- A new report from the National Quality Forum Measure Applications Partnership underscores the importance of quality measures targeted specifically at rural health and patient access to care.
The report focuses on the matters that are most important to patients living in rural areas and the various principles that illustrate quality care for them. Currently, 59 million patients – or 19 percent of all Americans – live in and receive care in rural areas, making it essential that different industry stakeholders measure specific elements of quality.
MAP was tasked with developing measure sets for rural health stakeholders to look at care quality. The Workgroup designed measures to be NQF-endorsed, meaning they fulfill a certain set of criteria. Measures must:
- Be supported by empirical evidence demonstrating clinical effectiveness and a link to desired health outcomes
- Demonstrate opportunity for improvement
- Rely on data that are readily available and/or can be collected without undue burden
- Be suitable for use in internal quality improvement efforts, as well as in accountability applications
The Workgroup also identified the specific health areas on which measures should focus. These areas included measures that address mental health, substance abuse, medication reconciliation, diabetes, hypertension, chronic obstructive pulmonary disease, hospital readmissions, perinatal conditions, and pediatric patients.
From there, the Workgroup stratified those measures with the NQF endorsement requirements, yielding a 20-measure set. Nine of these measures pertained to hospital settings, while 11 applied to outpatient clinic settings.
Hospital setting measures include:
- CAUTI measure outcome
- Falls with injury
- Emergency transfer communication measure
- Venous Thromboembolism Prophylaxis
- Cesarean birth
- Alcohol use screening
- National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure
- Hospital-Wide All-Cause Unplanned Readmission Measure (HWR)
The outpatient setting measures included a number of preventive care checks, such as:
- CAHPS Clinician & Group Surveys (CG-CAHPS)-Adult, Child
- Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention
- Preventive Care and Screening: Influenza Immunization
- Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%)
- Medication Reconciliation Post-Discharge
- Advance Care Plan
- Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
- Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up’
- Depression Remission at Six Months
- Optimal Diabetes Care
- Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
There are some gaps in those measures, the report noted. For example, none of the measures look at patient care access gaps, although access is an extremely pressing issue in rural health. Other gaps include disparities in care, patient-reported outcomes measures (PROMs), and measures that take into account different perceptions of quality between patients and providers.
As a part of its tasks, MAP further looked at developing measures that pertain to patient care access. Care access is a vital issue in rural health, as most patients experience some barriers to treatment.
“The Workgroup focused its efforts on identifying those aspects of access—availability, accessibility, and affordability—that are particularly relevant to rural residents, documenting, where appropriate, key challenges to access-to-care measurement from the rural perspective, and identifying ways to address those challenges,” the report authors wrote.
“The Workgroup agreed that access to care is an important measurement gap, but cautioned that measuring access should be done with careful consideration for potential unintended consequences,” they continued. “For example, members discussed measures of timeliness of care, recognizing their usefulness as indicators of access, but also the potential unintended effect of penalizing providers for factors beyond their control, such as increased wait time due to the need to transfer a patient to another facility.”
With those considerations in mind, MAP looked to identify facets of access that are specifically pressing for rural patients. The team also considered the challenges to measuring patient care access and the ways to address those challenges.
Ultimately, MAP’s approach took into account the notion that access and quality are related, that there are numerous barriers to access that are out of organizations’ control, and that geographic barriers are key to access issues.
Ultimately, MAP looked at three umbrella domain measures: availability, accessibility, and affordability.
Those areas were then brokenly down thusly:
- Availability: appointments, access to specialty care, timeliness of care
- Accessibility: language barriers, health information access, health literacy, transportation access, and physical spaces
- Affordability: out-of-pocket costs, delaying of care due to patient costs
These measures, especially those related to care access that are under development, will require more work, MAP added. To that end, MAP will need continued support from CMS to complete its work.
“While content with its work to date, the Workgroup strongly recommends that CMS continue to fund the MAP Rural Health Workgroup going forward,” the report concluded. “Continued funding of the Workgroup would allow monitoring and updating of the core set of measures as needed.”