The Relationship Between CMS Quality The Relationship Between CMS Quality Indicators and Long-term Outcomes Among Indicators and Long-term Outcomes Among

Hospitalized Heart Failure PatientsHospitalized Heart Failure Patients

Mark Patterson, Ph.D., M.P.H.Mark Patterson, Ph.D., M.P.H.Post-doctoral FellowPost-doctoral Fellow

Duke Clinical Research Institute (DCRI)Duke Clinical Research Institute (DCRI)

AcknowledgementsAcknowledgements

Duke Clinical Research Institute (DCRI)Duke Clinical Research Institute (DCRI) Lesley Curtis, Ph.D.Lesley Curtis, Ph.D. Adrian Hernandez, M.D.Adrian Hernandez, M.D. Bradley Hammill, M.S.Bradley Hammill, M.S. Kevin Schulman, M.D.Kevin Schulman, M.D. Eric Peterson, M.D.Eric Peterson, M.D.

UCLA Medical CenterUCLA Medical Center Gregg Fonarow, M.D.Gregg Fonarow, M.D.

Funding SourcesFunding Sources Contract with GlaxoSmithKlineContract with GlaxoSmithKline Duke CERTs grant (AHRQ grant #U18HS10548)Duke CERTs grant (AHRQ grant #U18HS10548)

Pay-for-Performance and Process MeasuresPay-for-Performance and Process Measures

Goal of Pay-for-Performance: Goal of Pay-for-Performance: Encourage Encourage providers to follow recommended clinical care providers to follow recommended clinical care by providing financial incentivesby providing financial incentives

Theory:Theory: Financial incentives Financial incentives improve improve providers’ adherence providers’ adherence improve clinical improve clinical outcomesoutcomes

Process Measures: Process Measures: Estimate provider-level Estimate provider-level adherence to this recommended clinical careadherence to this recommended clinical care

CMS Heart Failure Process MeasuresCMS Heart Failure Process Measures

Improving heart failure care remains a priority Improving heart failure care remains a priority for CMS for CMS Prevalence = 5 million; Cost = $30 billionPrevalence = 5 million; Cost = $30 billion

4 Core Process Measures4 Core Process Measures Providing discharge instructionsProviding discharge instructions Conducting left ventricular ejection fraction Conducting left ventricular ejection fraction

(LVEF) assessment(LVEF) assessment Prescribing ACE inhibitors or angiotensin Prescribing ACE inhibitors or angiotensin

receptor blockers at dischargereceptor blockers at discharge Providing smoking cessation counselingProviding smoking cessation counseling

Associations between process measures Associations between process measures (PM) and mortality(PM) and mortality

Mixed evidence in regards to the associations Mixed evidence in regards to the associations between process measures and mortalitybetween process measures and mortality Acute coronary syndromeAcute coronary syndrome11

AMIAMI22

Heart failureHeart failure33

No evidence in regards to associations between No evidence in regards to associations between PM and long-term mortality PM and long-term mortality

1: Peterson et al., JAMA, 2006

2. Bradley et al., JAMA, 2006

3. Fonarow et al., JAMA, 2007

1: Peterson et al., JAMA, 2006

2. Bradley et al., JAMA, 2006

3. Fonarow et al., JAMA, 2007

ObjectiveObjective

Measure associations between the 4 current Measure associations between the 4 current CMS heart-failure process measures and 1-year CMS heart-failure process measures and 1-year mortalitymortality

HH11: : Hospital-levelHospital-level process measures will be process measures will be associated with associated with patient-levelpatient-level mortality mortality

Data SourcesData Sources

Retrospective cohort study Retrospective cohort study

Matched HF patients within the OPTIMIZE Matched HF patients within the OPTIMIZE registry with their Medicare Part A claims (2003 registry with their Medicare Part A claims (2003 – 2004– 2004 OPTIMIZE-HFOPTIMIZE-HF Medicare Part AMedicare Part A CMS denominator filesCMS denominator files

Matched on age, gender, discharge date, and Matched on age, gender, discharge date, and hospitalhospital

ParticipantsParticipants

Medicare fee-for-service HF patients matched to Medicare fee-for-service HF patients matched to the OPTIMIZE-HF registry the OPTIMIZE-HF registry (N=22,483)(N=22,483)

Excluding patients who died before dischargeExcluding patients who died before discharge

Excluding hospitals with Excluding hospitals with missing process measuresmissing process measures with less than 25 patientswith less than 25 patients

Final analytic dataset Final analytic dataset (N=22,451)(N=22,451)

Hospital-level single process measures (PM)Hospital-level single process measures (PM)

Discharge instructions Discharge instructions N=15,142 (67%) N=15,142 (67%)

LVEF assessment LVEF assessment N=20,061 (89%)N=20,061 (89%)

ACEI or ARBs at discharge ACEI or ARBs at discharge N=5,457 (24%)N=5,457 (24%)

Smoking cessation at discharge Smoking cessation at discharge N=902 (4%)N=902 (4%)

Frequency of PM documentationFrequency of PM documentation--------------------------------------------------------------------------------------------------------------------------Number of patients eligible to receive PMNumber of patients eligible to receive PM

Hospital-level combined process measuresHospital-level combined process measures Composite Composite N=22,451N=22,451

Total number of processes documented Total number of processes documented ------------------------------------------------------------------------------------------------------------------------Total number of opportunities to performTotal number of opportunities to perform

Defect-free Defect-free N=22,451N=22,451

Proportion of patients within the hospital having Proportion of patients within the hospital having documentation for ALL the PM that they were documentation for ALL the PM that they were eligible to receiveeligible to receive

Outcome and Control VariablesOutcome and Control Variables

Patient-levelPatient-level Mortality Mortality CMS denominator fileCMS denominator file

Patient-levelPatient-level controls controls DemographicsDemographics ComorbitiesComorbities Clinical measuresClinical measures

Creatinine, weight, blood pressureCreatinine, weight, blood pressure

Hospital-levelHospital-level volume volume Total HF dischargesTotal HF discharges % HF discharges of total% HF discharges of total

Statistical AnalysisStatistical Analysis

Cox multivariate regressionsCox multivariate regressions Controlling for demographics, clinical measures, Controlling for demographics, clinical measures,

selected co-morbidities, and hospital volume selected co-morbidities, and hospital volume indicatorsindicators

Accounting for clustering of patients within Accounting for clustering of patients within hospitalshospitals

6 final models6 final models 4 Models for each single PM4 Models for each single PM 2 Models for each combined PM2 Models for each combined PM

Selected Baseline Characteristics (N=22,451)Selected Baseline Characteristics (N=22,451)

VariableVariable %%

Mean age (s.d)Mean age (s.d) 79 (7.8)79 (7.8)

MaleMale 44%44%

WhiteWhite 84%84%

BlackBlack 10%10%

OtherOther 6%6%

Prior AMIPrior AMI 23%23%

Prior PVDPrior PVD 15%15%

Prior HyperlipidemiaPrior Hyperlipidemia 33%33%

Mean Serum Creatinine (mg/dL) (s.d)Mean Serum Creatinine (mg/dL) (s.d) 1.6 (1.2)1.6 (1.2)

Mean Systolic BP (mmHg) (s.d)Mean Systolic BP (mmHg) (s.d) 142 (32)142 (32)

Mean Weight (kg) (s.d)Mean Weight (kg) (s.d) 77.4 (20.8)77.4 (20.8)

Hospital PM Adherence Rates (N=178)Hospital PM Adherence Rates (N=178)

Process Measure (PM)Process Measure (PM) Mean ScoreMean Score S.D.S.D. RangeRange

SingleSingle

Discharge InstructionsDischarge Instructions 0.520.52 0.300.30 (0 – 1.0)(0 – 1.0)

LVEF AssessmentLVEF Assessment 0.870.87 0.120.12 (0.29 – 1.0)(0.29 – 1.0)

ACEI / ARBs at DischargeACEI / ARBs at Discharge 0.750.75 0.160.16 (0.25 – 1.0)(0.25 – 1.0)

Smoking CessationSmoking Cessation 0.570.57 0.350.35 (0 – 1.0)(0 – 1.0)

CombinedCombined

CompositeComposite 0.720.72 0.150.15 (0.32 – 1.0)(0.32 – 1.0)

Defect-freeDefect-free 0.540.54 0.220.22 (0 – 1.0)(0 – 1.0)

Associations between hospital-level process measures Associations between hospital-level process measures and patient mortalityand patient mortality

HR (95 % CI)HR (95 % CI)

Process Measure (PM)Process Measure (PM) NN UnadjustedUnadjusted AdjustedAdjusted

SingleSingle

Discharge InstructionsDischarge Instructions 15,14215,142 1.0 (0.99 – 1.02)1.0 (0.99 – 1.02) 0.99 (0.98 – 1.01)0.99 (0.98 – 1.01)

LVEF AssessmentLVEF Assessment 20,06120,061 1.0 (0.96 – 1.04)1.0 (0.96 – 1.04) 1.0 (0.96 – 1.03)1.0 (0.96 – 1.03)

ACEI / ARBs at DischargeACEI / ARBs at Discharge 5,4575,457 0.94 (0.89 – 0.99)0.94 (0.89 – 0.99) 0.97 (0.93 – 1.02)0.97 (0.93 – 1.02)

Smoking CessationSmoking Cessation 902902 0.99 (0.96 – 1.03)0.99 (0.96 – 1.03) 0.98 (0.93 – 1.04)0.98 (0.93 – 1.04)

CombinedCombined

CompositeComposite 22,45122,451 1.0 (0.99 – 1.03)1.0 (0.99 – 1.03) 1.0 (0.98 – 1.01)1.0 (0.98 – 1.01)

Defect-freeDefect-free 22,45122,451 1.0 (0.99 – 1.03)1.0 (0.99 – 1.03) 1.0 (0.99 – 1.01)1.0 (0.99 – 1.01)

DiscussionDiscussion

Current CMS heart failure process measures Current CMS heart failure process measures (PM) are not associated with 1-year mortality in (PM) are not associated with 1-year mortality in Medicare beneficiaries diagnosed with HFMedicare beneficiaries diagnosed with HF

Explanation for null findingsExplanation for null findings Care given at discharge may not affect 1-year Care given at discharge may not affect 1-year

mortalitymortality Documentation of care does not capture the Documentation of care does not capture the

intensity or accuracy of careintensity or accuracy of care High variation for PM may prevent ability to High variation for PM may prevent ability to

detect small changes if they existdetect small changes if they exist

LimitationsLimitations

Cross-sectional designCross-sectional design

Unobserved factors confounding associationsUnobserved factors confounding associations Patient-levelPatient-level Hospital-levelHospital-level

Documentation of process measure at discharge Documentation of process measure at discharge may not reflect the care given over 1 yearmay not reflect the care given over 1 year

StrengthsStrengths

First known study to link clinical registry data First known study to link clinical registry data with CMS data to examine associations between with CMS data to examine associations between process measures and long-term outcomesprocess measures and long-term outcomes

Generalizeable to Medicare fee-for-service heart Generalizeable to Medicare fee-for-service heart failure patientsfailure patients1

Models Include both patient and hospital-level covariates Account for clustering

1: Curtis et al., Abstract Proceedings at AHA, 20071: Curtis et al., Abstract Proceedings at AHA, 2007

Conclusions & RecommendationsConclusions & Recommendations Null findings do not undermine the need to Null findings do not undermine the need to

continue providing care that is good clinical continue providing care that is good clinical practicepractice

Need to more firmly establish link between PM Need to more firmly establish link between PM and outcomes before broadly implementing P4Pand outcomes before broadly implementing P4P

Improve the accuracy of the measuresImprove the accuracy of the measures

Continue evaluating the effects of PM Continue evaluating the effects of PM Within the context of longitudinal dataWithin the context of longitudinal data Using PM with known clinical efficacyUsing PM with known clinical efficacy