September 18, 2002 Dr. Ed Kelley Senior Service Fellow National Healthcare Quality Report Center for Quality Improvement and Patient Safety 6011 Executive Blvd, Suite 200 Rockville, MD 20852 Re: Federal Register Vol. 67, No. 160, Preliminary Measure Set for the National Healthcare Quality Report Dear Dr. Kelley: On behalf of the American Health Quality Association (AHQA), the membership organization of the national network of Quality Improvement Organizations (QIOs), thank you for the opportunity to provide comments on the preliminary measure set for the National Healthcare Quality Report. We commend the Agency for Healthcare Policy and Research (AHRQ) for selecting valid and appropriate quality indicators used by the QIOs in the Medicare Health Care Quality Improvement Program. AHRQ’s decision to rely on process measures for many of its indicators is the right public policy decision. Process measures can be monitored immediately following the provision of services; in addition, process measures do not require identification of mitigating risk factors necessary when reporting on outcome measures. We strongly support the quality indicators proposed below: Supported by AHQA. Acute Care Hospital Indicators Rate of AMI patients receiving aspirin within 24 hours of admission. Rate of AMI patients with aspirin prescribed at discharge. Rate of AMI patients administered beta-blockers within 24 hours of admission. Rate of AMI patients with beta-blockers prescribed at discharge. Rate of AMI patients with LVSD with ACEI prescribed at discharge. Rate of AMI patients given smoking cessation counseling while hospitalized. Median time from admission to reperfusion for AMI patients with ST segment elevation or LBBB. Rate of heart failure patients having evaluation for LVSD. Rate of heart failure patients with LVSD prescribed an ACEI at discharge Rate of heart failure patients receiving smoking cessation counseling. Rate of patients with pneumonia who have blood cultures collected before antibiotics are administered. Rate of patients with pneumonia who receive the initial antibiotic dose within 8 hours of hospital arrival. Rate of patients with pneumonia who receive the initial antibiotic consistent with current recommendations. Rate of patients with pneumonia who receive influenza screening and vaccination. Rate of patients with pneumonia who receive screening and vaccination for pneumococcal pneumonia. Ambulatory Care/Physician Office Quality Indicators Rate of persons age 65 and older who received an influenza vaccination in the past 12-months. Rate of women who report they had a mammogram within the past 2 years Rate of patients with diabetes who had hemoglobin A1c measurements at least once within the past year. Rate of patients with diabetes who had a lipid profile in the past two years. Rate of patients with diabetes who had a retinal exam in the past year. Rate of patients with diabetes who had a foot exam in the past year. Rate of adults with diabetes who had an influenza vaccination in the past year. Rate of persons over age 65 who have ever received a vaccination for pneumococcal pneumonia. Long Term Care Facilities Rate of institutionalized adults (persons in LTCFs) who received influenza vaccinations in the past 12 months. Chronic Care: Inadequate pain management Chronic Care: Late-loss ADL Decline. Chronic Care: Infections prevalence. Chronic Care: Pressure Ulcer Prevalence. Chronic Care: Restraint Use. Post-acute Care: Inadequate pain management. Post-acute Care: Failure to improve delirium. Post-acute Care: Improvement in walking. AHQA Recommends Deleting the Following Measures. AHQA does not support the inclusion of some of the measures proposed by AHRQ. We believe the following measures should be reconsidered and dropped from the preliminary set: Ambulatory measure: "Rate of people with diabetes with condition diagnosed." While we agree that more aggressive screening and diagnosis of diabetes may lead to improved care, it is virtually impossible to determine a denominator for this measure. In order to understand the magnitude of the denominator we would need to know who has diabetes and is undiagnosed. It appears infeasible to identify this population. LTC Chronic Care: "Weight loss prevalence." This is the only LTC quality measure that was used in the pilot program and subsequently failed validation testing by CMS research contractor Abt Associates. Because this measure was invalidated, this measure was dropped from the national nursing home quality improvement initiative. Finally, we applaud the decision to move forward with the selection of quality indicators for the home health setting. CMS has directed the QIOs to work with home health agencies over the next 3 years. We are especially pleased that you have invited Dr. William E. Golden, AHQA Immediate Past President and NQF Board Member, to assist your agency in selecting these measures. For questions regarding our comments, feel free to contact me or Mark Boesen, Pharm.D. at 202-331-5790 or by e-mail at dschulke@ahqa.org, or mboesen@ahqa.org. Sincerely, David G. Schulke Executive Vice President DGS:mdb

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