Key result
Varying post-discharge beta-blocker metrics alters hospital ranks, yielding discordant performance in ~20%.
Why the study?
MedPAC recommended using claims data to measure clinical quality to reduce reporting burden, but the impact of quality metric methodology changes on measured performance, outcomes, and hospital rankings needed exploration in heart failure with reduced ejection fraction.
Cohort (n=295,494)
Yes
Small changes in quality metric methodology significantly impact measured quality performance and hospital rankings, highlighting the need for standardized methodologies and better case-mix adjustment.
Answers are grounded in this paper and cite their sources.
Methodological variations may reorder hospital quality rankings; leaves open the need for standardized metrics in heart failure performance assessment.
BACKGROUND: To combat the high cost and increasing burden of quality reporting, the Medicare Payment Advisory (MedPAC) has recommended using claims data wherever possible to measure clinical quality. In this article, we use a cohort of Medicare beneficiaries with heart failure with reduced ejection fraction and existing quality metrics to explore the impact of changes in quality metric methodology on measured quality performance, the association with patient outcomes, and hospital rankings. METHODS AND RESULTS: We used 100% Medicare Parts A and B and a random 40% sample of Part D from 2008 to 2015 to create (1) a cohort of 295 494 fee-for-service beneficiaries with ≥1 hospitalization for heart failure with reduced ejection fraction and (2) a cohort of 1079 hospitals with ≥11 heart failure with reduced ejection fraction admissions in 2014 and 2015. We used Part D data to calculate β-blocker use after discharge and β-blocker use over time. We then varied the quality metric methodologies to explore the impact on measured performance. We then used multivariable time-to-event analyses to explore the impact of metric methodology on the association between quality performance and patient outcomes and Kendall's Tau to describe impact of quality metric methodology on hospital rankings. We found that quality metric methodology had a significant impact on measured quality performance. The association between quality performance and readmissions was sensitive to changes in methodology but the association with 1-year mortality was not. Changes in quality metric methodology also had a substantial impact on hospital quality rankings. CONCLUSIONS: This article highlights how small changes in quality metric methodology can have a significant impact on measured quality performance, the association between quality performance and utilization-based outcomes, and hospital rankings. These findings highlight the need for standardized quality metric methodologies, better case-mix adjustment and cast further doubt on the use of utilization-based outcomes as quality metrics in chronic diseases.
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Gilstrap et al. (2020) conducted a cohort in Heart failure with reduced ejection fraction (HFrEF) (n=295,494). Varying claims-based quality metric methodologies (exposure window duration and adherence definitions) vs. Standard quality metric methodologies (e.g., 30-day post-discharge window, standard proportion of days covered) was evaluated on Hospital quality rank correlation between 15-day and 30-day exposure window methodologies (Kendall Tau 0.63, p=<0.001). Varying claims-based quality metric methodologies for post-discharge beta-blocker use led to substantial reordering of hospital ranks, with 20% showing discordant annual quality changes.
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