BACKGROUND/RATIONALE:
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.

OBJECTIVE(S):
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.

METHODS:
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.

FINDINGS/RESULTS:
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.

IMPACT:
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.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Asch SM, McGlynn EA, Hogan MM, Hayward RA, Shekelle P, Rubenstein L, Keesey J, Adams J, Kerr EA. Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample. Annals of internal medicine. 2004 Dec 21; 141(12):938-45. [view]
2. Hofer TP, Asch SM, Hayward RA, Rubenstein LV, Hogan MM, Adams J, Kerr EA. Profiling quality of care: Is there a role for peer review? BMC health services research. 2004 May 19; 4(1):9. [view]
3. Hayward RA, Asch SM, Hogan MM, Hofer TP, Kerr EA. Sins of omission: getting too little medical care may be the greatest threat to patient safety. Journal of general internal medicine. 2005 Aug 1; 20(8):686-91. [view]

Conference Presentations

1. Hofer TP, Asch S, Hayward RA, Hogan MM, Rubenstein LV, Adams JL, Kerr EM. How Many Reviews Do You Need? Measuring The Quality Of Care At Clinic Sites With Implicit Physician Review. Paper presented at: Society of General Internal Medicine Annual Meeting; 2004 May 14; Chicago, IL. [view]
2. Kerr EA, Hofer TP, Hayward RA, Hogan MM, Adams J, Asch SM. How Should We Profile? A Comparison of Three Methods to Assess Quality Across Sites of Care. Paper presented at: Society of General Internal Medicine Annual Meeting; 2005 May 13; New Orleans, LA. [view]
3. Asch SM, McGlynn EA, Hogan MM, Hayward RA, Shekelle P, Rubenstein LV, Keesey J, Adams J, Kerr EA. Is Better Quality in VHA Confined to Areas of Performance Measurement? Paper presented at: VA HSR&D National Meeting; 2004 Mar 9; Washington, DC. [view]
4. Hofer T. Measurement properties of implicit medical record review. Paper presented at: Agency for Healthcare Research and Quality Annual Conference; 2003 Mar 1; Arlington, VA. [view]
5. Kerr EA, Hofer TP, Hayward RA, Hogan MM, Adams J, Asch SM. Profiling Facilities Using Three Different Performance Measurement Systems. Paper presented at: VA HSR&D National Meeting; 2005 Feb 16; Baltimore, MD. [view]
6. Hofer T. Reliability of peer review. Paper presented at: St Joseph's Hospital Department of Surgery Research Annual Conference; 2002 Nov 7; Ann Arbor, MI. [view]

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