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Research
and Quality Improvement
Council
July
24, 2003
Kenneth
W. Kizer, M.D., M.P.H.
Chief Executive Officer
National Quality Forum
601 Thirteenth Street,
NW
Washington, DC 20005-6708
Dear
Dr. Kizer,
The
Research and Quality
Improvement Council
of the National Quality
Forum recently met
by telephone conference
call to discuss the
draft Nursing Home
Performance Measures.
Approximately 25 members
and organizations from
the RQI Council took
part in the discussions.
Council
members noted greater
clarity and exposition
of this measure set
and a continuing evolution
in the presentation
of the materials. Members
are still concerned,
however, that explicit
documentation of the
evidence to support
the recommended measures
remains less than robust.
Concern persists that
NQF is proposing national
standards based on
modest clinical evidence.
Other
general comments included
a perceived lack of
consistency in the
use of exclusions for
the measures. For example,
on Page A-1, there
is a fairly lengthy
list of exclusions
for residents who need
help with daily activities
but no such exclusion
list for residents
who lose too much weight.
It was not apparent
why there was such
a difference for these
two measures. A general
review of all the exclusions
for consistency might
be in order.
We
had extensive discussion
regarding the measure
on weight loss.
There was little support
for this measure amongst
participants on the
call. Some commented
that many patients
are deliberately placed
on weight reduction
diets in the long-term
care setting and they
should be excluded.
In addition, there
was no exclusion for
hospice patients. Finally,
and most concerning,
was the potential to
create perverse incentives
to insert feeding tubes
in patients with advanced
dementia or to force-feed
patients with severe
neurologic or dementing
diseases. A recent
article in JAMA
demonstrated widespread
variation in the use
of feeding tubes in
severe dementia and
questioned the use
of such technology.
Inclusion of a measure
that penalizes institutions
for patients with weight
loss might bring about
greater use of feeding
tubes, counter to evolving
practice standards.
Another participant
noted the lack of measures
dealing with oral health,
which could directly
affect the ability
to maintain caloric
intake.
Substantial
discussion focused
on staffing measures.
While this was not
considered a quality
measure per se, there
was concern that despite
consumer appeal, measures
pertaining to staffing
may lack consumer value
for decision making.
Since there is no adjustment
for patient acuity
levels, the raw numbers
of support staff may
misrepresent appropriate
workforce. Patients
at minimal risk or
with low acuity will
require lower intensity
supervision whereas
facilities that have
patients with advanced
health care needs will
require more personnel
with greater skills.
There was concern that
institutions with strong
staffing patterns may
decide that they have
overhired when compared
to a generic national
mean and might reduce
its staff to the detriment
of good patient care.
Should these measures
be used, a clear explanation
of the limitations
of these measures must
accompany their dissemination.
RQI
members also discussed
the post-acute
care pressure ulcer
measure. While
most on the call agreed
that some measure pertaining
to development of new
pressure ulcers is
useful for quality
improvement and public
information, the "failure
to improve" aspects
should be reconsidered
and dropped. In particular,
it was felt that the
length of stay in the
post-acute care settings
is sufficiently short
to limit noticeable
improvement in existing
pressure ulcers. To
include failure to
progress in a roll
up measure of pressure
ulcer care in the post-acute
care setting would
distort otherwise good
care being rendered
for patients with this
condition. We strongly
recommend elimination
of the "failure
to improve" aspect
of this measure.
We
also spent time discussing
the pressure
ulcer measure for the
chronic care setting.
The RQI Council supports
exclusion of patients
with pressure ulcers
on admission to long-term
care. While we were
under the impression
that this had been
accomplished, examination
of the specifications
for the proposed measure
indicates that all
patients whose MDS
data is derived from
the initial intake
were excluded from
the pressure ulcer
measure. Thus, all
patients with a pressure
ulcer 90 days into
their stay will be
included in the denominator.
Patients transferred
from hospital settings
with Stage IV pressure
ulcers will likely
still have a lesion
present 90 days after
admission to a long-term
care facility. RQI
council participants
felt that this could
unfairly represent
care rendered at that
facility. Such measurement
could produce perverse
incentives for long-term
care facilities to
avoid patients with
severe pressure ulcers.
The
RQI Council recognized
the amount of work
that has gone into
these measures and
the difficulty to satisfy
all stakeholders with
this complex task.
Nevertheless, we have
made recommendations
on four measures. We
remain concerned about
the potential utility
of many of these measures
as information for
the general population.
To make the data set
meaningful and valid
as both a quality improvement
vehicle and an effective
tool for patient selection
of health care providers,
clear public explanations
as to the value and
limitations of these
measures in the context
of diverse populations
at different facilities
are essential.
We
thank you for your
attention to these
measures. The RQI Council
would like to review
a revised draft at
a future date prior
to the balloting.
Sincerely,
William
Golden, M.D.
Professor
of Medicine,
UAMS
Past President,
American Health
Quality Assn
Chair, RQI Council
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Deborah
Nadzam, Ph.D.,
F.A.A.N.
Director, CCHS
Quality Institute
The Cleveland Clinic
Foundation
Vice Chair, RQI
Council |
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