July 15, 2002
Kenneth W.
Kizer, M.D., M.P.H.
President and
CEO
National Quality
Forum
601 Thirteenth
St, NW
Suite 500 North
Washington,
DC 20005
Dear Dr. Kizer:
On behalf of the
American Health Quality Association (AHQA), a National Quality Forum (NQF) member
representing the national network of Quality Improvement Organizations (QIOs,
formerly known as PROs), thank you for this opportunity to comment on the NQF
ballot, "Nursing Home Performance Measures" (completed ballot enclosed).
The American Health
Quality Association supports the efforts of the NQF and its work related to the
development of Nursing Home Measures. We are not supporting every measure contained
in the ballot, however. Please refer to our explanations below.
Measures that Require
Further Modification before Approval.
- Residents taking
anti-psychotic medication who are not diagnosed as having psychotic disorders.
AHQA supports the
inclusion of measures that track the quality of mental health. However, the approval
of this particular measure may lead to unintended adverse consequences for nursing
home residents if implemented.
It appears that
the underlying intention of this measure is to permit examination of the use of
chemical restraints in nursing homes. The inappropriate use of anti-psychotic
medications such as chlorpromazine and related substances for the purposes of
sedating residents who exhibit disruptive behavior is a quality of care issue.
AHQA supports measures that aim to end the prescription of medications for improper
and unethical purposes.
However, new anti-psychotic
medications such as olanzapine, and other atypical anti-psychotics, possess appropriate
and ethical off-label indications beyond the treatment of psychosis. The benefit
of using these new anti-psychotic agents in certain non-psychotic patients is
promising. In addition, the new atypical anti-psychotics lack the significant
sedative/hypnotic side effects that enabled the use of older generation anti-psychotics
to control behavior in non-psychotic patients.
The approval of
this measure may hamper the ability for practitioners to use these promising new
medications. To preserve the integrity of this measure while avoiding unintended
adverse consequences, NQF should revise the risk adjustment methodology for this
measure. The exclusion criteria provided for this measure should be refined to
exclude the use of anti-psychotic medications that do not possess serious sedative/hypnotic
side effects as defined by nationally recognized drug information publications
such as the USP-DI, Facts and Comparisons, or other appropriate
drug references.
Because the exclusion
criteria for this measure do not meet an acceptable threshold to allow for the
appropriate provision of mental health care, AHQA is voting no on this measure.
Measures that require
the analysis of new information due July 15, 2002.
AHQA is voting
no on all measures that require risk adjustment, pending the review of new research
due from the Abt Associates on July 15, 2002. Because validation of the risk adjustment
methodology is essential to establishing credibility for the risk adjusted measures,
AHQA cannot approve the risk adjusted measures before reviewing the validation
study results. Our no vote on the following measures is not a judgment on the
importance or content of the measures listed below. We are simply deferring judgment
on these measures until new evidence of the validity can be considered.
AHQA votes no on
the following measures, pending review of the validation study to be released
by the Abt Associates:
- Residents who
need more help with daily activities;
- Residents who
lose too much weight;
- Residents with
pain;
- Residents with
pressure ulcers;
- Residents who
frequently lose control of their bowel and have a catheter in the bladder at all
times;
- Residents who
remain in bed all of the timeÆ ;
- Short-stay residents
with delirium;
- Short-stay residents
with pain;and
- Short-stay
residents who maintained improved in walking;
Æ
The NQF is not proposing a risk adjustment method for this measure, however, AHQA
believes that this measure lacks important exclusion criteria such as the exclusion
of residents who are in a coma, under hospice care, or other similar diagnoses.
Affirmative Support
with Comments.
- Pneumococcal polysaccharide
vaccination; and
- Influenza vaccination.
AHQA is pleased
to offer our strong support for the two measures dealing with immunizations. Please
register our vote for the Pneumococcal and Influenza vaccines as a "Yea"
vote for purposes of counting the ballots. We wish to emphasize the importance
of the development of new MDS criterion that will permit tracking of these immunizations.
Because we do not want to lose the opportunity to add these measures to this NQF
endorsed core set, we are voting in the affirmative on this measure with the expectation
that the measures will be implemented as soon as the MDS instrument can be updated
to capture immunization status.
Unqualified Affirmative
Support.
AHQA is pleased
to offer our unqualified support for the following measures/recommendations, these
measures do not require risk adjustment validation and reflect appropriate quality
of care considerations:
- Residents who
are physically restrained on a daily basis;
- Nursing staffing
hours—4 parts;
- Recommendation
on risk adjustment;
- Recommendation
of public reporting; and
- Recommendation
on improving the core set.
Please communicate
to the Steering Committee our sincere appreciation for their dedication, hard
work and good service to the NQF and to older Americans, and thank you for affording
this opportunity to comment on the proposed nursing home quality measures. Please
contact Dr. Mark Boesen or me at (202) 261-7571 with any questions regarding this
letter.
Sincerely,
