Quality Indicators for High-Need Patients: a Systematic Review

Abstract

BACKGROUND: Healthcare systems are increasingly implementing programs for high-need patients, who often have multiple chronic conditions and complex social situations. Little, however, is known about quality indicators that might guide healthcare organizations and providers in improving care for high-need patients. We sought to conduct a systematic review to identify potential quality indicators for high-need patients. METHODS: This systematic review (CRD42020215917) searched PubMed, CINAHL, and EMBASE; guideline clearing houses ECRI and GIN; and Google scholar. We included publications suggesting, evaluating, and utilizing indicators to assess quality of care for high-need patients. Critical appraisal of the indicators addressed the development process, endorsement and adoption, and characteristics, such as feasibility. We standardized indicators by patient population subgroups to facilitate comparisons across different indicator groups. RESULTS: The search identified 6964 citations. Of these, 1382 publications were obtained as full text, and 53 studies met inclusion criteria. We identified over 1700 quality indicators across studies. Quality indicator characteristics varied widely. The scope of the selected indicators ranged from detailed criterion (e.g., "annual eye exam") to very broad categories (e.g., "care coordination"). Some publications suggested disease condition-specific indicators (e.g., diabetes), some used condition-independent criteria (e.g., "documentation of the medication list in the medical record available to all care agencies"), and some publications used a mixture of indicator types. DISCUSSION: We identified and evaluated existing quality indicators for a complex, heterogeneous patient group. Although some quality indicators were not disease-specific, we found very few that accounted for social determinants of health and behavioral factors. More research is needed to develop quality indicators that address patient risk factors.

Quality Measures for Patients at Risk of Adverse Outcomes in the Veterans Health Administration

“…We conceived of 3 major categories of clinical processes of care: (1) assessment of patient risk factors, (2) treatment of high-risk patients, and (3) features of high-risk patient care (the conceptual model is given in Figure 1). Each category consisted of care domains (eg, assessment of social determinants of health) that comprised measure concepts identified from the literature …”

“…Each category consisted of care domains (eg, assessment of social determinants of health) that comprised measure concepts identified from the literature. 15 We defined high-risk patients as those in the top 5% to 10% of risk for hospitalization and/or death. This definition aligns with the VHA's use of electronic algorithms (ie, Care Assessment Need score 20 ) in primary care to measure patient risk of hospitalization or death within 3 months.…”

“…To identify existing measure concepts that would apply broadly to the high-risk patient population, we first performed a systematic review from June 2020 to June 2021 of published studies that suggested, evaluated, or used quality indicators in high-risk patients. 15 The systematic review included empirical studies and expert panels evaluating proposed indicators; editorials were not included. At the time of our expert panel meeting, this review had identified 519 measure concepts that were supported by randomized clinical trials or validated by an expert or stakeholder panel.…”

“…Three weeks before the panel meeting, we provided the panelists with a brief summary of evidence supporting each proposed measure concept (eTable in the Supplement), including a summary of the systematic review. 15 Each measure concept was designated as evidence based, as judged by major nationally recognized expert or stakeholder panels (eg, Assessing Care of Vulnerable Elders, 23 the National Commission for Quality Assurance, and the US Preventive Services Task Force)…”

“…13 Primary care teams aim to assess and meet the needs of the patient through patient-centered, comprehensive, coordinated care 14 ; they need to quickly identify areas for further evaluation and/or treatment. First, we performed a rapid systematic literature review 15 to identify quality measures as the basis for an evidence-based and actionable dashboard of priorities for primary care patients. However, because few validated measures could be identified, we instead sought to identify measure concepts, which describe clinical activities that evidence suggests should be measured without actually specifying how to measure them, as a starting point for developing quality measures.…”