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VA Quality Measurement: Is There a “Halo Effect?” PowerPoint Presentation
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VA Quality Measurement: Is There a “Halo Effect?”

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VA Quality Measurement: Is There a “Halo Effect?”

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  1. VA Quality Measurement: Is There a “Halo Effect?” Steven M.Asch MD MPH VA Sepulveda HSR&D COE RAND Health Geffen School of Medicine at UCLA

  2. VA Performance Measurement • Dates back to 1995 • ~30 mostly chart-based process measures, varying evidence support • Facility-based primary care sampling • Feedback, public reporting • Regional managers have financial incentives

  3. VA Improves 12/13 Leading Indicators 1995- 2000 Jha NEJM 348:22 2003

  4. VA Beats Medicare 12-1 in 2000 Jha NEJM 348:22 2003

  5. Leading indicator systems Focus QI efforts, but Vulnerable to gaming, resource misallocation What about overall quality? How does VA overall quality compare to the community? What About Overall Quality?

  6. Overall Process Quality Measured by QATools • Literature reviews conducted to develop evidence-explicit indicators • 5 Delphi expert panels convened to evaluate recommended indicators • 348 clinically detailed process indicators for 26 clinical areas • Example: Patients with pre-existing coronary disease with an LDL > 130mg/dl should begin diet or drug therapy within 3 months.

  7. Example Clinical Areas Cardiopulmonary Conditions • Asthma (25) • Congestive heart failure(36) • COPD (20) • Coronary artery disease (37) • Hyperlipidemia (7) • Hypertension (26) • Pneumonia (5) • Stroke/TIA (10) General Medical Conditions • BPH (4) • Depression (14) • Diabetes (13) • Dyspepsia/PUD (8) • Headache (21) • Low back pain (6) • Orthopedic conditions (10) • Preventive care (35) • STDs (26) Oncologic Conditions • Colorectal cancer (12) • CA pain and palliation (3) • Prostate cancer (6)

  8. Study Sites • SEATTLE BOSTON SYRACUSE LANSING VISN 11 CLEVELAND NEWARK INDIANAPOLIS VISN 22 LITTLE ROCK ORANGE COUNTY GREENVILLE PHOENIX MIAMI

  9. % Receiving Indicated Care

  10. % Receiving Indicated Care

  11. Is There A “Halo Effect?” • Does the VA advantage exist only in specific processes subject to VA performance management? • Does it extend to clinically related conditions or areas? • Does it extend to clinically unrelated areas? P. Gaugin-”Self Portrait with a Halo”

  12. 3 Mutually Exclusive Summary Scores • In VA measurement set (26 indicators) • Not in VA measurement set, but in same condition (178 indicators) • Neither (167 indicators)

  13. Adjusted % Receiving Indicated Care VA Measures Neither

  14. Conclusions • VA is improving on leading indicators • VA beats Medicare on leading indicators • VA beats community on broader measures • “Halo effect” of performance measurement diminishes with clinical distance

  15. Wins: Performance measurement Losses: ????? Ties: Acute care, eye exams, COPD Errors: Hoping for too big a halo

  16. Questions

  17. Adjusted RR of Indicated Care 2.74* 2.04* 1.22*

  18. Sampling: Men>35 with 2 Visits/yr