Conditions (PM-MCC) conceptual model based on reviews of the literature and existing conceptual models of performance measurement,17-22 input from experts on the National Quality Forum Steering Committee, and input through an open public comment period.

MODEL OVERVIEW

This conceptual model centers on a patient with multiple conditions, represented by overlapping circles (see center circle of the Figure). Included are traditional diseases, but also conditions such as symptoms, disability, substance abuse, and hearing impairment that fall outside the traditional disease model.Any given condition may affect the patient to a greater or lesser magnitude at any one time, and may or may not be a dominant condition (ie, a condition so complex or serious that it eclipses the management of other conditions23). The patient and the family or friends who care for him/her have goals and preferences   for care of these diseases and conditions. Performance measurement should center on these goals and preferences.

The first circle surrounding the individual at the center of the model represents shifting sites and providers that support and care for the individual’s healthcare needs. These sites could include the ambulatory, hospital, postacute, nursing home, community, home (including formal home-based primary and skilled nursing care as well as informal care), and pharmacy settings. This list is not exhaustive; rather, it is intended to be illustrative of the possible sites of care for people with MCCs. At any given site, multiple types of providers may be providing care over time.

Moving outward from the sites and providers circle, there is a circle representing the types of care an individual may receive at any given site of care. The types of care patients receive (eg, screening, prevention, diagnosis, treatment, management, secondary prevention, community services, management of an acute exacerbation, rehabilitation, palliation, end-of-life care) are not necessarily linear or mutually exclusive. For example, a patient with congestive heart failure may be seen in the hospital for an acute exacerbation while receiving ongoing care for diabetes and depression at the same time. 

The outermost circle represents the domains of measurement that apply across sites and types of care. These domains are not mutually exclusive, and a given measure could fall into multiple domains; however, measures can be categorized under the 6 priority areas of the National Quality Strategy for improving healthcare: (1) health and well-being, (2) effective prevention and  treatment, (3) person- and family-centered care, (4) patient safety, (5) effective communication and care coordination, and (6) affordable care (Figure). These domains intentionally align with the  National Quality Strategy to promote harmonization across public- and private-sector programs supporting this population and to provide a way to track progress n filling of critical measure gaps.  In each measurement domain there are non–disease-specific measures such as pain screening (which would apply to all patients within a certain opulation regardless of their condition)  and disease-specific measures such as management of antidepressant medications (which would apply to patients with certain conditions). 

These circles, described above and shown in the Figure, re intended to be seen as a set of interlocking wheels that  rotate over time. At any given point in time, an individual may receive 1 or  more types of care in 1 or more settings from multiple providers. At the same time, the domains of performance measurement most important for that patient, site, or type of care vary. Some measures may be specific to a site and type of care, while others (eg, care coordination) apply across sites and types of care.

Each measurement domain can be measured over a period of time, which may be labeled as an episode. However, the PM-MCC model builds on the original National Quality Forum–endorsed patient-focused episodes of care framework by recognizing that distinct beginnings and ends to episodes of care are difficult to define and may need to be defined more arbitrarily in people with MCCs. Additionally, the elements of care highlighted on this model are not meant to be of equal importance. The amplification or minimization of any item in the model will vary with the individual and across time. The PM-MCC model places measures within the larger context of patient’s multiple conditions, sites of care, and types of care. We propose that in this context measurement  can be applied  and prioritized at the level of the individual, practice, site of care, health plan, or population.

Finally, the PM-MCC model falls within a social and environment context, as well as a public and private health policy context. These contextual factors surrounding the patients, their healthcare needs, and the delivery of healthcare will affect the way performance is measured. By using the PMMCC conceptual model, measurement developers, researchers, and policy makers can refine and implement performance measurement sets to effectively evaluate and improve care for individuals with MCCs.

APPLYING THE CONCEPTUAL MODEL

To demonstrate how the PM-MCC model can be applied, as well as its utility, we present the case of a 60-year-old woman with known congestive heart failure (CHF), diabetes, hypertension, and depression as just 1 example of a complex patient.24 Over the course of 6 months, this patient received care from an internist in primary care, a cardiologist in specialty care, a spousal caregiver at home, and a pharmacist in the pharmacy. The types of care provided included screening, prevention, treatment, and management. Over the episode of care, the patient had some weight loss and fatigue. There was no acute exacerbation of her conditions or change in the ites or types of care provided, although it is not clear that her depression was adequately treated initially given her fatigue and weight loss. Examples of the complex medical decision making her providers faced include how low to push her blood pressure and the choice and dose of antidepressants in light of a previous fall and her ongoing risk of falls. It is not rare for patients to be more complex than the patient described here—cognitive impairment due to traumatic brain injury or dementia, or a history of substance abuse, are just 2 examples. Cognitive impairment would increase the involvement of her spouse in her healthcare decision making and management, and would make care coordination more challenging.25,26

The ideal measurement framework would assess the goals and priorities of this patient, and tailor the performance measures to the priorities of the patient. For example, this patient, her spousal caregiver, and her physician may be more concerned about depression control and antidepressant medication management than blood pressure or diabetes control. This information could theoretically drive which denominators of performance measures should be applied to her (eg, the denominator of an antidepressant medication adherence measure but not the denominator of a glycated hemoglobin control measure) or the relative weight given to performance measures for this patient (with higher weight given to achieving antidepressant medication adherence than to achieving glycated hemoglobin control). This method of selecting or weighting performance measures based on individual patient goals and priorities is not currently feasible in most settings. However, personal health records and health information technology may make this type of patient-centered measurement more of a reality.

 
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