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POLICY WATCH: Academy Responds to Demand for National Quality Standards of Care

Butcher, Lola

doi: 10.1097/01.NT.0000421894.28498.6e


In response to the federal government's National Quality Strategy, the Academy is developing its own strategy to help neurologists join the quality improvement movement.

“There needs to be a coherent, organized approach to this for the benefit both of our members and our patients,” said Christopher T. Bever Jr., MD, MBA, chair of the AAN Quality Strategy Workgroup.

Quality improvement is rapidly developing in some areas — for example, care for patients with diabetes and some heart conditions — in which long-accepted quality measures are routinely used, results are publicly reported, and most providers are engaged in ongoing QI initiatives.

But in other areas of health care, neurology included, quality improvement as a standard practice is just now emerging. Quality measures for a few neurological conditions are now available, and many more measures are being developed. But many clinicians do not see the relevance of most existing programs to improving patient care.

“Quality assessment for the purpose of improving care is an entirely new idea to physicians,” said Nathan Fountain, MD, chair of the American Epilepsy Society's Quality Indicators Workgroup. “Physicians tend to think that quality improvement equates to things that aren't clinically relevant.”

That is because many hospital-based quality measures focus on patient satisfaction rather than patient outcomes and because the federal government's Physician Quality Reporting System (PQRS), now in its fifth year, has had so few neurology-specific measures that many neurologists opted not to participate.

By aligning its own quality improvement program with the national strategy, the Academy seeks to make sure that neurologists are in sync with changes in the way medicine is practiced. Specifically, the Academy's initiative seeks to expand its development of quality measures and other quality improvement tools, increase the number of neurologists working on the quality improvement program, and partner with other organizations concerned with neurological care.

Along the way, AAN's quality leaders hope to convince neurologists that quality improvement must be an essential element of their practice. Dr. Bever said most neurologists continually work to improve their knowledge and skills, but they do not systematically measure whether they are incorporating new evidence into their treatment protocols.

“Very few look at what they are actually doing with patients to determine whether they are translating (new knowledge) into some change in their practice,” said Dr. Bever, who practices at the Maryland Center for Multiple Sclerosis. “I think that will become part of the culture, but that's not instantaneous. That's going to take five to ten years, optimistically, to shift most neurologists into that mode of thinking.”

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The work group Dr. Bever heads includes members from the AAN Practice, Medical Economics, and Education Committees; the AAN Subcommittees on Guideline Development, Quality Measures and Reporting, Practice Improvement, Patient Safety, and the Stroke Systems Work Group.

Among its recommendations, the committees aim to develop outcome measures for neurological conditions and adapt measures for use in electronic health record systems. The measures currently used to evaluate care for neurology patients are process measures such as “percentage of patient visits with a diagnosis of epilepsy at which the frequency of each seizure type is documented in the patient record.” While most quality improvement programs start with process measures, they progress to outcome measures such as “percentage of patients with a diagnosis of hypertension who had most recent blood pressure level at goal.”

In addition, they are working on developing cost of care measures for neurological conditions, and hope to engage more Academy members to participate in quality-related committees and initiatives. Read more about the Academy's proposed quality strategy at

The AAN hopes to partner with patient advocacy, subspecialty and other organizations to avoid duplicated or competing quality improvement initiatives.

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That sounds good to Irene L. Katzan, MD, who practices at the Cleveland Clinic and is the immediate past chair of the Quality and Outcomes Committee of the American Heart Association (AHA) Stroke Council.

The AAN has the ability to disseminate information about quality measures to a wider range of neurologists than the Stroke Council typically reaches, she said. Additionally, the Stroke Council's committee is looking for opportunities to work with other organizations on quality improvement initiatives.

“The thought is to bring what everybody else is doing to the table so that the stroke folks within the AHA have a firm understanding of what's going on and how we at the AHA can actually help move things forward,” she said.

An example of the Academy's ability to partner with other organizations is seen in the development of quality measures for epilepsy care. As of January 2012, three epilepsy measures are included in the PQRS.

Traditionally, an affiliate of the American Medical Association has taken the lead in developing quality measures for various conditions and requested input from the relevant specialty societies. Instead of waiting for a call from the AMA, the National Association of Epilepsy Centers, the American Epilepsy Society (AES) and the Academy decided about four years ago to push ahead on their own.

“The epilepsy quality measures were the first measures initiated outside of the AMA,” said Dr. Fountain, chair of the AES Quality Indicators Workgroup. “The AAN is the group that became the driver.”

Representatives of 14 stakeholder groups helped develop eight epilepsy quality measures, and the AMA — appreciative of the leadership from neurology organizations — provided staff support for their efforts.

Neurologists also recognize that the CMS is moving “from the carrot to the stick,” Dr. Fountain said, and are looking for ways to win favor. Physicians who successfully participated in PQRS in 2011 received a 1 percent bonus on all Medicare payments, but the bonus decreases to 0.5 percent for 2012–2014 and turns into a penalty of 1.5 percent in 2015 based on a physician's participation in the 2013 program. For more on the PQRS, see past coverage in Neurology Today:

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The Affordable Care Act required the development of a National Quality Strategy to improve health care delivery, patient health outcomes and population health. The federal government contracted with the National Quality Forum, a nonprofit organization, to develop the strategy, which was published in early 2011. See

Physicians and other health care providers are being asked to submit data for a wide range of quality measurement initiatives, but the measures often seem cumbersome to collect and report and irrelevant for practice improvement. Thus, the National Quality Strategy seeks to build a consensus on how to measure quality so that various efforts can be aligned, reducing the burden on providers and offering more useful information.

—Lola Butcher

©2012 American Academy of Neurology