Are clinic care providers doing the right thing?

Appropriateness reviews have the answer

By Patrice Spath, ART

Consultant in Health Care Quality and Resource


Forest Grove, OR

(Editor's note: This is the second installment in a two-part series on the growing number of accreditation responsibilities quality management departments face as their health care organizations expand and integrate with non-hospital facilities. In May, Ms. Spath addressed record reviews and patient satisfaction surveys for outpatient facilities. This month, readers will learn how to perform appropriateness reviews and develop disease-specific criteria to assess the quality of outpatient care.)

Unlike record reviews and patient satisfaction surveys, appropriateness reviews answer the question "Are we doing the right thing?" from a clinical perspective. Studies of appropriateness help caregivers determine if their patient care choices are relevant to the patient's clinical needs. They help judge if care is provided to the patient at the suitable time and in the correct manner. Appropriateness reviews can also evaluate how well care is coordinated among all providers.

Appropriateness reviews can include process and outcomes measures. Process measures look at whatever the health care provider does to the patient. Appropriateness is judged by determining if the right intervention was used and if it was used correctly.

For example, a study of preventive care services may include the collection of data on the number of patients over age 65 who receive annual influenza vaccines. Outcomes are the results, or the consequences, of the medical care process. Outcomes measures look at the effect of that process on a patient's well-being and quality of life to determine how the patient was affected by the process-of-care variables. For example, the number of vaccinated and nonvaccinated patients who develop influenza might also be collected during the preventive services study as a measure of outcomes.

When the patient care process has already been established as "ideal," based on clinical trials or expert consensus, it may not be necessary to collect outcomes data. For example, there is considerable agreement that peak expiratory flow rates or spirometry are important diagnostic tools in the management of asthma patients. An appropriateness study of asthma care would include this criterion: "Evidence of current or past peak flow and spirometry results in the patient's record." If those diagnostic tools are not being routinely used by clinicians, the care could be considered inappropriate based on current guideline recommendations. No outcome measures are necessary to substantiate this conclusion.

Setting study priorities

Patient populations in ambulatory care are very diverse. Because of this, it may be harder for the clinic's quality management oversight group to establish priorities for appropriateness studies. Consider the following issues when selecting conditions to be studied:

Feasibility -- Are adequate data available? What is the likelihood that an appropriateness study will make a difference in an outcome of interest (for example, clinical practice, economic outcome, or patients' quality of life)?

Population -- How many people who receive outpatient care have the condition being considered for study?

Costs -- Is the procedure or therapy expensive in per-case terms or aggregate (all cases) terms? What are the cost implications of studying this condition? (For example, will previously unmet needs increase aggregate costs? Will inappropriate care, and thus aggregate costs, be reduced?)

Effects on population, costs, and practice -- Will the study likely result in improved quality of care and patient outcomes? How will the costs of study design and implementation compare with the projected savings of improved patient care?

Practice variation -- Variation in patient practices may expose patients to substantial harm or may have significant cost implications. Where there is significant variation, questions regarding appropriateness may be warranted.

Agreed-upon guidelines -- Is there sufficient clinical consensus on treatment approaches to evaluate appropriateness of care for this clinical condition? If controversy or uncertainty exists, another topic should be selected for study.

Study criteria

Once the high-priority appropriateness study topics have been selected, the next step is to establish the study's performance measures. To find study criteria, look first at relevant clinical practice guidelines published by professional associations. The Chicago-based American Medical Association annually publishes the Directory of Practice Parameters, which lists the guidelines developed by the medical professional society and government-funded organizations.

[Editor's note: To order this publication contact the AMA ordering department at (800) AMA-2350.]

Many medical, nursing, and allied health professional organizations have World Wide Web sites, and their published guidelines can be downloaded or ordered over the Internet. Atlanta-based American Health Consultant's World Wide Web site ( includes links to the home pages of many professional groups.

To reduce the cost of data collection, be sure to focus only on important aspects of care and critical outcomes when developing study criteria. Concentrate on answering important questions relative to appropriateness rather than responding to every "wouldn't it be nice to know" question.

Listed below are process and outcomes criteria used to evaluate the appropriateness of care for various categories of outpatient conditions:

Mastectomy patients

The record should document post-mastectomy treatment discussions, including chemotherapy for all stages of disease, and radiation therapy for stage II or higher.

Diabetic patients

Dietary counseling should be given to obese patients, or a statement that the patient does not wish dietary management should appear in the patients' records.

Patients receiving psychoactive drugs

The use of psychoactive drugs longer than 30 days should be associated with a medical management plan that specifies the objectives to be obtained by the drug and how the objectives will be assessed.

Patients with anxiety

If a patient is receiving medication for anxiety, a plan containing approximate duration of treatment and expected outcome should be documented in the record.

Patients with epilepsy/seizures

* Patients under treatment for epilepsy who have a seizure must have either a change in therapy or a statement in the record indicating why therapy was not altered.

* The record of patients receiving Dilantin should have documented evidence of inquiry concerning drug interactions. The same goes for any of the following drugs:

a) barbiturates;

b) warfarin;

c) disulfiram (Antabuse);

d) phenylbutazones;

e) isoniazid.

Patients with refractive errors

A diagnosis of refractive errors should be documented by at least the following:

a) a statement of chief complaint;

b) visual acuity with and without existing prescription;

c) retinoscopy;

d) diagnosis of refractive state;

e) ophthalmoscopy.

Patients with amblyopia

With a diagnosis of amblyopia, there should be documentation of an assessment of vision, examination of the interior of the eye, and measurement of alignment.

Patients with atrial fibrillation

Patients with uncontrolled atrial fibrillation should be started on anticoagulant therapy, or the record should document why anticoagulant therapy was not initiated.

Patients with headache

With three complaints of headache, the patient's history should document:

a) the character, position, duration, and time period of onset;

b) associated findings (i.e., flashing lights, nausea);

c) family history;

d) other possible causes (i.e., visual problems);

e) psychological problems;

f) allergies.

Patients with pneumonia

Record should substantiate appropriateness of diagnosis with documentation of chest X-ray positive for pneumonia, or sputum cultures positive for pneumonia-causing organism(s).

Patients with a breast condition

* History should include:

a) date of onset;

b) previous history of breast complaint;

c) description of signs and symptoms;

d) documentation pertinent to family history;

e) age of patient;

f) parity;

g) date of last mammogram and findings;

h) current problem list.

* Physical examination should include:

a) breast exam findings;

b) notation of presence or absence of mass;

c) notation of size and location of mass, if present;

d) notation of axillary node exam findings.

* Management should include:

a) mammogram -- if not previously done or the patient is older than 35;

b) documentation of follow-up plan;

c) mammogram report and films are available when patient has clinic visit;

d) all abnormal labs are followed up.

Patient with leg ulcer

* History should include:

a) date of presentation;

b) location of ulcer;

c) aggravating factors (vascular history, trauma, infection);

d) current problem list.

* Physical exam should include:

a) location of ulcer;

b) size of ulcer;

c) vascular exam, including pulses and varicosities.

* Management should include:

a) wound care;

b) follow-up;

c) therapeutic drug levels obtained as appropriate;

d) all abnormal labs are followed up.

Patient with burns

* History should include:

a) date of burn;

b) location;

c) disability;

d) type of burn (H2O, flame, electrical, or other);

e) tetanus status;

f) current problem list.

* Physical exam should include:

a) percent of total body surface involved;

b) site of burn;

c) depth of burn;

d) signs of infection (presence/absence).

* Management should include:

a) wound care;

b) plan for follow-up;

c) therapeutic drug levels obtained as appropriate;

d) all abnormal labs are followed up.

Patient with otitis media

* Description of tympanic membranes to include appearance, presence/absence of fluid, and mobility.

* Oral antibiotic prescribed for 7-10 days.

* Hearing test performed after three or more episodes of otitis media in a six-month period.

Newborn with hemoglobin trait found on newborn screening

* Laboratory result in record.

* Documentation that provider is aware of laboratory result.

* Documentation that result communicated to parent(s).

* Documentation of mother's hemoglobin status.

* If mother positive, documentation indicates partner status, or testing offered.

* Documentation of sibling status, or testing offered.

* Documentation that significance of results were discussed with parent(s).

* Trait status listed on problem list.

Child with elevated blood lead values

* Venous samples done if micro lead „ 25 mcg/dl or FeP (blood lead level) „ 110 mcg/dl.

* Elevated FeP noted on problem list.

* Elevated FeP noted in progress note.

* Focused diet history obtained.

* General diet history obtained/available.

* Lead exposure history obtained.

* Treatment plan indicated in progress notes.

* Iron-rich diet recommended.

* Iron preparation prescribed.

* Repeat specimen within three months and within six months of initial diagnosis.

* Patient normal or significantly improved in six months of initial diagnosis.

Evaluating appropriateness may require the collection of patient-reported information. Patient-reported outcomes data can be useful in determining the appropriateness of the intervention and whether or not the intervention achieved desired results. Figure 1 (see insert) is an example of a patient questionnaire used to gather information from patients undergoing cataract surgery. The survey is completed pre- and postoperatively. The results are used to judge long-term outcomes, as well as to retrospectively analyze whether or not the patient met cataract surgery indications preoperatively.

Quality management activities in ambulatory care should help caregivers identify important improvement opportunities. A comprehensive outpatient quality management program should measure the quality of record documentation, patient satisfaction, and clinical performance to ensure that all important aspects are being evaluated. In the initial stages of the program, record completeness reviews and patient satisfaction surveys may take precedent over appropriateness studies. Caregivers, however, should not overlook clinical performance evaluations that focus on prevention, early detection of diseases, appropriateness of patient services, and effectiveness of care. *