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Health Care Delivery Measure Domains

Measures of care delivered to individuals and populations defined by their relationship to clinicians, clinical delivery teams, delivery organizations, or health insurance plans. Denominators for these measures are defined by some form of affiliation with a clinical care delivery organization, e.g. recipients of health care, health plan enrollees, clinical episodes, clinicians, or clinical delivery organizations.

Clinical Quality Measures

Measures used to assess the performance of individual clinicians, clinical delivery teams, delivery organizations, or health insurance plans in the provision of care to their patients or enrollees, which are supported by evidence demonstrating that they indicate better or worse care.

Process: A process of care is a health care-related activity performed for, on behalf of, or by a patient.

1. Process measures are supported by evidence that the clinical process—that is the focus of the measure—has led to improved outcomes.
2. These measures are generally calculated using patients eligible for a particular service in the denominator, and the patients who either do or do not receive the service in the numerator.

Example: The percentage of patients with chronic stable coronary artery disease (CAD) who were prescribed lipid-lowering therapy.

Access: Access to care is the attainment of timely and appropriate health care by patients or enrollees of a health care organization or clinician.

1. Access measures are supported by evidence that an association exists between the measure and the outcomes of or satisfaction with care.

Example: The percentage of members 12 months to 19 years of age who had a visit with a primary care practitioner in the past year (based on evidence that annual visits lead to better health outcomes for children and youth).

Outcome: An outcome of care is a health state of a patient resulting from health care.

1. Outcome measures are supported by evidence that the measure has been used to detect the impact of one or more clinical interventions.
2. Measures in this domain are attributable to antecedent health care and should include provisions for risk-adjustment.

Example: The risk-adjusted rate of in-hospital hip fracture among acute care inpatients aged 65 years and over, per 1,000 discharges.

Structure: Structure of care is a feature of a health care organization or clinician related to the capacity to provide high quality health care.

1. Structure measures are supported by evidence that an association exists between the measure and one of the other clinical quality measure domains.
2. These measures can focus on either health care organizations or individual clinicians.

Example: Does the health care organization use Computerized Physician Order Entry (CPOE) (based on evidence that the presence of CPOE is associated with better performance and lower rates of medication error)?

Patient Experience: Experience of care is a patient's or enrollee's report of observations of and participation in health care, or assessment of any resulting change in their health.

1. Patient experience measures are supported by evidence that an association exists between the measure and patients’ values and preferences, or one of the other clinical quality domains.
2. These measures may consist of rates or mean scores from patient surveys.

Example: The percentage of adult inpatients that reported how often their doctors communicated well.
Example: The percentage of adult inpatients that reported how often their doctors communicated well.

Related Health Care Delivery Measures

Measures used to assess the non-quality aspects of performance of individual clinicians, clinical delivery teams, delivery organizations, or health insurance plans in the provision of care to their patients or enrollees. These measures are not supported by evidence demonstrating that they indicate better or worse care.

User-Enrollee Health State: A user-enrollee health state is the health status of a group of persons identified by enrollment in a health plan or through use of clinical services.

1. By definition, a user-enrollee health state is not known to be the result of antecedent health care.

Example: Prevalence of diabetes among health plan enrollees (inclusion in the denominator is based on membership in a particular health plan; however, the measured health state is not a result of that membership).

Management: Management of care is a feature of a health care organization related to the administration and oversight of facilities, organizations, teams, professionals, and staff that deliver health services to individuals or populations.

1. Management measures assess administrative activities that are important to health care but are not part of the direct interaction between individual patients and health care professionals.

Example: Whether a practice has a policy to ensure the prevention of fraud and has defined levels of financial responsibility and accountability for staff undertaking financial transactions.

Use of Services: Use of services is the provision of a service to, on behalf of, or by a group of persons identified by enrollment in a health plan or through use of clinical services.

1. Use of service measures can assess encounters, tests, or interventions that are not supported by evidence for the appropriateness of the service for the specified individuals.

Example: The percentage of patients in a health plan with an inpatient admission in the prior twelve months.

Cost: Costs of care are the monetary or resource units expended by a health care organization or clinician to deliver health care to individuals or populations. Cost measures are computed from data in monetary or resource units.

1. Costs may be reported directly (i.e., actual costs) or estimated based on the volume of resource units provided and the charges for those units.

Example: Hospital net inpatient revenue per discharge.

Clinical Efficiency Measures

Measures that may be used to assess efficiency directly (e.g., by comparing a measure of quality to a measure of resource use) or indirectly (e.g., by measuring the frequency with which health care processes are implemented that have been demonstrated by evidence to be efficient).

Efficiency: Efficiency of care is a measure of the relationship between a specific level of quality of health care provided and the resources used to provide that care.

1. Efficiency measures are linked to evidence supporting one of the five clinical quality domains.
2. In the context of NQMC, efficiency measures typically assess the relationship of the cost of care associated with a specified level of quality of care.
3. These measures may address the frequency with which a less resource-intensive intervention is substituted for a more resource-intensive intervention of equal or lesser effectiveness, or a more effective intervention is substituted for a less effective intervention that is equally or more resource-intensive.
4. Measures in this domain may also assess the performance of activities by a health care organization or clinician to minimize waste.

Example: Percentage of gastric ulcers treated with omeprazole (based on evidence that this is lower cost and at least equally effective as surgery).

Population Health Measure Domains

Measures that address health issues of individuals or populations defined by residence in a geographic area or a relationship to organizations that are not primarily organized to deliver or pay for health care services (such as schools or prisons). The responsibility for "performance" typically falls to public officials, public health agencies, or organizations that are not primarily deliverers of care.

Population Health Quality Measures

Measures applied to groups of persons identified by geographic location, organizational affiliation or non-clinical characteristics, in order to assess public health programs, community influences on health, or population-level health characteristics that may not be directly attributable to the care delivery system. These measures are supported by evidence demonstrating that they indicate better or worse performance of population health activities.

Population Process: A population process of care is a public health-related practice or service performed for, on behalf of, or by a population.

1. Population process measures are supported by evidence that the process—that is the focus of the measure—has led to improved outcomes for a population.
2. These measures are generally calculated using individuals eligible for a particular public health activity in the denominator, and those who receive the activity in the numerator.

Example: The proportion of adults ages 65 years and older in a county who have received an influenza vaccination in the past year.

Population Access: Population access to care is the timely and appropriate receipt of a public health intervention by a population.

1. Population access measures are supported by evidence that an association exists between the measure and the outcomes of or satisfaction with public health programs among the population.

Example: The percentage of smokers in a county who reported that they were able to access a smoking-cessation program.

Population Outcome: A population outcome is a health state of a population resulting from a public health intervention.

1. Population outcome measures are supported by evidence that the measure has been used to detect the impact of one or more public health interventions.
2. Measures in this domain are attributable to antecedent public health interventions or services and should include provisions for risk-adjustment.

Example: The proportion of children with elevated blood lead levels whose homes undergo lead remediation, and whose blood lead levels are subsequently reduced to normal levels.

Population Structure: Population structure of care is a feature of a public health program related to its capacity to provide high quality public health services to a population.

1. Population structure measures are supported by evidence that an association exists between the measure and one of the other population health quality measure domains.
2. These measures can focus on either organizations or individual clinicians who are working for a public health program.

Example: The number of licensed child care facilities and slots in a county.

Population Experience: Population experience is the report of the members of a population concerning observations of and participation in public health programs.

1. Population experience measures are supported by evidence that an association exists between the measure and population values and preferences, or one of the other population health domains.
2. These measures may consist of rates or mean scores from population surveys.

Example: The percentage of smokers in a county reporting that they have seen or heard public service announcements promoting a county health department-sponsored smoking-cessation program.

Related Population Health Measures

Measures applied to groups of persons identified by geographic location, organizational affiliation or non-clinical characteristics, in order to assess non-quality aspects of public health programs, community influences on health, or population-level health characteristics that may not be directly attributable to the care delivery system. These measures are not supported by evidence demonstrating a link to better or worse performance of population health activities.

Population Health State: Population health state is the health status of a population.

1. By definition, a population health state is not known to be the result of a public health intervention.

Example: The prevalence rate of asthma for a county.

Population Management: Population management is a feature of a public health system that is relevant to the system’s administration, oversight, or staff.

1. Management measures assess administrative activities important to health but not part of the direct interaction between members of a population and its public health systems.

Example: Whether a public health department uses competitive bidding to award contracts for social marketing campaigns.

Population Use of Services: Population use of services is the provision of services to, on behalf of, or use by a population.

1. Population use of service measures can describe public health program encounters, tests, or interventions that are not linked to evidence of the appropriateness of the service for the population.

Example: The percent of assisted-living facility beds that are occupied in a county.

Population Cost: Population costs of care are the monetary or resource units expended to deliver public health interventions to a population. Cost measures are computed from data in monetary or resource units.

1. Costs may be reported directly (i.e., actual costs) or estimated based on the volume of resource units provided and the charges for those units.

Example: The average per beneficiary Medicaid expenditures in a county.

Population Health Knowledge: Population health knowledge is the awareness and understanding of health-related information such as risk factors, prevention strategies, or treatment recommendations.
Example: The mean response score to a set of questions about human immunodeficiency virus (HIV) prevention.

Social Determinants of Health: Social determinants of health are characteristics of a population related to social position or economic status, such as age, gender, or poverty status, that evidence has shown to be related to health states.
Example: The proportion of families living at or below the poverty level.

Environment: Environment represents the conditions outside of the health care delivery system that may influence the health of a population.

1. Environment measures can be classified as pertaining to the physical environment, social environment, or food and water supplies.

Example: The number of days in the past year when the concentration of particulate air pollution in a community exceeds a defined threshold.

Population Efficiency Measures

Measures that may be used to assess efficiency directly (e.g., by comparing a measure of quality to a measure of resource use) or indirectly (e.g., by measuring the frequency with which population health processes are implemented that have been demonstrated by evidence to be efficient).

Population Efficiency: Efficiency of population health is the amount of resources used to attain a specific level of quality on measures related to maintaining or improving the health of a population.

1. Population efficiency measures are linked to evidence supporting one of the five population quality domains.
2. In the context of NQMC, population efficiency measures typically assess the relationship of the cost of public health programs associated with a specified level of quality.
3. These measures may address the frequency with which a less resource-intensive intervention is substituted for a more resource-intensive intervention of equal or lesser effectiveness, or a more effective intervention is substituted for a less effective intervention that is equally or more resource-intensive.
4. Measures in this domain may also assess the performance of activities carried out by public health programs to minimize waste.

Example: Day case surgery rates, as a percentage of all surgery cases that could be treated in an outpatient setting, in a county (based on evidence that day case surgery is equally or more effective and because day case surgery is presumably less costly).

1. Institute of Medicine. Lohr KN, editor(s). Medicare: a strategy for quality assurance. Vol. 1. Washington (DC): National Academy Press; 1990 May. p. 21.