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Ms. Fredland expressed her thanks to Kathy Green from Provider Solutions, who raised several issues based on tracking more than 300 agencies for several years. Agencies are having the most success in sustaining cognitive function, not improving it. They also have success in improving UTIs but not urinary incontinence. Other areas of success are pain, housekeeping, shopping, anxiety, and dyspnea.
Dr. McGee has been working on plain-language issues for communicating more effectively with multiple audiences. This applies to both the NHQR and CMS public reporting. Clear, simple writing is not only for audiences who are unskilled readers, but also for people in general, such as those who are pressed for time.
Dr. Gerteis pointed out that Dr. McGee had remarked that the term "emergent" should be emergency, because emergent is medical jargon. Consumers did not understand the emergency measures at first and assumed that these referred to a home health agency's responding appropriately to emergencies. If anything, consumers give agencies the benefit of the doubt and do not consider them accountable for as much as they actually are. When consumers realized that the measure addresses prevention of emergencies, they supported it. However, they did not distinguish between going to the emergency room and going home, and going to the emergency room and then being admitted to the hospital. From the policy perspective, it may be desirable to focus on inappropriate use of the emergency room, because the distinction will not make sense to consumers.
Ms. Teenier pointed out that by the time these measures are used, some items on the list that are not currently risk-adjusted might be risk-adjusted. Dr. Shaughnessy noted that even for the items that are risk-adjusted, the risk adjustment will probably improve. As the national data become more numerous and the data can be better screened, it is proper to continually update the risk adjustment. Some of the measures not currently risk-adjusted in the CMS OBQI reports are now making the risk-adjustment grade in terms of having an R2 of 0.10 or greater and a C-statistic of 0.70. There will be more risk-adjusted measures in the CMS reports to agencies in the next round. Still, some of the measures will not be risk-adjusted. For consumer reports, more are likely to be risk-adjusted, but it is not clear which ones. If the opinion is overwhelming that certain measures should be included in CMS consumer reporting, Dr. Shaughnessy and his colleagues will probably focus on risk-adjusting those.
Dr. McGee questioned whether risk adjustment needs to reach a threshold of 0.10. If only a small number of factors make a difference, this is not a problem. In many other measures, statistical adjustments for education, sex, age, etc., make little difference, although people often perceive them as making a large difference. Statistical rules are ultimately arbitrary. For this report, Dr. McGee would be less strict about risk adjustment.
Dr. Shaughnessy agreed. Perhaps the cutoff standards mentioned earlier in the meeting were inappropriately high in view of the substantive importance of some of these measures. It may be impossible, no matter how large the dataset, to risk-adjust certain types of outcomes with much greater explanatory power than is currently available because quality is what makes the difference. If members of the panel believe that certain items are critical for the AHRQ and CMS reports and risk adjustment is semi-adequate because no valid way exists to risk-adjust them better, these items should probably be included. Dr. McGee would be more concerned if the researchers had only considered a few variables, but they have a long list.
Mr. Fitzgerald said it appeared that emergency care would have made the cut. Dr. Hittle agreed that this is the case with the latest risk adjustment model.
Dr. Bartlett distributed the prioritization sheets to the expert panel members, who identified their top 12 measures for CMS public reporting and their top 12 for the NHQR, and added comments on the measures if they wished.