As for 2014, COPD was the third cause of death in the US. To improve these statistics, providers, insurers, and policymakers aim to improve the health outcomes of patients with COPD.
But what exactly should they improve? It seems that everyone has their own opinion on the measures that caregivers should take into account medical data analysis to fight efficiently with the risks of mortality, morbidity and complications. Especially, while the specific challenges of COPD impede the process of definition, measurement and analyze patient health outcomes.
Challenges of COPD that make it difficult to analyze health outcomes
It is incurable
All COPD treatment measures are aimed at relieving the patient’s symptoms (chronic cough, difficulty breathing, abnormal sputum and more) and slowing the progression of the disease. Therefore, caregivers cannot use any outcome measures related to a full recovery.
Differences in initial health status
It is more difficult to define appropriate measures to assess health outcomes, as patients with COPD differ in their general states. For example, when a person has chronic bronchitis, they may need to lose weight. On the other hand, patients with emphysema may be advised to increase weight and muscle mass. The goals and objectives of lung rehabilitation for these patients will definitely differ, and so will their results.
Slow progress of lung rehabilitation
Because functional improvement in lung capacity does not necessarily lead to objective improvement in lung function, it is useless to analyze short-term outcome data (apart from acute complications).
Patients with COPD may develop serious complications, such as:
- lung infections (eg pneumonia)
- osteoporosis, especially when a patient is taking oral corticosteroids
- heart attack
- pneumothorax and more
However, these complications can take a long time to develop, or develop “quietly,” for example, osteoporosis usually progresses without any symptoms until a fracture / collapse of the vertebrae occurs. Consequently, this delay between the provision of care and the improvement of the following patient’s health outcomes makes data analysis even more difficult.
CMS approach to define the essential measures for COPD
In its “Roadmap for Measuring Quality in the Traditional Medicare Service Payment Program,” CMS emphasizes that moving to a more value-based care environment means rethinking quality measures and changing the approach to process measures (which may be easier to produce). or evaluate) those based on evidence, including outcomes, resource use, and care transitions.
CMS also considers COPD a “priority area for the development of outcome measures because it is a common and debilitating condition associated with considerable morbidity and mortality.”
While this statement explicitly shows the importance of defining relevant measures to improve the health outcomes of patients with COPD, CMS offers providers to use two complementary measures:
- 30-day hospital readmission fee, for all causes, standardized for risk after hospitalization (objective result: readmission rate)
- 30-day hospital mortality rate, for all causes, standardized by risk after hospitalization (objective result: 30-day mortality rate for all causes)
In this “Roadmap for Measuring Quality,” CMS also states that outcome measures take into account morbidity and mortality from a disease, which may be a possible reason for such a set of measures. scarce. While this pair may be useful for general reporting on CMS, it’s still not the level of coverage we expect for the “priority area”.
For example, what about the most patient-oriented measures that address preventable complications, lung rehabilitation, and treatment progress? We check other sources to see if there is the answer.
Where to look for more guidance: AHQR, NQF
Currently, there are 3 COPD-related measures on the AHRQ National Quality Measures Clearinghouse (NQMC) website:
- 30-day hospital mortality rate, for all causes, standardized by risk after acute exacerbation (objective result: mortality rate)
- Proportion of patients admitted for acute exacerbation of COPD who die within 30 days of admission (objective result: mortality rate)
- Percentage of patients who quit smoking (100% quit target) (objective result: quit smoking)
The first two measures are similar to those provided by CMS, and we again doubt that the set presented can offer broad coverage of COPD health outcomes.
Because the AHRQ itself identifies COPD as a condition sensitive to outpatient care (ACSC), it is expected to address the challenges of outpatients and their outcomes. Patients with COPD should deal with dyspnea, weight problems, certain activity limitations, poor sleep, possible social isolation, anxiety, and depression.
Therefore, the sets of measures aimed at income, readmission, and mortality only seem insufficient, even with the additional measure to quit smoking.
The National Quality Forum website offers 6 measures that help assess COPD outcomes, but two of these are these mortality and readmission measures provided by CMS. So let’s not repeat ourselves and move on to different criteria:
- Admission rate for patients with COPD or asthma, 40 years and older (objective result: admission rate)
- Functional capacity in patients before and after pulmonary rehabilitation (objective results: functional state, ability to exercise)
- Health-related quality of life in patients with COPD before and after pulmonary rehabilitation (objective result: quality of life)
- Dying comfortably: Pain brought to a comfortable level within 48 hours of initial assessment (objective result: pain control)
Although such common measures as admission, readmission, and mortality are considered, this set also focuses on 2 outpatient measures – quality of life and functional capacity. We also want to highlight the importance of the pain control measure, which is created for hospices. It is a somewhat borderline measure between mortality and quality of life, as it aims at the comfort of the dying patient. It is an essential health outcome for hospices, allowing them to improve the provision of palliative care.
In general, although the level of coverage may not be sufficient, the above measures present both in-hospital and outpatient care provision. This is definitely a step beyond the CMS and AHRQ criteria sets, as providers can now define areas for improvement in outpatient conditions, such as applying more efforts to lung rehabilitation.
A look around: UK, NICE
The UK National Institute for Excellence in Health and Care (NICE) provides caregivers with guidance on improving healthcare across the country by developing standards, measures and indicators of healthcare quality. . In addition, providers can access guidelines on diagnosis and management, guidance on intervention procedures, and technology assessment guidance.
He quality standards part is where the measures belong. Here suppliers can find the sets of certain quality statements, where each statement is an independent measure. From 7 statements available for COPD, 6 focus on the health outcomes of multiple patients:
- Inhalation technique (objective results: exacerbation rates, hospital admission)
- Long-term evaluation of oxygen therapy (objective results: income from acute exacerbation, quality of life)
- Pulmonary rehabilitation after acute exacerbation (objective results: income from acute exacerbation, quality of life, ability to exercise)
- Pulmonary rehabilitation for stable COPD and exercise limitation (objective results: admission due to acute exacerbation, quality of life, ability to exercise, assistance to the general practitioner)
- Emergency oxygen during an exacerbation (objective results: frequency of non-invasive ventilation due to oxygen toxicity, morbidity rates)
- Non-invasive ventilation (target results: mortality rates)
Most NICE measures target multiple outcomes and the patient’s quality of life is the focus. There are also outpatient and inpatient measures. In our view, this approach allows for more systematic coverage of COPD health outcomes. Not only does it consider morbidity and mortality, but it also considers the patient’s health status apart from hospitalization (pulmonary rehabilitation).
NICE also explains the reasons for certain claims, their practical and research value, as well as the strong connection to patients ’health outcomes.
Final assessment on measures of COPD health outcomes
Here we are with different opinions. CMS aligns its measures with its own definitions, AHRQ supports them, and NQF creates a broader set based on the experience of two previous administrators. The NICE in the UK is going a different way with its practice.
Who is right? Of course, we cannot say that any of the sources are wrong in their approach to measuring COPD health outcomes.
However, the complete experience of the COPD patient with their condition includes, first, the outpatient setting and, to a lesser extent, hospitalization. In this case, to accurately address the high mortality and morbidity in patients with COPD, the outpatient part should also be considered. As simple as it is, improving health outcomes begins with the provision of relevant care and timely updates of the treatment plan. And the better the results of spirometry and oximetry, the higher the quality of life. As a result, the survival rate increases and the mortality rate decreases.