Tuesday, August 18, 2009

Heart Failure: JAMA Helps Us Understand Counting Measures and Measuring What Counts. Implications for CMS and Disease Management

Most population-based care afficionados will recognize these: measuring left sided heart function if there is a diagnosis of heart failure, using angiotensin converting enzyme inhibitors (ACEi) drugs among patients with low left-sided heart function, providing complete diagnosis-specific patient discharge instructions and giving tobacco cessation counseling when needed. That's right, these are the four state-of-the-art performance measures used by Medicare and the Joint Commission (thanks to recommendations from the National Quality Forum or NQF) to assess the quality of care for recently discharged patients with chronic heart failure.

JAMA has published (Aug 19, 2007;302(7):792) an important article on lingering quality-improvement disconnect between what is measured and what matters. Titled 'Heart failure performance measures and outcomes. Real or illusory gains' Drs. Gregg Fonarow and Eric Peterson of UCLA and Duke, respectively, point to the persistent gap between the gains in all four of the areas mentioned above versus the stubborn and persistently flat U.S. heart failure 30-day rehospitalization (about 20%) and one year mortality rates (close to 40%) over the last five years.

What is going on? The authors point out that the patients themselves may have changed: better care may have led to a relatively higher percent of sicker patients being left among those who make up the statistics in the latter part of the measure periods. Alternatively, the hospitals that are reporting these statistics may simply be doing a better job of documenting care that was really being given all along. Finally, the processes themselves may have limited impact. After all, only ACEi's have been definitively shown to slow the progression of heart failure.

It turns out that CMS is already looking at measures that matter, like readmission and mortality rates. Drs. Fonarow and Peterson point out that's a step in the right direction, but also suggest that future quality metrics should be linked to 'outcomes of interest' like tobacco cessation rates (not counseling), better statistical risk adjustment, developing registries that go beyond simple administrative claims and working with independent physicians and hospitals to create better buy-in.

This has implications for CMS' recent self-congratulations over the updated results from the MCMP and PGP demonstrations. The DMCB notes the demos included additional measures that could have accounted for the improvements, such as flu shots and use of beta blockers. On the other hand, much of what CMS is up to is still heavily laden with process instead of outcome measures. What's more, how well CMS can translate their promising successes among voluntary organized systems into the mainstream of its FFS payment environment remains to be seen.

Finally, there are important implications for other stakeholders in population-based management. The physicians from UCLA and Duke should know better and think about the track record of disease management in managing heart failure, including its endorsement by the American College of Cardiology/American Heart Association (check out p. e448) and its wide use by the participants in the very demos named above. Furthermore, they need to consider the emerging role of the medical home in better coordinating care once patients get discharged. These two (and soon to be one says the DMCB) systems of care may be just the ticket that pulls together all the resources it takes to reduce re-hospitalizations and decrease mortality rates. They can credibly apply their information technology, EHRs, registries and richer data bases to measure the progress really matters.

The DMCB thinks the population-based care approaches have a much better chance of success than a bureaucracy like CMS, no matter how much they read JAMA or try to follow the author's well-intentioned recommendations.

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