Time at Home as a Quality Measure

People care to have time in their own homes, rather than hospitals, skilled nursing facilities, nursing homes, and jails. Measuring time at home after a hospitalization for surgery has broad appeal as a metric for the quality of care before, during, and after surgery. People will believe that they understand it, and that more is better. The study reported in this issue of EClinicalMedicine [1] uses a large registry to build a reasonable model for this kind of metric, attributing variations mostly to care given during hospitalization for surgery. The authors have shown that the metric displays substantial variation and that the variation correlates with other measures of quality and with commonly accepted risk factors such as age and overall health [1].

The study has made a number of choices that might be made differently as others work with this class of metrics. The current specifications effectively discount long-term facility care, rehabilitation facility care, and death within 30 days as being equally inconsequential, whereas these are usually very important outcomes for the patient and family. Quality measures for surgery generally capture only short-term death, and residence in a long-term care facility may be enjoyed or disdained by patients and family members, so operationalizing these outcomes may be quite difficult. Nevertheless, new onset of using a long-term care facility for support or therapy is an important outcome, and death in the 30 days after surgery may be an acknowledged and accepted risk that would still offer a valuable few days or weeks of survival. These issues will merit further investigation as this metric matures.

However, the most challenging issue is likely to be the details of risk adjustment. Even patients and their families realize that very complex and risky surgery is likely to require more days away from home than more straightforward procedures. Sorting out how to adjust for severity of risk, support at home, co-morbidities, factors associated with hospitalization [2] and the receipt of surgical intervention in the first place, and the neighborhood effects of socioeconomic (dis)advantage will require substantial work.

Others have worked on time at home as a measure of the performance of a local care system with regard to the elderly population. The Medicare Payment Advisory Commission in the US (MedPAC) considered a ‘healthy days at home’ measure to assess how well a community or healthcare ‘market’ takes responsibility for a population to keep people alive and out of health care institutions [3]. The US has well-described variation in the likelihood of experiencing a hospitalization or a surgical intervention by geographic market, related to such variables as local practice norms and the availability of medical resources and non-medical support services [2]. The MedPAC metric, calculated among Medicare fee-for-service beneficiaries older than 65 years from 2013 to 2015, however, failed to demonstrate enough variation to be useful in the form that MedPAC tested [3].

The Centers for Medicare & Medicaid Services (CMS) Quality Innovation Network-Quality Improvement Organization program also worked to develop a (days at home)/year metric (called “community tenure”) to describe and monitor the experience of geographically defined community populations in avoiding institutional care associated with improvements in care coordination [4]. Calculating days at home for communities' entire elderly fee-for-service Medicare population showed little variation, because the majority of beneficiaries receive no institutional care in a given year. Instead, one would want to adjust for risks arising from the severity of illness that make institutional care more likely. However, in the US, the propensity to use hospitals and post-hospital facilities varies a great deal in association with the supply of services [2], the availability of volunteer (family) caregivers, and the poverty of the community [5]. Furthermore, the severity of illness is very difficult to estimate from claims, which fuels most US analyses since the US does not have all-patient registries with clinical data. These challenges may be less problematic for healthcare systems in countries with more standardized patterns of care, better clinical data, more support for caregiving, and more evenly distributed socio-demographic characteristics.

Researchers have proffered time at home as a metric to use to indicate gains in treatment options for heart failure [6], and for stroke [7]. One report from New Zealand showed that “days alive and out of the hospital” for persons hospitalized for heart failure had improved between 1988 and 2008 [8]. A recent report using the Current Medicare Beneficiary Survey showed that time at home correlated with various measures of disease severity and proffered that it could be useful in database studies [9] such as the one reported here [1]. However, we can find no evidence that researchers have previously used some form of this metric to assess quality of care across contemporaneous delivery systems.

The fact that “days at home” has such intuitive popular appeal and the appearance of simplicity [10] makes it important to test, evaluate, and evolve. The fact that the metric does not vary much across regions with different utilization patterns and differences in other measures of quality may indicate ongoing challenges in using this as a quality measure. Furthermore, the versions that find broad use will probably be different from this version. Nevertheless, the idea of honoring the way that our patients value being home is an important consideration and deserves to mature with further work.

Author Contributions

Both authors contributed equally to the literature search, concept development, drafting, and editing of this manuscript.

Declaration of Competing Interest

Dr. Lynn has no relevant conflicts of interest. Dr. Brock has funding from the Centers for Medicare and Medicaid Services and from the Patient-Centered Outcomes Research Institute (PCORI) to lead work on quality measurement and improvement. Both are publicly funded and chartered US institutions.