Scope of HAB Core Clinical Performance Measures
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| 1. Are the core clinical performance measures applicable to all Parts? |
Yes, the HAB PMs can be used by all programs funded by the Ryan White HIV/AIDS Program that provide HIV care or other relevant services. The measures can be used either at the provider or system level. The measures can be rolled up to look at issues from a system perspective, such as with Part A and B Programs. Programs can also work with their subcontractors, vendors or subgrantees to implement the performance measures at the provider level. Grantees are encouraged to include the core clinical performance measures in their quality management plan.
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| 2. How are these performance measures different from ones previously released by HAB? |
In April 2007, a draft set of performance measures were released for public comment. Based on the tremendous feedback received, the performance measures were revised to address many of the issues raised.
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| 3. Does this mean that HAB considers these measures the really important ones? |
HAB considers all of the clinical performance measures that were released in April 2007 critical to good care. The measures were released in phases to allow for staged implementation. If a clinical program has no performance measures, Group 1 measures provide an excellent start and can serve as a foundation on which to build. Group 2 measures are important measures for a robust clinical management program and should be seriously considered. Group 3 measures represent areas of care that represent "best practice," but may lack written clinical guidelines or rely on data that are difficult to collect.
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| 4. Are children included in the eligible population? |
No. Children aged 12 years and younger are not included in the HAB core performance measures. A separate set of measures targeted to children will be developed in 2009.
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| 5. Why aren't general health indicators included in the HAB core performance measures? |
National performance measures have been established for a wide range of general health conditions, such as immunizations, prenatal care and screenings. Since there are currently no national consensus performance measures for HIV care, the HAB HIV Core Clinical Performance Measures focus on key elements of care that are unique to the HIV-infected patient population served by the Ryan White HIV/AIDS Programs.
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| 6. Why isn't ophthalmology screening included in HAB's list of measures? |
Ophthalmology screening was removed from HAB's list of measures as a result of several factors. The primary method for preventing severe cytomegalovirus (CMV) disease is recognition of early manifestations of the disease. Current guidelines [ 1 ] recommend patients being made aware of the importance of increased floaters in the eye and advising them to assess their visual acuity regularly by using simple techniques, such as reading newsprint. This recommendation is considered a "BIII" recommendation. [ 2 ] Regular funduscopic examinations performed by an ophthalmologist are recommended by certain specialists for patients with low (e.g., <50 cells/µL) CD4 counts and is considered a "CIII" recommendation. Annual screening would not be sufficient to detect CMV retinitis as it invariably progresses, usually within 10-21 days after presentation in the absence of ART or anti-CMV therapy. The lack of clinical evidence, frequency of screening and cost all contributed to the removal of ophthalmology screening from HAB's performance measures.
[ 1 ] Centers for Disease Control and Prevention. Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents. June 18, 2008; 1-134. ( http://aidsinfo.nih.gov/contentfiles/Adult_OI.pdf )
[ 2 ] The PHS guidelines rate the strength of recommendations (A-E) and the quality of evidence (I-III). An "A" rating indicates a strong recommendation while an "E" should never be offered. An "I" ranking includes randomized trials with either clinical or validated laboratory outcomes, e.g. viral load. An "III" rating is a recommendation based on expert opinion.
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| 7. Why isn't basic patient education included in HAB's list of measures? |
A significant amount of feedback was received in regards to the measure related to general patient education and the similarity to other measures. Patient education is clearly an important element of care that should be integrated into every visit. Patient education permeates the other HAB measures and became redundant with this single measure. As a result, it was removed from the list of measures.
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| 8. Why is Hepatitis B screening and vaccination presented as two separate measures? |
Hepatitis B screening and vaccination are important for different reasons. Screening is important to identify those infected with HBV to assure appropriate counseling, care and treatment, both for their HBV and HIV. For those who are not infected with HBV, vaccination can prevent transmission. Additional information related to hepatitis can be found at www.cdc.gov/hepatitis/HBV.htm .
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| 9. Why isn't Hepatitis A vaccination included in HAB's list of measures? |
Hepatitis A vaccination was removed from HAB's list of measures because it is not uniformly recommended for all populations. According to the CDC guidelines [ 3 ], Hepatitis A vaccination is recommended in persons with chronic liver disease, men who have sex with men and injection drug users. HAV-susceptible, HIV-infected individuals with risk factors for HAV infection should also receive hepatitis A vaccination. The complexity of identifying the population of focus limited the utility of the measure. Combined with other measures that address similar topics, such as HBV screening, HBV vaccination, HCV screening and other immunizations, HAB elected to remove Hepatitis A vaccination from the core group of clinical indicators.
[ 3 ] Centers for Disease Control and Prevention. Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents. June 18, 2008; 1-134. ( http://aidsinfo.nih.gov/contentfiles/Adult_OI.pdf )
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| 10. Why aren't performance measures for case management or other supportive services included in the HAB core clinical performance measures? |
Because these measures focus on medical care, measures for case management and other supportive services have not been included. Separate performance measures were released for public comment in Fall 2008 related to case management, oral health, AIDS Drug Assistance Program (ADAP) and systems of care. These measures are anticipated to be released in their final form in Fall 2009.
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| 11. What is the difference between a performance measure and standard of care? |
A performance measure provides an indication of an organization's performance in relation to a specified process or outcome. Standards of care are guidelines that outline the expectations of care around a specific issue or topic and are created by a group of subject matter or clinical experts. Because performance measures and standards of care each serve a different purpose, they are not always in accordance. For instance, with the Medical Visit performance measure, the standard of care states that routine monitoring should occur at least every three to four months depending on the stage of disease. For the purpose of the performance measure, the time frame of six months was determined by clinical expert consensus to allow for those patients that are well controlled clinically and stable on their current regimen. Per the guidelines, patients can and should be seen at more frequent intervals as dictated by their current health status.
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| 12. Will data be used for punitive purposes? |
As a general rule of thumb, data for quality improvement purposes are not designed to be punitive or used to consider funding levels/decisions. Quality improvement data should be used to document areas of strength, identify areas for improvement and help guide, shape and enhance the delivery and quality of care. The intent is to minimize wide fluctuations in care and maintain a consistent level of service.
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