NQF Uses Clinical Quality Measures to Improve Health Equity

August 23, 2021 - The National Quality Forum (NQF) wants to make it easier to improve health equity, and that starts with an effort to embed equity into clinical quality measures across the care continuum.

The organization, which has a long history of working with policymaking bodies like the Department of Health & Human Services and the Centers for Medicare & Medicaid Services to inform federal rulemaking, has most recently set its sights on understanding not just clinical quality, but how that quality differs across various demographics.

That’s come to bear in NQF’s Health Equity Advisory Group, part of the organization’s overarching Measures Application Partnership (MAP) with CMS and HHS. MAP convenes stakeholders from across the healthcare industry to comment on and inform in the pre-rulemaking process to ensure federal rulemaking is fair and achieves the goals the industry, and its federal governing bodies, want to see.

This Health Equity Advisory Group specifically sets forth to advise CMS and HHS about how to embed health equity into clinical quality measurements, something most industry experts agree poses a considerable challenge.

“One of the challenges that we're working on solving is frankly having data available to even fully grasp the disparities and the impact of health equity on patient care and patient outcomes,” Amy Moyer, a director of Quality Measurement at NQF who leads the overall MAP project, told PatientEngagementHIT. “It's challenging to capture that data as part of the workflow clinically.”

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In other words, the medical industry can’t yet make use of clinical quality data to understand health equity issues, because most of that quality data isn’t stratified by demographic. Take patient safety for example. Any clinical quality measures about patient safety largely just look at patient populations as a monolith and don’t provide information about whether, for instance, Black or Hispanic patients experience more adverse patient safety events.

That’s not a hard and fast rule, but for the most part, that information is currently obscure and the NQF Health Equity Advisory Group wants to look into what drives that obscurity and how to overcome it.

According to Moyer, the historical distrust between healthcare and certain populations could be a driving force. Asking patients about race, ethnicity, preferred language, and other personal factors can be difficult for the patient or feel awkward for the clinician.

But the working group—and most of the medical industry—contends it’s important, said Chelsea Lynch, a director of quality measurement at NQF who is specifically leading the health equity group.

“We know there are gaps, but we can't really quantify them right now,” Lynch noted in a phone interview with Moyer. “So really trying to push the field forward and being able to actually measure this. As we all know, the whole point of measuring health care quality is to improve it, but you really need that data as well.”

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Inclusivity will be paramount to these efforts, both Lynch and Moyer pointed out. That starts with getting the right people around the table. NQF knew it wanted people from across the care continuum, including different types of clinicians, as well as patient advocates, payers, professional organizations, and others who don’t fall neatly into one category but who NQF believes bring an important perspective.

The organization started this endeavor with a nomination process, which yielded some 140 applications, the pair said.

“What we try really hard to do at NQF, because we do all of this work for patients, is to make sure that there's a strong patient voice at the table,” Lynch said. “And so they are a priority for us and when we are going through our nomination period. But then we're also looking at health plans and healthcare providers and professional organizations. We are really trying to have this really diverse group together so we can make sure we have those different perspectives.”

That’s part of what NQF is really good at, Moyer added. The organization has a long history of convening MAPs for other healthcare priorities, like rural health or maternal health, so it has the skillset for bringing together a diverse group that reflects the patient populations NQF seeks to serve.

“One of the strengths of NQF is that we bring lots of different groups together,” Moyer explained. “We really convene groups to have these discussions and to involve all kinds of different stakeholders, both healthcare stakeholders, patients, experts on measurement to have the difficult conversations around those measurements and around addressing gaps in this area.”

In the case of health equity measurement, that diversity is going to help NQF get to the heart of the industry’s biggest pain points. Take, for example, the pursuit of stratifying clinical quality measurements by demographics. The Health Equity Working Group will set out to define which demographics it thinks the industry needs to zero in on, and according to Lynch, that means casting a pretty wide net.

“Certainly, ethnicity and race are really important things to measure, but there are so many other health disparities to counteract that as we're trying to teach this MAP Health Equity Advisory Group, we really want to have all sorts of different perspectives at the table,” she said. “So expanding beyond just race and ethnicity, but also gender and sexual orientation and where people live and are they were rural, are they urban? And just get a full picture of where all of those disparities really can be.”

The Health Equity Working Group will also look at defining social risk, making sure the industry leaves no stone unturned and works from a standard set of definitions. The phrase “social risk” is a broad one, Lynch and Moyer agreed, and it can be hard to quantify.

Food insecurity, social isolation, and lack of a support system can all be deemed social risks, but NQF acknowledges it’s hard to measure that, prompting yet another challenge for the health equity MAP group.

“It's really hard to get your arms around everything and look at analysis and get the data and even look at the interplay of the different factors and which ones really driving the issues, or driving the disparity and outcomes can also be challenging,” Moyer asserted.

There are also some logistical challenges NQF plans to consider. For one thing, clinical quality measurement has always been a sticking point for already overburdened clinicians. Collecting demographic data to use to measure health equity could increase burden, something Moyer and Lynch acknowledged and said NQF wants to avoid.

The health equity MAP group will touch on that topic, and the pair said the multistakeholder nature of the group will ideally help spark good ideas about how to implement health equity measures without increasing clinician burden.

“We do look at the feasibility and there is a big push to move towards more electronic measures or electronic clinical quality measures, eCQMS, or measures that are EHR-based,” Lynch stated. “So again, that will decrease provider burden. And us being a multi-stakeholder convener, we do have patients at the table to kind of really give us a perspective of what is too intrusive, what is feasible for them. We do try to take in all of those perspectives.”

Part of that will include discussions about different requirements for different types of organizations that have varying resources. That’s been a hallmark of some clinical quality measurement programs in the past, where under-resourced organizations could get hardship exemptions.

That’s a growing debate in the medical industry right now as providers discuss health equity measures. Asking a critical access hospital to do quality measurement on par with a large, academic medical center doesn’t entirely sound like a fair request. But at the same time, the patients at that CAH might equally—or more greatly—experience the social risks these health equity measures seek to assess.

Moyer and Lynch said NQF doesn’t have an answer to this debate right now, but pointed out that the health equity MAP would likely discuss.

“Another part of our MAP health equity advisory group is also to look at those critical access hospitals and what does that impact look like?” Lynch queried. “So, from my perspective, it seems like we're really trying to dig into that discussion a little bit more, and that will be part of the things that we discussed for the measures under consideration that are being put forward for the measure applications partnership.”

For Moyer, part of this conversation will be the tension between measurements that hold providers accountable for factors within their control.

“So, factors that they can influence and that they can directly make a difference with the reasonable patient expectation of being met where the patient is at. So, taking those patients factors into account and incorporating those and giving care that's respectful at addressing those concerns. Personally, I think it's difficult to have one right answer, and I think this will be an ongoing conversation.”

These efforts come as the healthcare industry works to not just pinpoint health equity as a problem, but also begin to take action on it. By understanding the differences in clinical quality as stratified by demographic, stakeholders like NQF aim to equip providers with the information to make improvements.