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  • Measure Summary
  • NQMC:009355
  • Nov 2013

Palliative care for adults: percentage of adult patients with a serious illness who have documentation in the medical record of a completed advance directive.

McCusker M, Ceronsky L, Crone C, Epstein H, Greene B, Halvorson J, Kephart K, Mallen E, Nosan B, Rohr M, Rosenberg E, Ruff R, Schlecht K, Setterlund L. Palliative care for adults. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2013 Nov. 81 p. [92 references]

View the original measure documentation External Web Site Policy

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in January 2017.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of adult patients age 18 years and older with a serious illness who have documentation in the medical record of a completed advance directive.

Rationale

The priority aim addressed by this measure is to increase the completion, documentation and ongoing utilization of advance directives for patients with a serious illness.

Clinicians provide palliative care through effective management of pain and other distressing symptoms, while incorporating psychosocial and spiritual care according to patient and family needs, values, beliefs and culture(s) (Lorenz et al., 2008). The National Consensus Project (2013), National Quality Forum (2012) and the Joint Commission have outlined systematic components of palliative care services to support these outcomes. By intervening at the onset of a serious illness, health care professionals can assure that appropriate interventions are offered to meet the goal of reducing the burden of disease and maximizing the quality of life.

Advance care planning always consists of conversations among patient, family and clinician about who should make decisions if the patient is unable, and what type of care the patient desires. It is recommended to document that plan with a legal advance directive and/or Physician/Provider Order for Life-Sustaining Treatment (POLST).

There has been conflicting data on the influence of advance directives on health care spending. In a study using Health Retirement Study data – including Medicare claims data and interviews of relatives of decedents, as well as information on regional health care spending from the Dartmouth Atlas – evidence showed that in high health care spending regions, individuals with an advance directive limiting treatments at end of life were less likely to die in a hospital, more likely to receive hospice care and generated lower Medicare end-of-life care costs (Nicholas et al., 2011). Studies have shown that those who die at home and those enrolled in hospice programs have improved quality of life and symptom control. This suggests that for individuals who wish to limit treatments at the end of life, it is particularly important to document those preferences, if one's wishes vary considerably from the norms in one's area of residence.

Evidence for Rationale

Lorenz KA, Lynn J, Dy SM, Shugarman LR, Wilkinson A, Mularski RA, Morton SC, Hughes RG, Hilton LK, Maglione M, Rhodes SL, Rolon C, Sun VC, Shekelle PG. Evidence for improving palliative care at the end of life: a systematic review. Ann Intern Med. 2008 Jan 15;148(2):147-59. [152 references] PubMed External Web Site Policy

McCusker M, Ceronsky L, Crone C, Epstein H, Greene B, Halvorson J, Kephart K, Mallen E, Nosan B, Rohr M, Rosenberg E, Ruff R, Schlecht K, Setterlund L. Palliative care for adults. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2013 Nov. 81 p. [92 references]

National Consensus Project for Quality Palliative Care. Clinical practice guidelines for quality palliative care. 3rd ed. Pittsburgh (PA): National Consensus Project for Quality Palliative Care; 2013. 70 p.

National Quality Forum. National voluntary consensus standards: palliative care and end-of-life care – a consensus report. Washington (DC): National Quality Forum; 2012 Apr. 66 p.

Nicholas LH, Langa KM, Iwashyna TJ, Weir DR. Regional variation in the association between advance directives and end-of-life Medicare expenditures. JAMA. 2011 Oct 5;306(13):1447-53. PubMed External Web Site Policy

Primary Health Components

Palliative care; serious illness; advance directives

Denominator Description

Number of patients with a diagnosis of a serious illness (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Number of patients who have documentation in the medical record of a completed advance directive

State of Use

Current routine use

Current Use

Internal quality improvement

Measurement Setting

Ambulatory/Office-based Care

Professionals Involved in Delivery of Health Services

Physicians

Least Aggregated Level of Services Delivery Addressed

Clinical Practice or Public Health Sites

Statement of Acceptable Minimum Sample Size

Unspecified

Target Population Age

Age greater than or equal to 18 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Person- and Family-centered Care
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

End of Life Care

Living with Illness

IOM Domain

Effectiveness

Patient-centeredness

Case Finding Period

The time frame pertaining to data collection is monthly.

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
Number of patients with a diagnosis of a serious illness that includes but is not limited to:

  • Pulmonary disease
  • Cancer/neoplasm
  • Liver disease
  • Renal disease
  • Neurological disorders:
    • Stroke
    • Parkinson's
    • Amyotrophic lateral sclerosis
    • Multiple sclerosis

Population Definition: Patients ages 18 years and older.

Exclusions
Unspecified

Exclusions/Exceptions

Unspecified

Numerator Inclusions/Exclusions

Inclusions
Number of patients who have documentation in the medical record of a completed advance directive

Exclusions
Unspecified

Numerator Search Strategy

Fixed time period or point in time

Data Source

Electronic health/medical record

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Internal time comparison

Original Title

Percentage of adult patients with a serious illness who have documentation in the medical record of a completed advance directive.

Measure Collection Name

Palliative Care for Adults

Submitter

Institute for Clinical Systems Improvement - Nonprofit Organization

Developer

Institute for Clinical Systems Improvement - Nonprofit Organization

Funding Source(s)

The Institute for Clinical Systems Improvement's (ICSI's) work is funded by the annual dues of the member medical groups and five sponsoring health plans in Minnesota and Wisconsin.

Composition of the Group that Developed the Measure

Work Group Members: Martha McCusker, MD, FACP (Work Group Leader) (Hennepin County Medical Center) (Internal Medicine/Geriatrics); Becky Nosan, NP (Allina Medical Clinic) (Family Medicine/Palliative Care); Erin L. Rosenberg, LICSW (Allina Medical Clinic) (Social Worker); Joe Halvorson, RN (Essentia Health) (Nursing); Lyn Ceronsky, DNP, GNP-BC, FPCN (Fairview Health Services) (Family Medicine/Geriatrics); Ken Kephart, MD (Fairview Health Services) (Family Medicine/Geriatrics); Mabel Rohr, CNP (HealthPartners Medical Center and Regions Hospital) (Family Medicine/Geriatrics); Rob Ruff, BCC (HealthPartners Medical Center and Regions Hospital) (Chaplain); Chuck Crone (Patient Representative); Barbara Greene, MPH (Twin Cities Medical Society) (Cultural Care); Kristina Schlecht, MD (University of North Dakota Center for Family Medicine); Howard Epstein, MD, FHM (Institute for Clinical Systems Improvement [ICSI]) (Chief Health Systems Officer); Emily Mallen, MBA (ICSI) (Project Manager); Linda Setterlund, MA, CPHQ (ICSI) (Clinical Systems Improvement Facilitator)

Financial Disclosures/Other Potential Conflicts of Interest

The Institute for Clinical Systems Improvement (ICSI) has long had a policy of transparency in declaring potential conflicting and competing interests of all individuals who participate in the development, revision and approval of ICSI guidelines and protocols.

In 2010, the ICSI Conflict of Interest Review Committee was established by the Board of Directors to review all disclosures and make recommendations to the board when steps should be taken to mitigate potential conflicts of interest, including recommendations regarding removal of work group members. This committee has adopted the Institute of Medicine Conflict of Interest standards as outlined in the report Clinical Practice Guidelines We Can Trust (2011).

Where there are work group members with identified potential conflicts, these are disclosed and discussed at the initial work group meeting. These members are expected to recuse themselves from related discussions or authorship of related recommendations, as directed by the Conflict of Interest committee or requested by the work group.

The complete ICSI policy regarding Conflicts of Interest is available at the ICSI Web site External Web Site Policy.

Disclosure of Potential Conflicts of Interest

Lyn Ceronsky, DNP, CHPCA, GNP-BC (Work Group Member)
Director, Palliative Care, Fairview Health Services
National, Regional, Local Committee Affiliations: CAPC Advisory Council, MN Network Hospice and Palliative Care, National Board Certification Hospice and Palliative Nursing
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: Paid consultant to Stratis Health and CAPC

Howard Epstein, MD, FHM (Work Group Member)
Chief Health Systems Officer, Institute for Clinical Systems Improvement (ICSI)
National, Regional, Local Committee Affiliations: Board of Directors, Society of Hospital Medicine; Board of Directors and Executive Council of Minnesota Network of Hospice and Palliative Care
Guideline Related Activities: None
Research Grants: Primary investigator for a Choosing Wisely® grant from the ABIM Foundation
Financial/Non-Financial Conflicts of Interest: None

Barbara Greene, MPH (Work Group Member)
Director of Community Engagement, Honoring Choices Minnesota, Twin Cities Medical Society
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Joe Halvorson, RN (Work Group Member)
Nurse, Essentia Health
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Ken Kephart, MD (Work Group Member)
Medical Director, Fairview Senior Services, Fairview Health Services
National, Regional, Local Committee Affiliations: Board member of Twin Cities Medical Society
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: Paid consultant to Honoring Choices Minnesota

Martha McCusker, MD (Work Group Leader)
Physician, Internal Medicine, Geriatrics, Hospice and Palliative Care, Hennepin County Medical Center
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Becky Nosan, NP (Work Group Member)
Nurse Practitioner, Gerontology/Palliative, Allina Medical Clinic
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Mabel Rohr, RN, CNP (Work Group Member)
Geriatric Nurse Practitioner, Internal Medicine/Geriatrics, HealthPartners Medical Group
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: Received honoraria for teaching geriatric education at Augsburg College and MN Critical Care Nurses Association

Erin Rosenberg, LICSW (Work Group Member)
Clinical Manager, Social Worker, LifeCourse, Allina Health
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Rob Ruff, BCC (Work Group Member)
Director, Chaplaincy Services, HealthPartners Regions Hospital
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Kristina Schlecht, MD (Work Group Member)
Associate Director, Family Practice, University of North Dakota Center for Family Medicine
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2013 Nov

Measure Maintenance

Scientific documents are revised every 12 to 24 months as indicated by changes in clinical practice and literature.

Date of Next Anticipated Revision

The next scheduled revision will occur within 24 months.

Measure Status

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in January 2017.

Source(s)

McCusker M, Ceronsky L, Crone C, Epstein H, Greene B, Halvorson J, Kephart K, Mallen E, Nosan B, Rohr M, Rosenberg E, Ruff R, Schlecht K, Setterlund L. Palliative care for adults. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2013 Nov. 81 p. [92 references]

Measure Availability

Source available for purchase from the Institute for Clinical Systems Improvement (ICSI) Web site External Web Site Policy. Also available to ICSI members for free at the ICSI Web site External Web Site Policy and to Minnesota health care organizations free by request at the ICSI Web site External Web Site Policy.

For more information, contact ICSI at 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; Phone: 952-814-7060; Fax: 952-858-9675; Web site: www.icsi.org External Web Site Policy; E-mail: icsi.info@icsi.org.

NQMC Status

This NQMC summary was completed by ECRI Institute on April 28, 2014.

The information was reaffirmed by the measure developer on January 10, 2017.

Copyright Statement

This NQMC summary (abstracted Institute for Clinical Systems Improvement [ICSI] Measure) is based on the original measure, which is subject to the measure developer's copyright restrictions.

The abstracted ICSI Measures contained in this Web site may be downloaded by any individual or organization. If the abstracted ICSI Measures are downloaded by an individual, the individual may not distribute copies to third parties.

If the abstracted ICSI Measures are downloaded by an organization, copies may be distributed to the organization's employees but may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Improvement, Inc.

All other copyright rights in the abstracted ICSI Measures are reserved by the Institute for Clinical Systems Improvement, Inc. The Institute for Clinical Systems Improvement, Inc. assumes no liability for any adaptations or revisions or modifications made to the abstracts of the ICSI Measures.

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