Talk to the Veterans Crisis Line now
U.S. flag
An official website of the United States government

VA Health Systems Research

Go to the VA ORD website
Go to the QUERI website

IIR 98-103 – HSR Study

IIR 98-103
Evaluating the Performance of Explicit Quality Monitoring Systems in the VHA
Eve A. Kerr, MD MPH
VA Ann Arbor Healthcare System, Ann Arbor, MI
Ann Arbor, MI
Alan Sooho MD MBA
Battle Creek VA Medical Center, Battle Creek, MI
Battle Creek, MI
Funding Period: January 2000 - September 2003
As the Veteran’s Health Administration reorganizes for a more competitive 21st century, it must compete successfully with other delivery systems in providing high quality care at a reasonable cost. The first step in quality improvement is quality assessment, yet there remains much controversy as to the relative costs and benefits of alternative approaches to measuring quality.

Our research objectives are: 1) to compare the assessments of quality of care using a focused explicit medical record review tool, a global explicit medical record review tool and implicit medical record review using a structured tool; 2) to investigate whether global quality differs for VA for patients versus those from a national sample; and 3) to further investigate reasons for inadequate quality.

We have sampled 621 veterans’ records from Veteran’s Integrated Service Network (VISN) 11 and VISN 22 ambulatory care populations. Trained nurses abstracted the complete medical record for FY98 and FY99//or for a two year time period using the two explicit tools and trained physician reviewers evaluated the records using a structured implicit review abstraction format. We are comparing the performance of the global and focused explicit instruments and examining each tool's reliability at the case and facility levels, convergent validity with implicit physician review, and ability to discriminate among quality of care in different facilities. Further, we have extensively examined the reliability of the implicit review instrument. We have also examined whether global quality of care differs between VA patients and a national sample of patients for whom quality was measured using the global tool. Finally, we are investigating reasons that physicians rated care as inadequate and further exploring the classification of inadequate care.

Preliminary results suggest that each tool is capturing some common and some unique aspects of quality for these patients, and explaining differing proportions of facility level variation. For COPD and acute conditions the reliability of a single physician implicit review was low and similar to other implicit reviews. However, reliability of the implicit review for diabetes and hypertension, both conditions having a fairly well developed evidence base, was better than most previously published estimates (icc= 0.46). Using the global explicit instrument and comparing VA patients with a national population with adjustments for the number of chronic conditions, number of acute conditions and the number of outpatient visits, VHA patients had almost twice the odds of receiving indicated care (OR=1.92). When looking at subsets of indicators, VHA patients were no more likely to receive indicated care for acute conditions, but were more likely to receive chronic condition care (OR=1.85) and preventive care (OR=2.30). Analyses are ongoing.

Our current results show that quality of care for certain conditions can be measured reliably with a structured implicit review instrument and that VA care compares favorably with quality of care received by a national sample. By comparing the performance of three different methods of quality assessment, we will be able to address whether there is an underlying quality construct for the conditions studied. At a time when a considerable amount of money is being expended on quality monitoring, a thorough understanding of the reliability, validity and costs of different methods of quality measurement will help the VHA and other health care systems refine their quality monitoring instruments and contribute to the national discussion about quality monitoring methods.

External Links for this Project

Dimensions for VA

Dimensions for VA is a web-based tool available to VA staff that enables detailed searches of published research and research projects.

Learn more about Dimensions for VA.

VA staff not currently on the VA network can access Dimensions by registering for an account using their VA email address.
    Search Dimensions for this project


None at this time.

DRA: Health Systems
DRE: Epidemiology, Prevention
Keywords: Diabetes, Quality assessment
MeSH Terms: none

Questions about the HSR website? Email the Web Team

Any health information on this website is strictly for informational purposes and is not intended as medical advice. It should not be used to diagnose or treat any condition.