COVID-19 and quality: What we know and don’t know

Although our knowledge of COVID-19 is growing, there is a great deal that we still do not know about this disease and its full effects on the body, both acutely and long-term. In light of that, how can we assess quality of care delivered to COVID-19 patients? Additionally, how can we assess overall quality of care to all patients during a pandemic.

Our hospital resources have been stretched, safety protocols increased and only the most unwell patients are being admitted to inpatient care. Therein lies a double-edged sword: fewer patients overall who will most likely have more complications considering their co-morbid conditions (and not just those patients with COVID-19).

Most quality metrics set risk-adjusted expected rates for complications. Those risk-adjusted rates are determined over years of study and many are calculated using a range of years of data (which would have included some healthier, elective surgical patients). It can be logically assumed there will be an increase in complication rates (calculated by number of discharges) in the “remaining” inpatient population. Will this be a fair measure of quality knowing the population in our baseline risk-adjusted metrics is very different than our current inpatient population? This impact may not have been as significant if the pandemic passed quickly as it did in other countries. Since we are presumably still in the first wave, the inpatient population is and will be altered for some time to come.

Now, let’s turn our attention to patients with COVID-19. Due to the unusual and variable disease presentation and progression, I believe COVID-19 should either be utilized in risk-adjustment models for quality metrics or provide an exclusion from reporting. However, as I previously noted, the current methodology could not include a disease that never existed when the methodology was created or last modified. So many of the commonly measured complications such as postoperative sepsis, respiratory failure and PE/DVT are occurring in COVID-19 patients and many of these conditions are not present at time of admission. But how can we differentiate between poor care versus progression of disease? As noted, the methodology cannot be asked to automatically exclude them, but should there be a change? AHRQ recently released an update to the patient safety indicator (PSI) methodology (v2020). This update only includes code changes from version 37.0 (effective October 1, 2019) and does not include COVID-19 (version 37.1). So, we cannot currently account for the impact of COVID-19 or use COVID-19 as an exclusion without an urgent update from AHRQ.

There is no easy answer to how our quality programs such as HACRP, HRRP and HVBP should handle hospital payment adjustments this upcoming fiscal year. When the pandemic hit, CMS suspended mandatory reporting for first quarter 2020 and extended it through the second quarter. However, there has been no notification beyond that on how quality will be measured during this pandemic.

I recommend institutions carefully follow CMS and other quality organizations for updates and perform due diligence in reviewing cases with quality concerns. There are many unknowns yet to come as this disease---and our understanding of it---evolves.

Cheryl Manchenton is a senior inpatient consultant and project manager for 3M Health Information Systems.

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During a pandemic, healthcare information is gathered, studied, and published rapidly by scientists, epidemiologists and public health experts without the usual processes of review. Our understanding is rapidly evolving and what we understand today will change over time. Definitive studies will be published long after the fact. 3M Inside Angle bloggers share our thoughts and expertise based on currently available information.