The QMs are not fatally flawed, but they do require careful examination By Steven B. Littlehale, MS, APRN, BC, and Sam Simon, MA
Despite efforts to refine them, QMs still have their problems
BY STEVEN B. LITTLEHALE, MS, APRN, BC, AND SAM SIMON, MA The Centers for Medicare and Medicaid Services' (CMS) Quality Measures (QMs) are publicly reported measures documenting outcomes for long- and short-stay nursing home residents. Although they were designed to provide fair measurement of facility quality across variations in facility case-mix, long-term care staff would be well-advised to understand the QMs' strengths and limitations. For a variety of reasons explained in this article, QMs may not always reflect excellent care, and other measures might well identify quality of care more accurately. QMs are grouped into chronic care measures and post-acute measures (Table). The QMs are similar to the CMS Quality Indicators (QIs), in that they define quality of care in terms of the nursing home's clinical/functional outcomes. Like QIs, they do not evaluate directly the specific processes of care in the nursing home. QMs are based on Minimum Data Set (MDS) assessments conducted over a three- or six-month period and represent outcomes that are (1) amenable to quality improvement efforts and (2) of interest to stakeholders (e.g., consumers, families, providers, insurers, etc.).
The six chronic care QMs are intended to measure conditions germane to long-stay residents of long-term care facilities. The proportion of residents with a particular condition allegedly comments on the quality of care provided in the facility. Because excluding admission assessments lessens the impact of pre-existing chronic conditions on QM reports, the 90-day (quarterly) assessment is considered "ideal" for the chronic care population. The practice of excluding 5-day Medicare assessments has the same effect for post-acute measures. In this case, 14-day Medicare assessments are targeted for analysis (although this is not the case for all post-acute measures).
As a practical matter, excluding admission assessments (required by both OBRA and Medicare) does exclude many pre-existing conditions. Pressure ulcers, delirium, and pain upon admission are not considered in the calculation of QMs, for example. However, the very nature of a chronic condition can result in pre-existing conditions being included in QM calculations. Consider, for instance, a resident admitted with a stage III pressure ulcer. It is important to recognize that most facilities will not "cure" such an ulcer within 90 days. Indeed, debridement may make a wound appear to have worsened; other appropriate "best practices" might cause the ulcer to reduce to stage II. In either case, the pressure ulcer will be reflected in the facility's QM score once it is coded on the "postadmission" MDS. Our firm, LTCQ, found empirical evidence of this. We recently studied 3,700 residents from a large national nursing home chain. The study found that 362 residents (9.8%) had triggered the pressure ulcer QM, but more than half of those residents (54.4%) had a pressure ulcer upon admission. Thus, for more than half of all residents who triggered the pressure ulcer QM, facility care or lack thereof was not necessarily responsible for the development of the ulcer.
Although the intention of using the QMs' postadmission MDS is to target Medicare 14-day and OBRA 90-day assessments, other assessments not anticipated but mandated when a resident change occurs (e.g., significant change and corrections assessments) also are included in QM results. These significant change or correction assessments can cause pre-existing conditions to trigger a QM as soon as within the first 10 days of residency. In another study of a large multistate chain, LTCQ identified 2,379 residents who, over a one-year period, had been discharged from long-term care "with a return anticipated" and readmitted with a "significant change" assessment. Of these residents, 540 (22.7%) developed a new pressure ulcer while in the hospital. These new pressure ulcers were included in the facilities' pressure ulcer QM.
CMS uses two risk adjustment practices that attempt to "level the playing field" when calculating QMs: exclusions and covariates. Each practice has merit and, when used together, they come closer to accurate assessment and more fair comparison.
Exclusions remove select residents from the QM analysis-for example, as mentioned above, not counting admission assessments is one form of exclusion. Additionally, few would argue that there is value in measuring a resident's "improvement in walking" when he or she is near death. Most QMs have identified exclusions, and providers incorporating QMs into their quality improvement activities should be versed in these technicalities. CMS provides many excellent resources for understanding the subtle nuances of the QMs (see "Historical Background).
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