Composite Measure Discussion Points
The three concepts, and perhaps different types of composites are:
1. Reporting out 2 different rates based on subpopulations for the same population (i.e.,
more expansive interventions for patients with septic shock than those with sepsis without shock).
Note, if the measure only wants a combined calculation, there may actually be a more complex but
single numerator expression (i.e., if shock did x, if no shock did y)
2. Reporting an aggregate result by weighting the results of separately defined measures. Examples
include the PSI measure
3. Reporting a single patient’s performance (a bundle) with respect to multiple existing measures (the
diabetes composite example. In this example, individual reports from each component measure
have been calculated in the past but now there is a need to see that any individual diabetic patient
has all interventions performed. At this point, from an HQMF R1 perspective, we would need a new
measure since the aggregate report from any practice is the proportion receiving intervention A, the
proportion receiving intervention B and so on. The new measure is the proportion receiving all of
interventions A, B, C, etc. Similar to option 1 there may be a need to report individual intervention
rates and combined (bundled) rates - this option was managed in the past using different
populations in the HQMF R1.
Details:
I.
NQF 0500 Severe Sepsis and Septic Shock: Management Bundle
The numerator requires a complete set of interventions to have occurred to meet the criteria:
A. measure lactate level
B. obtain blood cultures prior to antibiotics
C. administer broad spectrum antibiotics
D. administer 30 ml/kg crystalloid for hypotension or lactate >=4 mmol/L
E. apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a
mean arterial
F. pressure >= 65)
G. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial
lactate >=4 mmol/L (36
H. mg/dl) measure central venous pressure and central venous oxygen saturation
I. remeasure lactate if initial lactate is elevated
1.
2.
All patients presenting with severe sepsis or septic shock who have had A, B, and C within 3 hours after
presentation
All patients with lactate > 4 mmol/L OR septic shock (i.e., SBP <90 mm Hg or MAP <70 mm Hg, or
decrease in SBP by > 40 mm Hg or <2 SD below normal for age or known baseline) who have had A, B, C,
D, E, F, and G ---- [Note, the ‘decrease in SBP section will be difficult to define even with more robust
expression language.]
Technically, this is a single definition of the numerator. An alternative is to have two report outs since the
interventions are more expansive for septic shock patients:
1. those with severe sepsis and not septic shock
2. those with septic shock
For discussion:
If it is one calculation, is it still a “composite” measure? If it is two calculations, how will the HQMF depict it –
previous attempts have used different “populations” to provide different results but that seems tedious.
II.
AHRQ Patient Safety Indicators
This composite measure seems to be a combination report for a hospital that combines the results of 11
existing “single” measures, weighting the value of each, and deriving a hospital Patient Safety Value:
PSI #03 Pressure Ulcer
PSI #11 Postop Respiratory Failure
PSI #06 Iatrogenic Pneumothorax
PSI #12 Postop PE Or DVT
PSI #07 Central Venous Catheter-related Bloodstream Infections
PSI #13 Postop Sepsis
PSI #08 Postop Hip Fracture
PSI #14 Postop Wound Dehiscence
PSI #09 Postop Hemorrhage or Hematoma
PSI #15 Accidental Puncture or Laceration
PSI #10 Postop Physiologic and Metabolic Derangments
This option is different from the first sepsis measure. It definitely requires 11 individual calculations, then
instructions on how to combine and weight each result. The HQMF R1 does not provide such an option.
Perhaps a modular approach could allow an HQMF to refer to results from other HQMFs within a defined
time frame – and still requires the ability to weight components.