Rate-Based Quality Measures in Nursing Practice Explained

Introduction to Quality Measurement in Nursing

Quality measurement is important in nursing practice because it helps ensure the successful assessment and delivery of quality health services. Without quality measurement, there would be no reliable way of determining whether patients have access to meaningful and competent care. Information derived from quality measurements is used to determine what is appropriate in practice and what is not. Quality measures use various tools to quantify aspects of healthcare delivery, and there are numerous measurement frameworks available to nursing practitioners. These are largely dependent on certain dimensions of healthcare, which may include — but are not limited to — population and public health, patients' perceptions of their care, patient engagement, care coordination, efficient use of healthcare services, patient safety, clinical processes, and patient outcomes.

For the purposes of this paper, the focus is on three rate-based quality measurements that relate to patient outcomes in healthcare settings: smoking cessation for pneumonia risk reduction, restraints prevalence, and falls with injury.

Description and Definition of the Three Measures

With regard to smoking cessation for pneumonia risk reduction, worsening outcomes among various pneumonia cases have been associated with tobacco and cigarette smoking. During an annual measurement period in a population-based control study, the risk of invasive pneumococcal disease among ex-smokers and those who had never smoked was reduced by 14 out of 100 cases after smoking cessation was included as an intervention (Baskaran et al., 2019). The restraints prevalence measure was used to determine the level of knowledge and awareness regarding the use of restraints among residents in nursing homes during the entire measurement period (Schnelle et al., 2004). The falls with injury measure was used to determine the risk of falling among residents living in nursing homes (Hestekin et al., 2013).

These rate-based measures were selected because they relate to the quality of clinical nursing practice and directly reflect how patients are cared for and their experiences within that care. These indicators can be used to measure the quality of services patients receive in healthcare facilities by adjusting for other risk factors. For instance, the smoking cessation for pneumonia risk reduction measure can be used to determine the likelihood of developing community-acquired pneumonia when patients smoke or are exposed to smoke (Baskaran et al., 2019). Information gathered in this way would then be used to create or improve smoking cessation programs to reduce those risks. With regard to the restraint prevalence measure, data on the prevalence of restraints in nursing homes provides crucial information about settings that do not use restraints, creating an opportunity for knowledge dissemination and education on the importance of appropriate restraint use. Similarly, information from the falls with injury measure would be used to determine the prevalence and incidence of fall-related injuries in healthcare facilities, enabling quality improvement efforts to reduce falls.

The smoking cessation measure is aimed at addressing problems related to smoking, given that smoking has been associated with various health concerns — including an increased risk of community-acquired pneumonia (Baskaran et al., 2019). A meta-analysis study was conducted to assess the role cigarette smoking plays in the development of community-acquired pneumonia among adults. As the authors note, "undoubtedly, quitting smoking is among the most important steps smokers can take to lower the risk of respiratory infections and pneumonia" (p. 81). The study focused on smokers and ex-smokers aged between 18 and 64 years. However, it is worth noting that adults aged 65 years and above ought to have also been included, given that they are also at risk of developing community-acquired pneumonia — in many cases as passive or secondhand smoke recipients (Baskaran et al., 2019). The meta-analysis showed that adults who currently smoke are at the highest risk of developing community-acquired pneumonia, with a likelihood 53% greater than that of ex-smokers. Current smokers also possessed more than twice the risk of developing community-acquired pneumonia compared to those who had never smoked. The likelihood of developing CAP among ex-smokers was approximately 49% higher than among never-smokers (Baskaran et al., 2019). A related study similarly found that older adults faced a higher risk of developing community-acquired pneumonia (Campagna, Amaradio, Sands, & Polosa, 2016, p. 132).

Reduction in restraint use in healthcare facilities has been associated with a lack of adequate knowledge regarding restraints and related care processes (Schnelle et al., 2004). This concern largely relates to residents in nursing homes. To determine the prevalence of restraints, the authors utilized a cross-sectional study involving 413 residents from fourteen nursing homes (Schnelle et al., 2004). Falls with injury cases are associated with high death rates and disabilities, and are caused by various risk factors including — but not limited to — severe sleep problems, diminished grip strength, arthritis, and depression (Hestekin et al., 2013). The population most affected by fall-related injuries is older adults aged over 50 years, and the problem tends to disproportionately affect middle- and low-income families (Hestekin et al., 2013). To determine the prevalence and risk factors associated with fall-related injuries, a longitudinal WHO SAGE study was conducted using samples of older adults from South Africa, the Russian Federation, Mexico, India, Ghana, and China.

Numerical Descriptions and Rate Construction

With regard to the numerator measure counts for smoking cessation and pneumonia, the counts relate to the number of adults who are current smokers, ex-smokers, and non-smokers (never-smokers). The denominator count includes adults aged 15 years and above who had been diagnosed — through radiology or clinical assessment — with community-acquired pneumonia (Baskaran et al., 2019). To construct the rate, the study used percentages to express the likelihood of developing community-acquired pneumonia among adults. Specifically, the percentage of smokers, ex-smokers, and non-smokers at risk of developing community-acquired pneumonia was calculated.

For the restraints prevalence measure, the numerator counts included restraint prevalence scores from 38 national health facilities. The denominator count includes all residents in those 38 facilities who were not in Medicare or transitional care and had been identified as using restraints during the seven days prior to the Minimum Data Set assessment (Schnelle et al., 2004). To calculate the rate of restraint prevalence, averages were derived from the Minimum Data Set (MDS), whereby the daily number of restrained residents was divided by the total number of residents across the 38 facilities (Schnelle et al., 2004).

In the falls with injury measure, the numerator count relates to socioeconomic, environmental, behavioral, and biological domains identified as fall determinants (Hestekin et al., 2020). The denominator count includes adults aged 50 years and above from the six SAGE countries. To calculate the rate of falls with injury, biological covariates were derived from WHO algorithms, behavioral covariates were calculated using the Global Physical Activity Questionnaire, environmental covariates were calculated using counts based on a 5-point Likert scale, and social determinants were assessed using household economic status indexes (Hestekin et al., 2020).

References

Baskaran, V., Murray, R. L., Hunter, A., Lim, W. S., & McKeever, T. M. (2019). Effect of tobacco smoking on the risk of developing community acquired pneumonia: A systematic review and meta-analysis. PloS One, 14(7), e0220204. https://doi.org/10.1371/journal.pone.0220204

Cecere, L. M., Williams, E. C., Sun, H., Bryson, C. L., Clark, B. J., Bradley, K. A., & Au, D. H. (2012). Smoking cessation and the risk of hospitalization for pneumonia. Physiotherapy, 106(7), 1055–1062.

Campagna, D., Amaradio, M. D., Sands, M. F., & Polosa, R. (2016). Respiratory infections and pneumonia: Potential benefits of switching from smoking to vaping. Pneumonia, 8(4), 130–136.

Hestekin, H., O'Driscoll, T., William, J. S., Kowal, P., Peltser, K., & Chatterji, S. (2013). Measuring prevalence and risk factors for fall-related injury in older adults in low- and middle-income countries: Results from the WHO Study on Global AGEing and Adult Health (SAGE).

Slade, S. C., Carey, D. L., Hill, A., & Morris, M. E. (2017). Effects of falls prevention interventions on falls outcomes for hospitalized adults: Protocol for a systematic review with meta-analysis. BMJ Open, 7, e017864.

Schnelle, J. F., Bates-Jensen, B. M., Levy-Storms, L., Grbic, V., Yoshii, J., Cadogan, M., & Simmons, S. F. (2004). The Minimum Data Set prevalence of restraint quality indicator: Does it reflect differences in care? The Gerontologist, 44(2), 245–255.

Thomann, S., Zwakhalen, S., Richter, D., Bauer, S., & Hahn, S. (2020). Restraint use in the acute-care hospital setting: A cross-sectional multi-center study. International Journal of Nursing Studies, 114, 103807.