Article In Brief
An AAN work group developed these evidence-based quality measures for the general neurologist: falls outcomes and plans of care, activity counseling for back pain, maltreatment screening and action, overuse of imaging in primary headache, medication reconciliation, pain assessment and plans of care, advance care planning, and driving risk and referral.
Responding to requests from general neurologists who have often felt underrepresented by the standards of care set forth by government agencies or by subspecialty groups within neurology, the AAN has released a set of eight quality measures to guide clinicians treating an array of conditions. That paper appears in the February 1 online edition of Neurology.
“While touching different disease states and subspecialties is really helpful for subspecialists, as a general neurologist, it may be difficult to keep track of the growing list of quality measures. We wanted to create something for the average neurologist who sees different disease states and would like to make sure that they are adhering to and able to report on some set of quality measures,” said Justin Martello, MD, a movement disorder specialist at Christiana Care Neurology Specialists in Newark, DE, and first author of the universal neurology measures.
Dr. Martello spoke with Neurology Today about the importance and impetus for this work, as well as the AAN's ongoing efforts to dispel the persistent misinformation about the role of quality measures. Excerpts of the interview appear below.
Why did the AAN work group come together to establish these quality standards now?
There were comments on other measures by general neurologists about it being difficult for subspecialty measures to be applied when they see a broad array of disease states. We wanted to come up with a set for the general neurologist to be able to apply to their patients universally. As a general neurologist, you may see a seizure patient, followed by a headache patient, followed by a back pain patient. Why not have something cross-cutting?
The other thing that we realized looking at all of our measures is that there's a lot of overlap. For example, do we really need a separate falls measure for Parkinson's disease and for neuro-otologyand for multiple sclerosis, or are there enough data to reflect just having a falls measure for whole populations of patients across neurology? Finally, whenever we would talk to CMS [Centers for Medicare and Medicaid Services] or other organizations that back different standards for quality measures, we understood that they were looking for more cross-cutting measures to be applicable to more patients, versus one subset.
Why did you choose these eight areas for quality measures?
The working group looked at the most common neurologic diagnoses that a general neurologist sees. We looked more broadly at current AAN and CMS quality measures to see if any of those could be adjusted based off of appropriate data and more broadly to encompass all neurology patients. For the most part, all of us in the working group were pretty agreeable on these measures.
We conducted a comprehensive literature search and identified 2,201 relevant abstracts, which included 23 guidelines that we used to create the final set of quality measures. The eight areas we chose to focus on based on evidence were falls outcomes and plans of care, activity counseling for back pain, maltreatment screening and action, overuse of imaging in primary headache, medication reconciliation, pain assessment and plans of care, advance care planning, and driving risk and referral.
We considered adding in a patient-reported outcome measure but decided to leave that to the new outcomes working group. We discussed adding more measures in regard to back pain management, but data were not complete regarding gaps in care and consensus in recommendations.
We receive a lot of helpful information over the public comment period and we answer every single comment. Some comments lead to changes in the measures, some comments lead to measures not being finally submitted or being reworded. So it is very impactful to participate. I think unfortunately there are still a lot of negative connotations around quality measures, and it's our job to provide better education and awareness about their importance.
What are the challenges in getting neurologists to adopt some of these standards in practice?
Awareness of quality measures and unfortunate myths about what they are and their importance would be the leading factor, which we are actively trying to rectify with the Quality and Safety Subcommittee. The standardization of tracking measures and changing the way a neurologist forms his note would be the other biggest factor.
One of the most common myths is that quality measures offer something new or act as new guidelines or recommendations. [Ultimately], they operationalize current guidelines and current recommendations that already exist based on current, in-depth data and randomized clinical trials. We hold a strict, high-end standard on the amount of data that needs to be available to create a quality measure. So we're somewhat limited by the data available, which is why we review the quality measures at least every three years.
The other big myth that exists (with guidelines as well) is that measures need to be done 100 percent of the time for every patient, and that's not true. This is not supposed to be applicable for every patient situation; that's why there are exclusion criteria in the measures. It also is not supposed to be penalizing to the doctors. That's explicitly written out in the details of every measure set.
“The reason we're so intent on developing this from the AAN's perspective is that if we don't do this, someone else from CMS or from the government who [likely] won't be a neurologist will. We don't want to have to continue to adhere to measures that have nothing to do with neurology.”
—DR. JUSTIN MARTELLO
The reason we're so intent on developing this from the AAN's perspective is that if we don't do this, someone else from CMS or from the government who [likely] won't be a neurologist will. We don't want to have to continue to adhere to measures that have nothing to do with neurology.
What might the concerns be for general neurologists using some of these measures versus specialists who may be more experienced in specific subspecialty areas?
For many neurologists who treat neurodegenerative conditions like I do, such as Parkinson's, we're very commonly involved in end-of-life discussions and care. But there are a lot of other neurologists who may be headache specialists or sleep specialists, who may not necessarily get involved with patients who are older or towards the end of their life. They may not feel that that's as important to address during the visit. There are actually recommendations now from the American Medical Association for all doctors to discuss end-of-life care with any adult at any age, regardless of their condition. I think it helps the medical field as a whole to be clearer with patients' wishes, but it may be a little bit hard to convince all neurologists that they should also be included in this standard and expectation.
The other measure that may seem difficult to implement is screening for maltreatment. I think we should make it a standard part of the visit, either as a screening tool before the visit or something that the medical assistants or nurses ask about. It's not necessarily something that doctors need to bring up every visit, but it's something that should be screened in a better way, similar to how we screen for depression at every visit.
What education and/or policy actions will be taken to improve implementation of these measures?
As part of the Quality Measures Subcommittee, we've been trying to submit different commentary articles to Neurology: Clinical Practice, Neurology Today, and other publications to try to dispel myths about quality measures. We do have a whole section within the AAN website that we're trying to lead more people to with different information about what quality measures are, the process and how we develop them, and their importance. The website also includes additional implementation and quality improvement tools, which the AAN began to develop in 2018. We'll be at every annual meeting with some kind of booth and in the experimental learning area with different talks to share information about these quality measures. I'm also asked to speak at different societal and state meetings.
I think as reimbursement starts to become more and more tied to quality of care, we'll see more practices proactively asking us about it. We're looking to set up a mentor program this summer where we bring in different practices, engage them on how to implement quality improvement using quality measures, and then they would go out and train others to do the same.
How will you track implementation of these measures?
For all of our different measures, we're starting to vet them with the Axon Registry® to see which of them can be created as e-measures to be tracked and implemented. Then we're able to see first, how are practices doing with adhering to these measures and then second, and the most important thing, does adherence to these quality measures lead to improved patient outcomes? And what are the ways that we can track that? Axon is doing a great job collecting lots of data to see how we can do that.
Hopefully there'll be a system sooner rather than later where we'll submit this measure set, or as many of these measures that can be created as e-measures, into the Axon Registry. They'll process them, they'll look at their validity, their reliability, and whether they translate to improved patient outcomes. Then they'll be able to spit out that data within a certain amount of time to say these measures are worthwhile. Once we have the data, we're going to get a lot more buy-in with physicians and practices. Right now, there's a lot of lack of trust about whether these measures really lead to better outcomes.
We're always eager to engage other areas or practices that are either looking for help or who want to help us to understand what their needs are to try to correct and dispel these myths and misconceptions. We try and make ourselves as openly available as possible, so neurologists should keep that in mind if they want to contact us.
Dr. Martello has received personal compensation for consulting on a scientific advisory speaking board, speaking, or other activities with Neurocrine, Medtronic, Teva, Abbvie, and Lundbeck.
Quality Measures for the General Neurologist
Specifications for these eight measures—including how to measure them, applicable exclusions, and how to derive at a quality-of-care score—are detailed on the AAN website: http://bit.ly/NT-AANmeasures.
- 1) Falls Outcome/Falls Plan of Care: Record the number of falls patients report and ensure their safety by providing them with a plan for preventing falls
- 2) Activity Counseling for Back Pain: To advise patients to stay active when they are diagnosed with back pain
- 3) Malpractice Screening/Malpractice Action: To ensure the safety of patients with neurological conditions
- 4) Overuse of Imaging in Primary Headache: To reduce unnecessary imaging for primary headache patients
- 5) Medication Reconciliation: To ensure the safety of patients by reviewing and updating the medication list at every visit
- 6) Pain Assessment/Pain Plan of Care: To assess and manage pain
- 7) Advance Care Planning: To document an advance care plan or discuss advance care planning for patients with neurologic conditions
- 8) Driving Risk Discussion/Driving Risk Referral: To ensure safe driving for patients with seizures and dementia