VA Quality Measurement: Is There a “Halo Effect?” Steven M.Asch MD MPH VA Sepulveda HSR&D COE...
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Transcript of VA Quality Measurement: Is There a “Halo Effect?” Steven M.Asch MD MPH VA Sepulveda HSR&D COE...
VA Quality Measurement: Is There a “Halo Effect?”
Steven M.Asch MD MPH
VA Sepulveda HSR&D COE
RAND Health
Geffen School of Medicine at UCLA
VA Performance Measurement
• Dates back to 1995• ~30 mostly chart-based process measures,
varying evidence support• Facility-based primary care sampling• Feedback, public reporting• Regional managers have financial
incentives
VA Improves 12/13 Leading Indicators 1995- 2000
0
10
2030
4050
6070
8090
100
Hgba1c Flu vac CRC Screen ASA MI
19951996199819992000
Jha NEJM 348:22 2003
VA Beats Medicare 12-1 in 2000
01020
3040
5060
708090
100
Mammo Pneumovac DM eye
MedicareVA
Jha NEJM 348:22 2003
What About Overall Quality?
• Leading indicator systems – Focus QI efforts, but– Vulnerable to gaming, resource
misallocation
• What about overall quality? • How does VA overall quality
compare to the community?
Overall Process Quality Measured by QATools
• Literature reviews conducted to develop evidence-explicit indicators
• 5 Delphi expert panels convened to evaluate recommended indicators
• 348 clinically detailed process indicators for 26 clinical areas
• Example: Patients with pre-existing coronary disease with an LDL > 130mg/dl should begin diet or drug therapy within 3 months.
Example Clinical Areas General Medical Conditions
• BPH (4)• Depression (14)• Diabetes (13)• Dyspepsia/PUD (8)• Headache (21)• Low back pain (6)• Orthopedic conditions (10)• Preventive care (35)• STDs (26)
Oncologic Conditions • Colorectal cancer (12)• CA pain and palliation (3)• Prostate cancer (6)
Cardiopulmonary Conditions• Asthma (25)• Congestive heart failure (36)• COPD (20)• Coronary artery disease (37)• Hyperlipidemia (7)• Hypertension (26)• Pneumonia (5)• Stroke/TIA (10)
Study Sites
•SEATTLE
ORANGE COUNTY
PHOENIX
LITTLE ROCK
INDIANAPOLIS
• CLEVELAND•
GREENVILLE
MIAMI•
NEWARK•
• BOSTON
• SYRACUSE
• • •
•
•
LANSING•
VISN 22
VISN 11
% Receiving Indicated Care
53
67*
58
73*
44
64*
5653
0
10
20
30
40
50
60
70
80
Overall Chronic Prev Acute
CommVA
% Receiving Indicated Care
5969
63
81*
52
68*
0
10
20
30
40
50
60
70
80
90
COPD HTN DM
CommVA
Is There A “Halo Effect?”
• Does the VA advantage exist only in specific processes subject to VA performance management?
• Does it extend to clinically related conditions or areas?
• Does it extend to clinically unrelated areas?
P. Gaugin-”Self Portrait with a Halo”
3 Mutually Exclusive Summary Scores
In VA measurement set (26 indicators) Not in VA measurement set, but in same
condition (178 indicators) Neither (167 indicators)
Adjusted % Receiving Indicated Care
53
67*
42
69*
58
71*
51 54
0
10
20
30
40
50
60
70
80
Overall VAConditions
Comm
VA
VAMeasures
Neither
Conclusions
• VA is improving on leading indicators
• VA beats Medicare on leading indicators
• VA beats community on broader measures
• “Halo effect” of performance measurement diminishes with clinical distance
Wins: Performance measurement
Losses: ?????
Ties: Acute care, eye exams, COPD
Errors: Hoping for too big a halo
Questions
Adjusted RR of Indicated Care
1.22*
2.04*
2.74*
0.00
0.25
0.50
0.75
1.00
1.25
1.50
1.75
2.00
VA PerformanceMeasures
VA PerformanceMeasure Conditions
Non-VA PerformanceMeasure Conditions
Sampling: Men>35 with 2 Visits/yr
Community VA
Source Random digit dial
Admin data
Response rate 48% 97%
N 992 597
Study period 1/98-12/99 1/98-12/99
Sites 12 cities 26 facilities