Using Utilization Measures to Improve Quality of Care in

Health Systems

Stephen M. Davidson, Ph.D.Boston University School of Management

Presentation to CHMR Industry Advisory BoardPhoenix, AZ

October 7, 2005

The Problem

It is widely recognized that safety and quality are not high enough or

consistent enough.

Therefore, there is much interest in trying to improve the level of safety and

quality.

First Step

Leaders of health care organizations and health plans need to know the state of quality in their systems:

– The extent to which care provided meets established criteria.

– When it does not meet those criteria, where in the process of care are improvements needed?

Knowing the state of care in their systems will help leaders

– To set specific improvement goals.– To engage clinical professionals in

improvement efforts.– To measure progress.

Organization of the Presentation

1. The suitability of utilization measures to assess quality of care.

• Define quality and its measurement.• Examine 2 sources of utilization data:

medical records and claims.

2. Using utilization measures in a quality-improvement strategy.

Quality of Care

“the degree to which health services… increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

K. Lohr

– Selecting services.– Delivering service with skill.– Producing improved health.

Implications

• Ultimate criterion: the impact of services on health outcomes.

• Other factors besides health services affect a person’s health status.

• Since quality of care cannot be recognized by observing a team of clinicians providing services,

– To measure quality of care for a health plan, studies are needed that compare the care received by groups of similar patients.

– The test: the probability of good outcomes in the two groups.

Questions about Measurement

1. What do we count?

2. How do we know it is related to quality?

3. How do we distinguish between good quality and lesser quality?

Donabedian’s Conceptualization

Chances that care is of good quality improve if

1. Good structural conditions are in place.

2. Processes of care meet certain standards.

3. Outcomes improve after receiving care.

Utilization is a measure of process.

Studies need to relate utilization (process) to outcomes.

Sources of Utilization Data

Medical records.

Claims for services rendered.

Factors Affecting Adequacy

CONTENT1. Completeness

2. Accuracy

USEABILITY BURDEN1. Retrievability

2. Confidentiality

3. Suitability for Analysis

What Utilization Data Can Do

1. Show what services were provided.

2. Identify patterns of services provided.

3. Determine whether indicated follow-up services were provided.

4. Include details of patient visits:• Values from tests.• Progress notes.

Outpatient Visit

Yes

No

Yes

Yes Yes

No

No

No

No

HbA1c Test HbA1c Test

ER Visit orHosp. Admit

PrescriptionContinuity

Level 4 Level 3 Level 1Level 2Level 5

FPOA*

PrescriptionContinuity

Yes Yes

Yes

No No

PrescriptionContinuity

FPOA*FPOA*

3+ <3<3 <33+ 3+

*F=Flu Shot; P=Podiatry Visit; O=Ophthalmology Visit; A = microalbumin test or ARB or ACE inhibitor

Exhibit 1

Caveats

1. Understand the data’s limitations.

2. Use care in transcribing to an analysis file.

3. Understand the nature of the sample.

4. Do not over-interpret the results.

Using Utilization Measures to Improve Quality of Care

Key Fact:

To change the way care is delivered in order to improve quality and outcomes

requires the active participation of clinicians.

Doctors must believe 3 things to be willing to participate

1. Whatever the level of quality and safety in the organization, they can be improved.

2. The consequences of not improving quality will affect not just the organization, but also themselves.

3. Even though they are not to blame, what they do as individuals can help improve care.

Other Obstacles

1. Managers & doctors have different orientations.

2. They have different connections to the organization.

3. Doctors tend to assume managers want to constrain their autonomy.

4. Managers are reluctant to engage doctors on clinical issues.

5. Doctors consider non-clinical activity to be a diversion from seeing patients.

Assets

• Information is the major asset in the process.

• Payoff from success: Patients who are more appreciative of their doctors.

• Opportunity to ease the pain, especially through financial compensation and other benefits.

• An intangible benefit: sense of accomplishment for all participants.

The Process

Step One: Organizational Assessment.

Step Two: Picking a Place to Start.

Step Three: Choosing a Target for Change.

The Process – 2

1. Put together a multi-disciplinary group to lead.

2. State objectives clearly; invite comment; be willing to modify.

3. Share information.

4. Do not work uphill – pick projects that are real and likely to succeed.

5. Set milestones so expectations are clear.

Conclusion

1. Stakes are high – quality, cost.2. Change is hard – but unavoidable.3. Utilization information can be a major

asset – it shows the problems are real; they are systemic; and therefore, the system needs to change.

4. The process does not end – but significant milestones can be achieved.