OBJECTIVE To develop a risk adjustment approach and test reliability and validity for oncology survival measures. DATA SOURCES AND STUDY SETTING We used the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 2010 to 2013, with mortality data through 2015. STUDY DESIGN We developed 2-year risk-standardized survival rates (RSSR) for melanoma, non-small cell lung cancer (NSCLC), and small cell lung cancer (SCLC). Patients were attributed to group practices based on the plurality of visits. We identified the risk-adjustment variables via bootstrap and calculated the RSSRs. Reliability was tested via three approaches: (1) signal-to-noise ratio (SNR) reliability, (2) split-half, and (3) test-retest using bootstrap. We tested known group validity by stage at diagnosis using Cohen's d. DATA COLLECTION/EXTRACTION METHODS We selected all patients enrolled in Medicare and linked to SEER during the measurement period with an incident first primary diagnosis of stage I-IV melanoma, NSCLC, or SCLC. We excluded patients with missing data on month and/or stage of diagnosis. PRINCIPAL FINDINGS Results are based on patients with melanoma (n = 4344); NSCLC (n = 16,080); and SCLC (n = 2807) diagnosed between 2012 and 2013. The median (interquartile range) for the RSSRs at the group practice-level were 0.89 (0.83-0.87) for melanoma, 0.37 (0.30-0.43) for NSCLC, and 0.19 (0.11-0.25) for SCLC. C-statistics for the models ranged from 0.725 to 0.825. The reliability varied by approach with median SNR 0.20, 0.25, and 0.13; median test-retest 0.59, 0.57, and 0.56; median split-half reliability 0.21, 0.29, and 0.29 for melanoma, NSCLC, and SCLC, respectively. Cohen's d for stage I-IIIa and IIIb+ was 1.27, 0.86, 0.60 for melanoma, NSCLC, and SCLC, respectively. CONCLUSIONS Our results suggest that these cancer survival measures demonstrated adequate test-retest reliability and expected findings for the known-group validity analysis. If data limitations and feasibility challenges can be addressed, implementation of these quality measures may provide a survival metric used for oncology quality improvement efforts.

BACKGROUND: Intraoperative hypotension is common and associated with organ injury and death, although randomized data showing a causal relationship remain sparse. A risk-adjusted measure of intraoperative hypotension may therefore contribute to quality improvement efforts. METHODS: The measure we developed defines hypotension as a mean arterial pressure <65 mm Hg sustained for at least 15 cumulative minutes. Comparisons are based on whether clinicians have more or fewer cases of hypotension than expected over 12 months, given their patient mix. The measure was developed and evaluated with data from 225,389 surgeries in 5 hospitals. We assessed discrimination and calibration of the risk adjustment model, then calculated the distribution of clinician-level measure scores, and finally estimated the signal-to-noise reliability and predictive validity of the measure. RESULTS: The risk adjustment model showed acceptable calibration and discrimination (area under the curve was 0.72 and 0.73 in different validation samples). Clinician-level, risk-adjusted scores varied widely, and 36% of clinicians had significantly more cases of intraoperative hypotension than predicted. Clinician-level score distributions differed across hospitals, indicating substantial hospital-level variation. The mean signal-to-noise reliability estimate was 0.87 among all clinicians and 0.94 among clinicians with >30 cases during the 12-month measurement period. Kidney injury and in-hospital mortality were most common in patients whose anesthesia providers had worse scores. However, a sensitivity analysis in 1 hospital showed that score distributions differed markedly between anesthesiology fellows and attending anesthesiologists or certified registered nurse anesthetists; score distributions also varied as a function of the fraction of cases that were inpatients. CONCLUSIONS: Intraoperative hypotension was common and was associated with acute kidney injury and in-hospital mortality. There were substantial variations in clinician-level scores, and the measure score distribution suggests that there may be opportunity to reduce hypotension which may improve patient safety and outcomes. However, sensitivity analyses suggest that some portion of the variation results from limitations of risk adjustment. Future versions of the measure should risk adjust for important patient and procedural factors including comorbidities and surgical complexity, although this will require more consistent structured data capture in anesthesia information management systems. Including structured data on additional risk factors may improve hypotension risk prediction which is integral to the measure’s validity.

This article describes the reliability of the instruments embedded in a mental health screening instrument designed to detect risky drinking, depression, and post-traumatic stress disorder among members of the Armed Forces. The instruments were generally reliable, however, the risky drinking screen (Alcohol Use Disorders Identification Test-Consumption) had unacceptable reliability (α = 0.58). This was the first attempt to assess psychometric properties of a screening and assessment instrument widely used for members of the Armed Forces.

The fourth annual report of the Money Follows the Person (MFP) Evaluation includes analyses on (1) program implementation for the first five years; (2) descriptions of MFP participants and costs and types of services received; (3) trend analyses to detect shifts in the balance of state long-term care systems that may have occurred; and (4) an assessment of how participant quality of life changes after they leave the program.

This annual report shows that the national Money Follows the Person (MFP) demonstration, now in its fourth full year of implementation, appears to be achieving its broad goals. They include (1) transitioning people who need long-term care and supports from institutions to the community, and (2) helping states establish the infrastructure necessary to increase the capacity of long-term care systems to serve people in the community.

Care coordination for adults with disabilities is typically marked by costly services delivered by a variety of providers, but comparative effectiveness research can help address these challenges. This research brief presents a framework for describing the range of personal characteristics, services, outcomes, and financing issues to consider in a systematic review of care coordination. It also presents key findings from a systematic review of the recent care coordination literature, summarizes what additional information is needed, and discusses implications for future research on which care coordination strategies work best for various disabled populations.

This report presents the quality-of-life experiences of 803 MFP participants who transitioned to community living between January 2008 and December 2009 and responded to grantees’ administration of pre-transition and one-year post-transition surveys. The authors examine how reported quality of life changed after participants transitioned to community living.

This is the second annual report on the Money Follows the Person (MFP) demonstration, a federal initiative to help states reduce their reliance on institutional care for people needing long-term care and expand options for elderly people and individuals with disabilities to receive care in the community. During 2010, MFP increased the number of Medicaid beneficiaries transitioned by more than 50 percent over the previous year and expanded into 13 additional states. By the end of 2010, nearly 12,000 beneficiaries transitioned to community living through MFP programs, and participants generally fared well in the community and improved their quality of life.

Despite federal nursing home policies designed to prevent inappropriate institutionalization, many Medicaid beneficiaries under age 65 with serious mental illness may be inappropriately admitted to nursing facilities. A combination of the Medicaid policy requiring coverage for nursing home care and a lack of appropriate community-based care options may be the cause.

Many Medicaid beneficiaries aged 22 to 64 with serious mental illness may be admitted to nursing facilities rather than psychiatric facilities as a result of Medicaid policies prohibiting coverage of inpatient psychiatric care in institutions of mental disease while requiring states to cover nursing facility care. Using nationwide Medicaid Analytic Extract claims from 2002, we found that nearly 16% of nursing home residents aged 22 to 64 had a diagnosed mental disorder, while 45.5% received antipsychotic medication, but these rates varied widely across states. Further research is necessary to determine whether, among the nation's youngest nursing home residents, care in nursing homes is potentially substituting for care in institutions for mental disease or community-based settings.

Hospitals and post-acute care providers have developed quality measures to evaluate their effectiveness in preventing readmissions, but these measures are lacking in long-term care. This issue brief discusses the need for similar measures to assess the quality of long-term care for people in nursing homes and other home- and community-based service settings. It also identifies evidence-based care models and interventions for reducing potentially avoidable hospitalizations and highlights the need to develop financial incentives for providers to measure and improve performance.

Hospitals and post-acute care providers have developed quality measures to evaluate their effectiveness in preventing readmissions, but these measures are lacking in long-term care. This issue brief discusses the need for similar measures to assess the quality of long-term care for people in nursing homes and other home- and community-based service settings. It also identifies evidence-based care models and interventions for reducing potentially avoidable hospitalizations and highlights the need to develop financial incentives for providers to measure and improve performance.