Methods for the guideline-based development of quality indicators--a systematic review

<p>Abstract</p> <p>Background</p> <p>Quality indicators (QIs) are used in many healthcare settings to measure, compare, and improve quality of care. For the efficient development of high-quality QIs, rigorous, approved, and evidence-based development methods are needed. Clinical practice guidelines are a suitable source to derive QIs from, but no gold standard for guideline-based QI development exists. This review aims to identify, describe, and compare methodological approaches to guideline-based QI development.</p> <p>Methods</p> <p>We systematically searched medical literature databases (Medline, EMBASE, and CINAHL) and grey literature. Two researchers selected publications reporting methodological approaches to guideline-based QI development. In order to describe and compare methodological approaches used in these publications, we extracted detailed information on common steps of guideline-based QI development (topic selection, guideline selection, extraction of recommendations, QI selection, practice test, and implementation) to predesigned extraction tables.</p> <p>Results</p> <p>From 8,697 hits in the database search and several grey literature documents, we selected 48 relevant references. The studies were of heterogeneous type and quality. We found no randomized controlled trial or other studies comparing the ability of different methodological approaches to guideline-based development to generate high-quality QIs. The relevant publications featured a wide variety of methodological approaches to guideline-based QI development, especially regarding guideline selection and extraction of recommendations. Only a few studies reported patient involvement.</p> <p>Conclusions</p> <p>Further research is needed to determine which elements of the methodological approaches identified, described, and compared in this review are best suited to constitute a gold standard for guideline-based QI development. For this research, we provide a comprehensive groundwork.</p

Patient-Centered Research: Disenrollment From Medicare Managed Care Plans in Connecticut

PURPOSE: Disenrollment behavior has important implications for the cost, quality, and continuity of care under Medicare Managed Care (MMC). Although disenrollment data are sometimes used as a quality indicator, uncertainty about how personal and plan characteristics influence disenrollment decisions complicates their use as a valid quality measure. METHODS: To determine how personal characteristics influence MMC disenrollment decisions, we analyzed data from the Medicare Beneficiary File, the US Census, and MMC plans. The study population consisted of MBs enrolled in one of 9 MMC Risk plans during a 6 month period, January through June 1998. We estimated logistic regression models with disenrollment (i.e. leaving a plan during the study period) as the dependent variable, and individual MB characteristics (age, gender, race, education, economic indicators) as independent variables, adjusting for plan characteristics. For disenrolling MBs we also estimated models using rapid disenrollment and disenrollment to fee-for-service (FFS) as dependent variables. RESULTS: Of 84,443 Medicare Beneficiaries (MBs) enrolled in one of 9 MMC risk plans in Connecticut, 4,102 (4.9%) disenrolled at least once during the 6 month study period, January through June, 1998. Of 4,022 MBs who disenrolled only once, 2,661 (66.2%) joined another MMC plan, while 1,361 (33.8%) returned to fee-for-service (FFS). 948 (23.6%) disenrolled "rapidly" (<90 days after joining). MBs who switched to another MMC plan had been enrolled longer than those who went back to FFS (Median 303 vs. 120 days, p < .001). In logistic regression analysis, adjusting for plan characteristics, disenrollment was associated with non-White race/ethnicity, age <75, and residence in areas with higher poverty rates and lower education levels. Among disenrollees, rapid disenrollment and disenrollment to FFS were associated with female gender, age ≥75, and residence in areas with higher poverty rates. CONCLUSION: Higher disenrollment among poorer, minority MBs suggests that these groups may have more problematic experiences with MMC, or may be more severely affected by coverage limitations. The higher rate of rapid disenrollment and return to FFS among older, poor, female disenrollees may be related to inadequate plan information at enrollment. Further research is needed do determine how patient characteristics influence disenrollment decisions, and whether MMC plans can improve member retention by paying more attention to the medical needs of specific groups and the information provided to enrollees

Benefits and Harms of Screening Mammography by Comorbidity and Age: A Qualitative Synthesis of Observational Studies and Decision Analyses

OBJECTIVE: We conducted a systematic review to assess the quality and limitations of published studies examining benefits and harms of screening mammography in relation to comorbidity and age. METHODS: We searched MEDLINE and EMBASE from January 1980 through June 2013 for studies that examined benefits or harms of screening mammography in women aged 65 years or older in relation to comorbidity. For each study, we extracted data regarding setting, design, quality, screening schedule, measure of comorbidity, and estimates of benefits and/or harms. We reviewed 1760 titles, identifying 7 articles that met the inclusion criteria: prospective cohort (two studies), retrospective cohort (two studies), and decision analyses (three studies). No randomized controlled trials were identified. RESULTS: At least one measure of life expectancy or reduction in the risk of breast cancer death as a marker of benefit was examined in four studies, whereas three studies addressed the harms of screening mammography, including false-positive results. Both cohort studies and decision analyses showed that screening benefits decreased with increasing age and comorbidity burden. CONCLUSIONS: The limited evidence currently available suggests that, apart from older women with severe comorbidity, women 65 and older may experience improvements in life expectancy from screening. Given the potential for harm, it is unclear whether the magnitude of the benefit is sufficient to warrant regular screening. Women, clinicians and policymakers should consider these factors in deciding whether continue screening