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Washington DL, Danz M, Cordasco KM. Development of Quality Indicators for the Care of Women with Abnormal Uterine Bleeding. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2014 Apr 25; San Diego, CA.
Research Objective: Abnormal uterine bleeding (AUB) is among the most common gynecologic complaint of reproductive-age women in ambulatory care settings, with up to 30% of women seeking medical care for AUB during their reproductive years. We translated consensus recommendations and evidence-based guidelines for AUB care into quality indicators (QIs) that are measurable from electronic health records (EHRs), with the goal of applying these QIs to assess variations in clinical management and guide women's health education for healthcare providers. Study Design: We first performed an extensive literature review to develop a set of potential QIs for the evaluation and management of women with AUB, targeting aspects of care that are within the purview of primary care providers (PCPs). For each potential QI, we specified a numerator, denominator, exclusions, relevant definitions, period of assessment, underlying evidence and data source. We then used a modified Delphi consensus technique based on the RAND/UCLA Appropriateness Method, which consisted of three steps. First, nine experts (women's health PCPs, obstetrician/gynecologists, quality measurement experts, policy stakeholders) independently rated the indicators using nine-point scales on three metrics: consistency with established guidelines; importance to women's health; and reliability of measurement from Veterans Health Administration (VHA) EHRs. Second, panelists discussed potential indicators by tele-conference, with internet-based sharing of presentation materials. Finally, all indicators were independently re-rated by panelists, using the same nine-point scales. Final QIs were selected if they had a median score of 7 or higher on all three metrics, and high consistency in their ratings, based on the interpercentile range adjusted for symmetry (IPRAS), using an interpercentile range of 0.3 - 0.7. Population Studied: Quality indicators for the care of women with abnormal uterine bleeding. Principal Findings: This process resulted in selection of 19 QIs covering multi-dimensional aspects of AUB care, spanning reproductive and post-menopausal life phases, profuse vaginal bleeding, and hormonal contraception/IUD use. Five QIs relate to documentation of critical aspects of the history; 6 to diagnostic evaluation; and 8 to management. Evaluation QIs highlight the need to recognize pregnancy, need for emergency care, and elevated endometrial cancer risk. Management QIs focus on current profuse bleeding, follow-up of diagnostic studies, and indications for gynecologist referral. Areas of disagreement in panelists' ratings and discussion centered around the acceptable timeframe for completion of different actions, with generalist panelists being more likely to consider the constraints of the ambulatory care setting in their decision-making. Conclusions: We developed a multi-dimensional set of QIs for primary care AUB evaluation and management, based on published data, consensus recommendations, guidelines, and a modified Delphi process. These QIs are being formulated into an EHR quality assessment tool. Once pilot-tested for feasibility, this tool will be applied to measure the care quality provided to women with AUB in VHA primary care settings. Implications for Policy and Practice: This rigorously designed set of QIs should facilitate measuring and improving the quality of care for women with suspected AUB. Future work should focus on developing educational programs that are concordant with these Qis, and assess potential changes in quality outcomes associated with their implementation.