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Measures and Methods

Qualis Health analyzed Medicare Fee-for-Service claims data for three of the measures included in reports produced by the state's Choosing Wisely task force and three additional measures that are ongoing priorities at CMS.

Measures also included in Washington's task force reports

Imaging (CT scan or MRI) for simple syncope.
While there may be instances where imaging is required, multiple organizations do not recommend it as a standard practice.

Imaging (CT scan or MRI) for uncomplicated headache.
Imaging may be warranted in some cases, but providers and patients should be familiar with the American College of Radiology's recommendation against it for most situations.

Antibiotics for upper respiratory infection.
Overuse of antibiotics can lead to complications for individual patients as well as the larger public; read the Infectious Diseases Society of America's recommendation on this topic.

Measures added for Qualis Health's reporting

Antipsychotic medications for the behavioral symptoms of dementia.
The risks of giving antipsychotic medications to dementia patients generally outweigh any potential benefits; read the recommendations against this practice from AMDA, the American Geriatrics Society, and the American Psychiatric Association.

New Chemotherapy or radiation during the last 30 days of life for patients with solid tumor cancers.
Although this is not a Choosing Wisely measure per se, it is related to three similar ones. (See the statements by the American Society of Clinical Oncology regarding the care of patients for whom additional chemotherapy or radiation is not warranted and the need to define goals with end-stage patients, as well as patient-centered recommendations from the Commission on Cancer.) None of these statements are formulated in such a way that they can be tracked using Medicare claims data. The more straightforward measure that Qualis Health has chosen is included in Hutchinson Institute for Cancer Outcomes Research (HICOR) analyses.

New Hospice, palliative care, or advance planning services during the last 90 days of life for patients with solid tumor cancers.
This is an expansion of a similar Choosing Wisely measure (described by the American Academy of Hospice and Palliative Medicine) and of a similar HICOR metric. Neither of those measures included advance planning services, which became a billable item for Medicare providers in 2016. (Please note that, unlike the other Choosing Wisely measures, higher rates are better. Clinicians are encouraged to order hospice or palliative care, and to provide advance planning services.)

Methodology

As much as possible, data selection criteria mirrored those used by the state's task force and specified in the national Choosing Wisely guidelines. For the two end-of-life measures, data selection generally aligned with HICOR criteria.

County- and race-specific rates

To generate the county- and race-specific rates, Qualis Health divided the denominators by the numerators (both defined below) then calculated the corresponding 90% Wilson confidence intervals.

End-of-life cancer measures

A. Denominator (relevant population)
The denominator is identical for both measures; it includes the population of Medicare beneficiaries who met all of the following criteria:

Had a Washington address
Died during the study period (July 2016 – June 2017)
Were enrolled in both Medicare Part A and Part B for at least 90 days prior to death
Received care for solid tumor cancer (principal or secondary diagnosis) during the final 90 days of life, from a provider with either a practice location or mailing address in Washington

(Please note that because the location designations are dependent upon the address of the beneficiary and not the care provider, data included in the county-specific rates may include some care provided outside the county.)

Exclusions:

Beneficiaries with co-occuring blood cancers

B. Numerator (among the denominator population, those who received the treatment of focus)

Chemotherapy or radiation therapy
All those who met both of the following:

With procedure codes related to chemotherapy or radiation therapy in Medicare Part A or Part B, with treatment occurring in the last 30 days of life

Without claims related to hospice use, palliative care visit, or advance care planning, that occurred:
1. Within 90 days of death
  and
2. Prior to the final chemotherapy/radiation treatment

Hospice, palliative care, or advance care planning
All those with Medicare Part A or Part B claims related to any of the following:

At least three days of hospice in the last 90 days of life
Palliative care consult, three to 90 days before death
An advance planning services discussion, three to 90 days before death

All other measures

A. Denominator (population of Medicare beneficiaries with targeted diagnosis)

Diagnosis

Simple Syncope

Uncomplicated Headache

Upper Respiratory Infection

Dementia

Study Period

October 2016 - Septemeber 2017

Enrollment

Beneficiary must have been enrolled in Part A and B for at least one month during study period

Beneficiary must have at least one instance of Part D claim during study period

Location

Provider must have either a practice location or mailing address in Washington

Beneficiary must have a Washington address; beneficiary’s address used to assign to county

(Please note that because the location designations are dependent upon the address of the beneficiary and not the care provider, data included in the county-specific rates may include some care provided outside the county.)

Claims Source

Principal diagnosis codes in Medicare Part B

Principal diagnosis code in Medicare Part A or B

Exclusions

Claim excluded if the provider taxonomy was radiologist, interventional radiologist, ambulance, or laboratory

Exclude beneficiaries if they had:

Exclude beneficiaries with schizophrenia, bipolar disorders, Huntington’s Disease, Tourette’s Syndrome

comorbid diagnoses within 12 months prior to index case

competing diagnoses between 30 days prior, through 7 days after, the index case

Index Case

First diagnosis in study period

All beneficiaries meeting the criteria above

B. Numerator (among the denominator population, those who received the treatment of focus)

Claims Source

Procedure codes related to CT or MRI in Medicare Part A or Part B, within 30 days following the index case

National Drug Codes related to antibiotics in Medicare Part D, within three days following the index case

National Drug Codes related to antipsychotics in Medicare Part D, during measurement period

Methods for provider-specific rates and the identification of outlier providers

Starting with the data sets described above, Qualis Health attributed the claims to specific providers as follows:
- The care of beneficiaries with simple syncope, uncomplicated headache, or upper respiratory infection was attributed to the provider who made the index diagnosis during the measurement year, regardless of who may have provided the scan/prescribed the antibiotics.
- Beneficiaries with dementia were attributed to providers when the principal reason for the visit was dementia. Further, the providers associated with the dementia measure were grouped into one of four categories depending on where most of the dementia-related care was provided. The categories are inpatient, outpatient, nursing home, and assisted living / adult family home.
- If beneficiaries with end-stage cancers were treated by an oncologist during the last year of life, they were attributed to that oncologist. If they were not treated by an oncologist, they were attributed to the healthcare professional who provided the most cancer-related care during the last year of life.
To calculate the provider-specific rates, the new denominators were divided by the new numerators; the statewide aggregate was calculated from the overall results. (The aggregates for the dementia settings of care were calculated in the same way.)
To determine which providers were outliers with particularly poor rates, 90% Wilson confidence intervals were calculated for each provider's rate. (Providers with 10 or fewer patients in the denominator were excluded.)