Composite measures of healthcare quality: sensible in theory, problematic in practice

Friebel, Rocco; Steventon, Adam

doi:10.1136/bmjqs-2018-008280

Cited by 24 publications

(31 citation statements)

References 15 publications

(13 reference statements)

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“…Additionally, through electronic administrative data, audits and registries, a vast amount of clinical outcome measures are available which can be difficult to understand. A composite measure can condense a number of outcome measures into a single score which can simplify the data and provide an overview of patient recovery and quality of care [27]. Combining PROMs with objective clinical outcomes into a single composite measure ensures that both the clinician and patient perspectives are captured, providing an overview of patient recovery and quality of care [27].…”

Section: Discussionmentioning

confidence: 99%

Development of a percutaneous coronary intervention patient level composite measure for a clinical quality registry

Ayton

Soh

Morello

et al. 2020

BMC Health Serv Res

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Background: Composite measures combine data to provide a comprehensive view of patient outcomes. Despite composite measures being a valuable tool to assess post-intervention outcomes, the patient perspective is often missing. The purpose of this study was to develop a composite measure for an established cardiac outcome registry, by combining clinical outcomes following percutaneous coronary interventions (PCI) with a patientreported outcome measure (PROM) developed specifically for this population (MC-PROM). Methods: Two studies were undertaken. Study 1: Patients who had undergone a PCI at one of the three participating registry hospital sites completed the 5-item MC-PROM. Clinical outcome data for the patients (e.g. death, myocardial infarction, repeat vascularisation, new bleeding event) were collected 30 days post-intervention as part of routine data collection for the cardiac registry. Exploratory factor analysis of clinical outcomes and MC-PROM data was conducted to determine the minimum number of constructs to be included in a composite measure. Study 2: Clinical experts participated in a Delphi technique, consisting of three rounds of online surveys, to determine the clinical outcomes to be included and the weighting of the clinical outcomes and MC-PROM score for the composite measure. Results: Study 1: Routine clinical outcomes and the MC-PROM data were collected from 266 patients 30 days post PCI. The MC-PROM score was not significantly correlated with any clinical outcomes. Study 2: There was a relatively consistent approach to the weighting of the clinical outcomes and MC-PROM items by the expert panel (n = 18) across the three surveys with the exception of the clinical outcome of 'deceased at 30 days'. The final composite measure included five clinical outcomes within 30 days weighted at 90% (new heart failure, new myocardial infarction, new stent thrombosis, major bleeding event, new stroke, unplanned cardiac rehospitalisation) and the MC-PROM score (comprising 10% of the total weighting). Conclusions: A single patient level composite score, which incorporates weighted clinical outcomes and a PROM was developed. This composite score provides a more comprehensive reported measure of individual patient wellbeing at 30 days post their PCI-procedure, and may assist clinicians to further assess and address patient level factors that potentially impact on clinical recovery.

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Section: Discussionmentioning

confidence: 99%

Development of a percutaneous coronary intervention patient level composite measure for a clinical quality registry

Ayton

Soh

Morello

et al. 2020

BMC Health Serv Res

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“…Even though direct comparisons with the composite measure are not possible, encouragingly, the adherence to other individual FeSS processes was found to be comparable or even improved against the QASCIP post-implementation cohort [6]. Limitations to the use of composite measures have been reported [47]. However, our methods to negate the influence of missing data with decision rules to ensure all patients were eligible to receive all processes in the measure and in-built logic checks in the data tool could address some of these concerns.…”

Section: Discussionmentioning

confidence: 99%

Inclusion of a care bundle for fever, hyperglycaemia and swallow management in a National Audit for acute stroke: evidence of upscale and spread

et al. 2019

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Background In the Quality in Acute Stroke Care (QASC) trial undertaken in stroke units (SUs) located in New South Wales (NSW), Australia (2005–2010), facilitated implementation of a nurse-led care bundle to manage fever, hyperglycaemia and swallowing (FeSS protocols) reduced death and disability for patients with stroke. We aimed to determine subsequent adherence to the bundled FeSS processes (reflective of the protocols) between 2013 and 2017 in Australian hospitals, and examine whether changes in adherence to these processes varied based on previous participation in the QASC trial or subsequent statewide scale-up (QASCIP—Quality in Acute Stroke Care Implementation Project) and presence of an SU. Methods Cross-sectional, observational study using self-reported organisational survey and retrospective clinical audit data from the National Acute Services Stroke Audit (2013, 2015, 2017). Mixed-effects logistic regression was performed with dependent variables: (1) composite outcome measure reflecting compliance with the FeSS protocols and (2) individual FeSS processes, including the year of audit as an independent variable, adjusted for correlation of outcomes within hospital. Separate models including interaction terms between the year of audit and previous participation in QASC/QASCIP and year of audit and SU were also generated. Results Hospital participation included the following: 2013—124 hospitals, 3741 cases; 2015—112 hospitals, 4087 cases; and 2017—117 hospitals, 4192 cases. An 80% increase in the odds of receiving the composite outcome in 2017 compared to 2013 was found (2013, 30%; 2017, 41%; OR 1.8; 95% CI 1.6, 2.0; p < 0.001). The odds of FeSS adherence from 2013 to 2017 was greater for hospitals that had participated in QASC/QASCIP relative to those that had not (participated OR 2.1; 95% CI 1.7, 2.7; not participated OR 1.6; 95% CI 1.4, 1.8; p = 0.03). Similar uptake in adherence was evident in hospitals with and without an SU between 2013 and 2017. Conclusion The use of the FeSS protocols within Australia increased from 2013 to 2017 with the inclusion of these care processes in the National Audit. Greater uptake in hospitals previously involved in QASC/QASCIP was evident. Our implementation methods may be useful for other national initiatives for improving access to evidence-based practice. Electronic supplementary material The online version of this article (10.1186/s13012-019-0934-y) contains supplementary material, which is available to authorized users.

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“…Such composites offer two advantages—the simplicity of a single overall measure and increased statistical power from having more eligible events. But, these composites can create problems,34 35 just as with composite outcomes in clinical trials 36 37. Composite outcomes pose particular problems when the components vary substantially in terms of their frequency and/or severity and when an intervention exerts differential effects on the various components.…”

Section: Heterogeneity As the Fundamental Challenge To Using Aes As Amentioning

confidence: 99%

Identifying adverse events: reflections on an imperfect gold standard after 20 years of patient safety research

Shojania

Mheen

2020

BMJ Qual Saf

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Composite measures of healthcare quality: sensible in theory, problematic in practice

Cited by 24 publications

References 15 publications

Development of a percutaneous coronary intervention patient level composite measure for a clinical quality registry

Development of a percutaneous coronary intervention patient level composite measure for a clinical quality registry

Inclusion of a care bundle for fever, hyperglycaemia and swallow management in a National Audit for acute stroke: evidence of upscale and spread

Identifying adverse events: reflections on an imperfect gold standard after 20 years of patient safety research

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