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[Federal Register: March 24, 2003 (Volume 68, Number 56)]
[Page 14240-14242]
From the Federal Register Online via GPO Access []
[DOCID: fr24mr03-68]                         



Agency for Healthcare Research and Quality

Preliminary Measure Set for Home Health in the National 
Healthcare Quality Report—Request for Comments

AGENCY: Agency for Healthcare Research and Quality, HHS.

ACTION: Request for comments.


SUMMARY: The Agency for Healthcare Research and Quality (AHRQ) 
announces a request for public comment on the Preliminary Measure Set 
on home health to be used in preparing the National Healthcare Quality 
Report (NHQR). The NHQR is a congressionally 
mandated annual report (see 42 U.S.C. 299b-2(b)(2)) on national trends 
with respect to health care quality. The legislation mandated that AHRQ 
submit this report on an annual basis beginning in 2003. The 
preliminary Measure Set for the NHQR was generated through a call for 
health care quality measures to Federal agencies and private 

DATES: Written comments on this notice must be received by April 23, 

ADDRESSES: Written comments should be submitted to: Judith Sangl, 
Sc.D., Center for Quality Improvement and Patient Safety, Agency for 
Healthcare Research and Quality, 540 Gaither Road, Suite 3000, 
Rockville, MD 20850; Fax: (301) 427-1341; E-mail:

Public Review of Comments

    Comments and responses received will be available for public 
inspection at AHRQ's Information Resource Center (IRC) public reading 
room between the hours of 8:30 a.m. and 5 p.m. on regular business days 
at 540 Gaither Road, First Floor, Rockville, MD 20850.  Arrangements 
for reviewing the submissions may be made by calling (301) 427-1280.
Responses may also be accessed through AHRQ's Electronic Freedom of 
Information Reading Room on AHRQ's Web site at 

Availability of Technical Expert Panel (TEP) Meeting Transcript and 
Background Materials

    Copies of the transcript from the TEP meeting are available from 
the AHRQ Web site at: 
organizations without access to the Internet, AHRQ will make a paper 
version available either through overnight mail or by fax upon written 
request. Requests for paper versions of the preliminary measure set 
should be faxed to the above fax number. The background materials will 
be available in the IRC (see address above).

FOR FURTHER INFORMATION CONTACT: Judith Sangl, Sc.D. (See information 
under addresses).


1. Background

    This request follows up on an earlier request for public comments 
on the preliminary measure set dated August 19, 2002. At that time, no 
home health measures were proposed for the preliminary measure set 
because AHRQ was working together with the Centers for Medicare & 
Medicaid Services (CMS) to determine as appropriate set of measures for 
the CMS public reporting initiative on home health as well as the NHQR. 
AHRQ and CMS decided that, in the short term, the Outcome and 
Assessment Information (OASIS) measures would be used as the initial 
measure set because there is more standardization around these measures 
than any other in home health care. This view was reiterated in the one 
comment received in response to the August request, i.e., that OASIS 
measures were the best currently available to measure the quality of 
home health care.
    OASIS is a uniform set of patient assessment items developed for 
monitoring and measuring outcomes of care, adjusted for patient factors 
that might affect those outcomes. The OASIS data set is the only 
national, standardized data source on adult home health care delivery. 
The OASIS instrument was created over a 14-year period to measure 
functional outcomes for the purpose of improving quality of home health 
care. It was developed through a scientific process, using input from 
the home healthcare industry, and has been tested for validity and 
reliability. All Medicare certified home health agencies (HHAs) 
implemented the OASIS instrument nationwide for collection and 
reporting of comprehensive patient assessments in October 1999. There 
are 41 measures derived from OASIS data covering (1) functional 
outcomes; (2) physiologic outcome; (3) emotional/behavioral/cognitive 
outcomes; and (4) utilization outcome measures. When one includes the 
additional 13 low-frequency adverse patient outcomes identified from 
OASIS data, there are a total of 54 measures. The Web site at contains extensive detail on the 
development of OASIS, a copy of the OASIS data collection form (OASIS 
B1) and measure definitions.
    Because CMS currently wanted to select a subset of OASIS measures 
for its home health public quality reporting initiative, AHRQ decided 
to convene a technical expert panel (TEP) to review the set of OASIS 
home health quality measures as candidates for both the NHQR and the 
CMS home health care public reporting initiative. Accordingly, AHRQ 
convened a TEP on October 21-22, 2002 with the purpose of addressing 
these two independent but overlapping efforts being planned by CMS and 

2. TEP Composition and Meeting Process

    The TEP was composed of 18 members representing a wide range of 
disciplines and interests: home health agency representatives, 
clinicians (both physicians and nurses), an epidemiologist, consumer 
reporting experts and a consumer groups organization, quality 
improvement organizations, State survey agencies, and home health 
services researchers. The panelist list is included in the meeting 
transcript on the AHRQ site at

    AHRQ and CMS staff gave introductory remarks and overviews of the 
two parallel purposes and goals of the meeting. Speakers gave 
background presentations on: (1) Development of the OASIS measures, 
their statistical properties, and their use in quality improvement and 
(2) results of testing OASIS measures (in plain language) in focus 
group with consumers and interviews with physicians and discharge 
planners, who would be users of such quality measure information. 
Results of these focus groups are also on the above referenced AHRQ Web 
    After presentation of the introductory background material, the 
meeting facilitator described how the remainder of the meeting would 
proceed. Since this technical expert panel was not established as a 
formal Federal advisory committee, AHRQ would not seek any formal votes 
from the panel nor consensus from the panel members. Instead, the 
emphasis would be on viewpoints of the individual panel members as each 
of the existing OASIS measures was discussed according to pre-
established criteria (see Attachment A in the meeting transcript on the 
AHRQ Web site), derived from criteria for quality measures developed by 
the Institute of Medicine for the NHQR. Panelists were given a workbook 
with criteria worksheets and statistical properties for each of the 
measures. The presenters stayed during the entire meeting for technical 
support and clarifications.
    At the end of the second day, all of the panel members were asked 
to bring together their values, insights and assessments to provide 
input to AHRQ on which of the 41 OASIS measures should be priority 
items for the two purposes: (1) AHRQ's NHQR and (2) CMS's home health 
public reporting initiative. It was acknowledged that these two 
priority measure lists might be different.
    The meeting was open to the public and representatives from the 
home health industry trade associations, industry consultants, agencies 
and journalists attended.

3. OASIS Measures Reviewed by Panel

    The Panel was charged with focusing on 41 OASIS measures, a subset 
of the 54 measures in OASIS. To facilitate discussion, these 41 measures 
were put into 13 categories (used in consumer testing) and three domains 
(adapted from the Foundation for Accountability framework) as follows:

	o Domain: Getting Better

Category 1: Physical Health

    Improvements in: Dyspnea, status of surgical wounds, number of 
surgical wounds, urinary tract infection, urinary incontinence, bowel 

Category 2: Mental Health

    Improvements in: Behavior problem frequency, cognitive functioning, 
confusion frequency, anxiety level.

Category 3: Meeting Basic Daily Needs

    Improvements in: Eating, upper body dressing, lower body dressing, 
in bathing, grooming, management of oral medications.

Category 4: Getting Around

    Improvements in: Ambulation/locomotion, toileting, transferring, 
pain interfering with activity.

Category 5: Meeting Household Needs

    Improvements in: Light meal preparation, laundry, shopping, 

Category 6: Talking With People

    Improvements in: Speech and language, phone use.

Category 7: Staying at Home Without Home Care

    Discharged to community.

	o Domain: Living With Illness or Disability

Category 8: Meeting Basic Daily Needs

    Stabilization in: Bathing, grooming, management of oral 

Category 9: Meeting Household Needs

    Stabilization in: Light meal preparation, laundry, shopping, 

Category 10: Mental Health

    Stabilization in: Cognitive functioning, anxiety level.

Category 11: Getting Around

    Stabilization in: Transferring.

Category 12: Talking With People

    Stabilization in: Speech and language, phone use.
	o Domain: Staying Healthy/Avoiding Injury or Harm

Category 13: Medical Emergencies

    Any emergency care provided, acute care hospitalization.
    CMS and AHRQ focused panel attention on just these 41 measures 
because they assess long-term quality improvement issues that every 
home health agency should address. These OASIS measures are not 
specific to particular diagnoses but the functional outcomes they 
measure apply to many diagnoses. There are an additional 13 adverse 
event outcome OASIS measures that were not considered by the panel 
because they cover events that occur infrequently.

4. AHRQ Proposed Recommendations for Home Health Care Measures for the 

    Based on the Home Health Quality Measures Technical Expert Panel 
input, including: the individual panelist prioritization lists (i.e., a 
significant proportion of panelists listed particular measures as 
priority items for inclusion), their written comments and the meeting 
discussion, AHRQ proposes using results collected on the following 12 
OASIS measures for reporting on the quality of home health care in the 

--Improvement in dyspnea (physical health category);
--Improvement in urinary incontinence (physical health category);
--Improvement in upper body dressing (basic daily needs category);
--Improvement in management of oral medications dressing (basic daily 
needs category);
--Improvement in ambulation/locomotion (getting around category);
--Improvement in toileting (getting around category);
--Improvement in transferring (getting around category);
--Improvement in pain interfering with activity (getting around 
--Improvement in bathing (basic daily needs category);
--Stabilization in bathing (basic daily needs category);
--Improvement in confusion frequency (mental health);
--Acute care hospitalization (medical emergencies category).

    AHRQ is soliciting public comment on this proposed set of 12 home 
health care measures selected from the 41 OASIS measures considered. 
Ten of these measures are the same as CMS has announced for use in its 
initial home health public reporting effort. Based on panel input 
regarding the NHQR, AHRQ is recommending two additional measures, 
"Improvement in dyspnea" and "Improvement in urinary incontinence." 
Finally, although CMS is using the measure, "Any Emergency Care," 
(one of the OASIS measures listed above in Category 13), AHRQ is not 
recommending this measure for the NHQR at this time because we believe 
that this measure raises some significant issues that warrant further 
investigation. AHRQ would like to hear comments on the advantages and 
disadvantages of this measure in particular.

Carolyn M. Clancy,
[FR Doc. 03-6879 Filed 3-21-03; 8:45 am]


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