Table Of Content

A project to Develop and Evaluate Methods to Promote Ambulatory Care Quality Volume Final Report, 1 .A3 DEMPAQ: A project to Develop and Evaluate Methods to Promote Ambulatory Care Quality Final Report, Vol. 1 This report describes the development and evaluation of a set of performance measures designed to assess the quality of care delivered to Medicare beneficiaries. Because this project was a test of a methodology, the results presented in this report should be regarded as preliminary rather than definitive. R. Heather Palmer, M.B., B.Ch., S.M. Linda E. Clark, R.N. Ann G. Lawthers, Sc.D. Jean E. Edwards, B.A. Jinnet Fowles, Ph.D. Deborah Garnick, Sc.D. Jonathan Weiner, Dr.PH 1994 > 2135 Developing and Evaluating Methods to Promote Ambulatory Care Quality Table of Contents, Volume 1 and 2 Chapter 1 Conclusions and Recommendations Chapter 2 DEMPAQ Overview and Philosophy of the Project Chapter 3 Building a Collaborative Project v Chapter 4 Focus on Quality: Profiling Physicians' Practice Patterns Chapter 5 Developing a Quality Improvement Database Using Health Insurance Data: A User's Guide with Application to Medicare's National Claims History File Chapter 6* DEMPAQ The Claims Review System: Results for Maryland Chapter 7* The DEMPAQ Claims Review System: Results for Alabama Chapter 8* The DEMPAQ Claims Review System: Results for Iowa Chapter 9 Agreement Between Physicians' Office Records and Medicare Claims Data Chapter 1 Evaluating the DCRS: Assessment by Physicians Chapter 1 The Record Review Instrument Chapter 1 Comparison of Participants and Nonparticipants in the DEMPAQ Record Review Chapter 1 Evaluating DRRS: Inter-rater Reliability for Data Abstraction Chapter 14 Evaluating the DRRS: Assessment by Physicians Chapter 1 Evaluating DRRS and DCRS: Feedback of Results to Physician Groups * Contained in Volume II DEMPAQ Final Report > 9 Developing and Evaluating Methods to Promote Ambulatory Care Quality Chapter 16* DEMPAQ The Record Review System: Results for Maryland 7* Chapter 1 The DEMPAQ Record Review System: Results for Alabama Chapter 18* DEMPAQ The Record Review System: Results for Iowa Chapter 1 Variation in Office-Based Quality: A Three-State Comparison of Care Provided to Medicare Patients with Diabetes and Congestive Heart Failure Chapter 20 Patterns of Variation, Record Review Chapter 21 DEMPAQ Costs of Implementing the Record Review System (DRRS) References Table of Contents, Volume 3 Chapter 1 Summary and Recommendations Chapter 2 DEMPAQ Background and Overview of Feedback and Education Chapter 3 The CME Workshops Chapter 4 CME Workbook Chapter 5 Claims Reports Chapter 6 Records Reports References * Contained in Volume II DEMPAQ Final Report ii Developing and Evaluating Methods to Promote Ambulatory Care Quality Acknowledgments The DEMPAQ project involved the collaboration of many individuals in diverse geographic locations from different institutional affiliations. Peer Review Organizations Delmarva Foundation for Medical Care, Inc. (DFMC) Special acknowledgment is being made to Linda E. Clark, R.N., who in her role as Chief Executive Officer and Executive Vice President of the Delmarva Foundation for Medical Care, Inc., recognized the need for the Foundation to engage in research in the area of ambulatory care quality. She reached out to the health care research community through the American Medical Review and Research Center, and, together with Dr. Heather Palmer, was successful in obtaining funding from the Health Care Financing Administration we now DEMPAQ. for this project that call The Delmarva Foundation for Medical Care has been the prime contractor for the project. At DFMC, Jean Edwards has acted as the Project Director and coordinated many of the administrative aspects of the project. She represented the PRO community during researcher meetings and conference calls and en- sured that project deliverables and deadlines were met. Sandra Ray Moentmann, M.S., R.N., Project Manager, coordinated the record review for DFMC and the two other PROs. She developed materials with the research team to guide the review and trained and monitored the review teams in Alabama and Iowa. She also coordinated the physician review of records and claims in Maryland and directed the claims reliability study. Ms. Moentmann completed the final proofing of this report. Finally, Ms. Moentmann has had an active role in the Feedback and Education Modification to this project. Lori Collier, R.N., served as review supervisor. Under her able guidance, the reviewers completed the record review study in Maryland and initiated the physician review ofrecords. The nurse reviewers at DFMC included Cathy Asche, Marge Boone, Judy Brower, Nancy Eber, Geri Gill, Janet Herlihy, Teri Richardson, and Leona Schmidt. JillJenkins, Publications Manager, designed and produced this report, the DEMPAQ Quarterly, and the overheads and slides for the DEMPAQ project. She also designed the CME workbook and the slides used for the CME activity. Mary Ann Cowley, Publications Assistant, assisted with the production of this report. Secretarial support staff for the project included: Carrie Cassidy, Executive Secretary; Bevlee Burks, Assis- tant Executive Secretary; and Annette Newcomb, Assistant Executive Secretary. This staff typed monthly reports and deliverables, as well as completed the transfer of documents from the researchers and orga- nized the attachments for this report. Cherie Adams, Cleora Wheedleton, and Danielle Helmer were responsible for copying the two reports to physicians (claims and records) and the CME workbook. As each report book was tailored to the indi- vidual, this difficult task involved producing almost 300 unique books. Ms. Adams, Ms. Wheedleton, and Ms. Helmer are also responsible for the copying of this final report. Seven physicians recruited by the primary specialty societies and trained by DFMC participated in the peer review activities of the project. These individuals were Joseph Zebley, III, M.D.; Sheldon Goldgeier, M.D.; Christine Marino, M.D.; Alfred Ossman, M.D.; Howard Wilson, M.D.; Abdul Nayeem, M.D., and Christian E. Jensen, M.D., M.P.H. DEMPAQ Final Report Developing and Evaluating Methods to Promote Ambulatory Care Quality Alabama Quality Assurance Foundation, Inc. (AQAF) Nadine Schiesz, R.N., was Alabama's primary liaison to the DEMPAQ project. She coordinated all aspects ofAQAF's participation in the project: the record review; the liaison briefing sessions; the CME workshop; and periodic project meetings. Laurie Hall, M.D., physician reviewer at AQAF, conducted all of the peer review for AQAF and contrib- CME uted substantially to the workshop in Alabama. Carlene Gibbons, R.N., and Barbara Baites, R.N., were the nurse reviewers for Alabama. Iowa Foundation for Medical Care, Inc. (IFSAC) Nancy Paine, R.N., was the primary liaison for the Iowa Foundation for Medical Care to the DEMPAQ project. She coordinated all aspects of IFMC's participation in the project: the record review; the briefing sessions; and the CME workshop. Ms. Paine was assisted by Sherrie Segebart. Jenny Van Gundy, R.N., Dottie Klein, R.N., and Nina Larson were nurse reviewers for Iowa. Thirteen physicians, recruited by the primary specialty societies and trained by IFMC, participated in the peer review activities of the project. These individuals were Milton VanGundy, M.D.; Steven Craig, M.D.; Robert Good, D.O.; Kevin deRegnier, D.O.; John Carroll, M.D.; Jay Rosenberger, D.O.; Darwin Shassow, D.O.; Kevin Quinn, M.D.; Larry Severidt, M.D.; Mary Ann Nelson, M.D.; Andy Edwards, M.D.; Lane Dvorak, M.D.; and Dana Shaffer, D.O. Researchers R. Heather Palmer, M.B., B.Ch., S.M., of the Harvard School of Public Health (HSPH) has been the project's principal investigator. She provided the core concept for the overall project. Ann G. Lawthers, Sc.D., also from HSPH, served as the project's Research Director. Dr. Lawthers contributed to, and assumed responsibility for, many aspects of the project, both record and claims. She was the critical technical link between the PROs and the researchers, and coordinated many of the CME activities for the Feedback and Education Modification. She assumed a major role in the completion of this final DEMPAQ report and authored six chapters relating to the Record Review System (DRRS). Jinnet Fowles, Ph.D., ofPark Nicollet Medical Foundation, coordinated the claims profiling effort and assumed primary responsibility for the design of claims-record comparison and the participant/nonparticipant analysis. Deborah W. Garnick, Sc.D., of the Heller School of Public Policy, Brandeis University, contributed to the claims profiling and designed and executed the cost study. Jonathan Weiner, Dr.PH of the School of Hygiene and Public Health, Johns Hopkins University, contributed to the claims profiling component of the project and directed the Johns Hopkins team responsible for claims profiling systems development and data processing. Many individuals at the research institutions contributed to the DEMPAQ project. AtJohns Hopkins, Stephen Parente, M.S.P.H., was the project manager of the claims profiling activity. Other members of the systems analysis/programming team at theJohns Hopkins Health Services Research and Development Center included Tom Richards, M.S.E., Paul Chandler, and Andrew Baker. At the Harvard School of Public Health, Naomi Banks, M.B.A., designed the record review system and the peer review of records. Howard Frazier, M.D., provided consultation and clinical recommendations for development of the record review criteria. John Orav, Ph.D., provided statistical direction for both the DEMPAQ iv Final Report Developing and Evaluating Methods to Promote Ambulatory Care Quality record and the claims studies. The following consultants, Gerry Schumacher, D.Pharm., Patricia O'Shea, M.D. and Helen Burstin, M.D., drafted the initial criteria for the project. Mary Adams, Ph.D., Mark Monane, M.D., and Carol Ellenbecker, Ph.D., researched the references for the criteria and prepared de- tailed documentation of the clinical rationales. Barbara Lightfoot typed countless tables for feedback to physicians, both liaison and participant. At Park Nicollet Medical Foundation, Doris Petrie performed the programming and statistical analyses for the claims reliability study and the participant/nonparticipant analysis. Data Consultants Several individuals gave of their time to review the claims profiling specifications (see Chapter 10). These individuals included: Neil Powe; Lisa Iezzoni; Hal Luft; Elliot Fisher; and Kathleen Lohr. Liaison Physicians The DEMPAQ project has relied heavily on the good will and input from practicing physicians. Many individuals at both the national and state level have devoted countless unpaid hours to the review and de- DEMPAQ velopment of the criteria. National Consultants American Osteopathic Association James Cole, D.O. Director of Professional Affairs Cranston General Hospital Cranston, Rhode Island American Academy of Family Physicians Harry L. Metcalf, M.D. Williamsville, New York American College of Physicians G.C Woodson, M.D. Decatur, Georgia American Medical Association W. Lamar Weems, M.D. Jackson, Mississippi American Society of Internal Medicine William E. Golden, M.D. Director, General Internal Medicine Division University of Arkansas for Medical Sciences Little Rock, Arkansas Maryland Medical-Chirurgical Faculty of Maryland Robert Ruderman, M.D. Maryland Academy of Family Physicians Joseph Zebley, M.D. Maryland Society of Internal Medicine Sheldon Goldgeier, M.D. Park Espenschade, M.D. Alabama Medical Association for the State ofAlabama Peter Morris, M.D. Alabama Chapter of the American Society of Internal Medicine Pink Folmar, M.D. DEMPAQ Final Report v Developing and Evaluating Methods to Promote Ambulatory Care Quality Alabama Chapter of the American Association of Family Physicians Brian Perry, M.D. Iowa Iowa Medical Society Jeffrey Ver Huel, M.D. Iowa Clinical Society of Internal Medicine Steven Craig, M.D. Mary Stuart, M.D. Iowa Academy of Family Physicians Milton VanGundy, M.D. Iowa Osteopathic Medical Association Robert G. Good, D.O. Kevin deRegnier, D.O. Gary Janssen, D.O. Committees DEMPAQ Several committees were convened at the beginning of the project to facilitate communication among the diverse parties and groups involved. Scientific Oversight Committee This committee reviewed the initial project design. Members included: William E. Golden, M.D.; Robert L. Kane, M.D.; Kathleen N. Lohr, Ph.D.; Carole Magoffin, M.S.; Michael R. McGarvey, M.D.; David B. Nash, M.D., M.B.A.; and William Thomas, Ph.D. J. Project Committee The Project Committee was formed to provide overall direction to the project, to provide group problem identification and resolution, and to maintain various liaison relationships. The Committee met during the project's early phases. It consisted ofLinda Clark (DFMC), Heather Palmer (HSPH), Jean Edwards (DFMC), Ann Lawthers (HSPH), Nancy Paine (IFMC) and Nadine Schiesz (AQAF). PRO Advisory Committee The PRO Advisory Committee consisted of individuals representing the original seven PROs interested in the DEMPAQ project: Heather Palmer (HSPH); Linda Clark (DFMC);Jean Edwards (DFMC); Dan — Emmott (UPRO); Elizabeth Hamel (Health Care Review, Inc. Rhode Island); Nadine Schiesz (AQAF); Marcia Petrillo (ConnPRO); Debra Nixon (Health Services Advisory Group, Inc.); and Frederick Dettmann (WPRO). As with the other committee, the PRO Advisory Committee met only during the project's early phases. Record Review Committee This committee was designed to review and advise on the methods and criteria for the record review. It met during the first year of the project and consisted of Heather Palmer (HSPH), Linda Clark (DFMC), Jean Edwards (DFMC), ChristianJensen (DFMC), James Maroc (IFMC), Robert Sherrill (AQAF), and Ann Lawthers (HSPH). Health Care Financing Administration Paul Elstein, Ph.D., initially served as the project officer and assisted the project in many ways. He helped to secure the required databases, established liaisons between HCFA and the research team, and provided continuous guidance throughout the three years. Peggy Bowen, R.N., served as the project officer for the latter part of the project and provided support and guidance to the project and in particular to DFMC, the prime contractor. DEMPAQ vi Final Report