Paul J. Nietert, PhD
Ruth G. Jenkins, MS
Andrea M. Wessell, PharmD
Sarah T. Corley, MD
Steven M. Ornstein, MD
The Medical University of South Carolina
AcademyHealth, Boston MA June 2005

Accelerating Translation of
Research Into Practice (A-TRIP)
• AHRQ-funded demonstration project to improve preventive services
• 92 ambulatory care practices around the
U.S.
• All practices use an electronic medical record.
• All are part of Practice Partner Research
Network (PPRNet).
• Quarterly data extracts from each practice

• Quality indicators are helpful tools for translating research into clinical practice.
• Providing feedback to clinicians on these indicators and assisting them with process change through on-site visits by our research staff have been shown to help them make system changes that improve the quality of the care they provide.

• We provide practice reports, showing practice’s performance on 78 unique quality indicators from 8 clinical domains:
– Hypertension
– CHD and Stroke – MH/SA
– Cancer – Respiratory/Infectious Disease
– Immunizations
– Inappropriate Rx in Elderly
– Nutrition and Obesity

• Analyzing improvements in 78 quality indicators presents challenges:
– Many measures are correlated with each other
• LDL < 100 (CHD pts)
• LDL < 100 (DM pts)
– Some lab measures have different targets based upon morbidity
• BP < 130/80 (DM pts)
• BP < 140/90 (HTN pts)
– Some pts not eligible for some measures

• Goal: Design a method for summarizing the
78 quality measures that:
– Is clinically relevant and interpretable
– Is statistically sound
– Allows for the evaluation of QI efforts over time

• For each pt, add all 78 indicator variables together
– Bad idea! (Many pts not eligible for certain measures)
• Use principal component analysis techniques for analysis
– Bad idea! (Too complicated to explain)
• Use the S ummary Qu ality I n d ex
– Good idea!

• Define processes and outcomes of interest, regardless of target
– BP Monitoring
– LDL Monitoring
– HgbA1C Monitoring
– BP Control
– LDL Control
– HgbA1C Control
78 indicators reduced to 32 processes & 5 outcomes

• Create indicator variables (e i
) that reflect whether pt is eligible for each process and outcome measure
– PAP Test (Women > 18 yrs old)
– FOBT (Men & Women > 50 yrs old)
• Create indicator variables (m i
) that reflect whether pt has met the target for a process or outcome, given his/her demographics and/or morbidity
– If pt has DM, then BP must be < 130/80
– If pt has HTN, BP must be < 140/90

• E = The number of measures for which the pt is eligible (denominator) = Σ e i
• M = The number of eligible measures for which the pt has met his/her morbidity-specific target
(numerator) = Σ m i
• Create a pt-level SQUID =
M
E
• Create a practice-level SQUID = average of all pt-level SQUIDs

• A patient’s SQUID reflects the percentage of targets met out of the total number of targets for which he/she is eligible.
• A practice’s SQUID reflects the average percentage of targets achieved by their patients.

• Across the 92 physician practices, adult pts were eligible, on average, for 9.7 out of a total of 37 processes and outcomes.
• On average, pts met 3.7 of their eligible targets.
• Across all pts, the average SQUID was
31.5%.

20
18
16
14
12
10
8
6
4
2
0
0% 10% 20% 30% 40% 50% 60%
SQUID Mean

35%
30%
27.3%
25%
20%
15%
31.5%
10%
5%
0%
Apr
03
May
03
Jun
03
Jul
03
Aug
03
Sep
03
Oct
03
Nov
03
Dec
03
Jan
04
Feb
04
Mar
04
Apr
04
May
04
Jun
04
Jul
04
Aug
04
Sep
04
Oct
04
Nov
04
Dec
04
Jan
05
Feb
05
Mar
05
Apr
05

• SQUIDs can be used in patient-level or practice-level analyses.
• Because it is a continuous measure, and because of its relative normality, certain linear models may be appropriate.
• Examples:
– Mixed effects regression models
– Generalized estimating equations models

• The SQUID is an effective tool to aid in the evaluation of multiple quality indicators.
– Nice statistical properties
– Clinically meaningful
• In future research studies and quality improvement efforts that include multiple quality indicators, the SQUID should be considered as a measure of overall quality.