Utah doctors target measures for otitis media
This common condition presents challenges
Otitis media, an inflammation of the middle ear, presents an obvious target for outcomes management: It is the most common diagnosis among preschool children, affecting 75% of all children by the time they are 6 years old, and it costs an estimated $3 billion a year to treat. So why is it so hard to define and track quality treatment for this condition?
As physicians in Salt Lake City seek to measure and compare the use of treatment guidelines for otitis media with effusion (OME), their work is trailblazing in the area of pediatric quality measurement. The National Committee on Quality Assurance (NCQA) in Washington, DC, which accredits health plans, launched a measure for acute otitis media in 1996 but withdrew it after problems emerged with the data collection. An American Academy of Pediatrics instrument on OME remains a draft, with multiple options for potential users. (See related story, p. 131.)
Now, otolaryngologists, pediatricians, and family practitioners are working together on a pilot project that is coordinated by HealthInsight, a Salt Lake City-based health care quality improvement organization. They will be measuring the use of procedures related to patient assessment, such as pneumatic otoscopy, tympanometry, and hearing testing.
The project may become a model for quality improvement systems approved by the new American Medical Accreditation Program (AMAP) of the American Medical Association in Chicago, so both AMAP and the Utah Medical Association are providing support.
"In otitis media, it’s a lot harder to [create] a standard that says this is a right way and every one of your episodes should look like this," says Mark Bennett, MA, chief operating officer of HealthInsight. "We’re measuring how their episodes look. Are they consistent from patient to patient? How do they compare to a set of peers? The science isn’t perfect here in terms of translation from guidelines into measures," he says.
The bottom line: Gathering information for quality improvement is a more effective goal than setting standards for performance assessment. "We would like to make sure we have the first focus on helping physicians have data they can use in changing the way they interact with patients," Bennett says.
How do you identify OME from codes?
Otitis media with effusion carries the danger of hearing loss for young children, with corresponding developmental delays and the possible costs of surgery for ear tube insertion. Yet even identifying cases of OME can be fraught with difficulty. "It’s actually very difficult from claims databases to tell if it’s otitis media with effusion or acute otitis media," he says. "You have to look at episodes over time."
Coding problems may make it difficult to determine if a hearing test occurred, and pharmaceuticals must be tracked through chart review.
Meanwhile, the guideline developed by the Agency for Health Policy and Research (AHCPR) in Washington, DC, doesn’t contain easily trackable events that can be linked to clear standards about what is right or wrong, Bennett says. "None of the guidelines are written to imply there is a certainty in the right course."
However, physicians will be able to compare their processes of care, such as the amount of time patients are followed before they receive tympanostomy tubes.
In fact, even the planning stage of the project was significant because it brought together otolaryngologists, family physicians, and pediatricians. "That’s the beginning of the improvement [cycle] we believe is possible in this system," says Bennett.
Project tests methods of data collection
To tackle the technical problems of assessing care for OME, the HealthInsight project involves three different methods of collecting data and a comparison of the wealth of information generated by each.
This fall, HealthInsight began recruiting some 300 physicians to give permission for the data to be siphoned from the Utah Health Information Network, an electronic data interchange that transmits information between payers and providers. HealthInsight will detect "entry" visits from the claims of family practitioners and pediatricians and will follow referrals through matching patient identification numbers.
These physicians will receive information on their treatment of OME without devoting time and resources to data collection.
Yet more information is necessary even to develop and assess an appropriate method of tracking OME care. So HealthInsight will try to recruit 20% of the participants to allow abstraction and review of patient charts using a sampling methodology.
Finally, HealthInsight hopes that another 10% of participating physicians will complete forms in a "self-coding" version of data collection, tracking the measures for a sample of patients.
Physician interaction is the linchpin of this project, which may become a model for other, non-pediatric targets of outcomes management.
HealthInsight plans to invite physicians to "breakthrough improvement sessions," using a system developed by the Institute for Healthcare Improvement in Boston for physicians to identify best practices and share what works.
"They have to leave busy practices and that will be tough," acknowledges Bennett. "But that [meeting] is an important component of the experiment. Sharing data [alone] will only give us a very small fracture of the improvement that we think is useful."
Meanwhile, the Utah project represents an important step for AMAP, which identified otitis media among its key areas for outcomes measurement development.
The AMAP system is likely to develop in a similar direction as the ORYX initiative of the Joint Commission on Accreditation of Health Care Organizations, says says Richard Hughes, MD, director of clinical performance evaluation. Currently, participation in quality improvement provides additional points toward accreditation for physicians.
Eventually, quality improvement efforts will be required, and further in the future, physicians may be required to meet some defined performance standards, says Hughes. Physicians will likely choose among different systems that have been approved by AMAP. HealthInsight hopes to develop one such system.
"The criteria for showing improvement will vary," he says. "It’s something that will be shaped as much by physicians as by other stakeholders [such as payers and purchasers]."
Hughes acknowledges that HealthInsight has chosen a difficult diagnosis for its first AMAP-related project. But he calls it a "critical" effort in AMAP’s move toward quality improvement and assessment.
"There have been a lot of statewide efforts for quality assurance and performance measurement," he says. "Utah’s is the first effort to try to link a statewide measurement with a fledgling national measurement — AMAP."
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