An Elusive Ideal—Why a Pragmatic “Home Time” Quality Measure Remains Hard to Define

“Days at home,” “facility-free days,” “excess days of acute care,” and “healthcare contact days” are increasingly common measures used to evaluate the outcomes of healthcare interventions [1-4]. These home time measures have broad appeal, and researchers have used them as outcomes in a range of studies [5-8]. These measures are also gaining traction in policy circles. For example, the Centers for Medicare & Medicaid Services (CMS) include home time performance measures in alternative payment models such as the Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health (REACH).

Part of the reason for the increased use of these outcomes is their intuitive appeal. We as clinicians think most patients value being at home, and many believe it is cheaper for the health care system—a rare win-win. In addition, home time measures are viewed as “pragmatic” because they can be derived from existing administrative claims data [9]. However, these measures have not been subjected to careful evaluation to understand the degree to which they are truly person-centered [1, 10].

In this issue of JAGS, Van Houtven and colleagues describe [11] part of a larger effort to address this gap and develop a universal person-centered quality of life measure, based on time spent at home as compared to time spent in healthcare settings. This study is noteworthy in its focus on anchoring days at home to older adults' quality of life. The authors convened a panel of Veterans Affairs (VA) leadership, clinician scientists, and researchers and presented the panel with data from a mixed methods study that combined quantitative analyses and qualitative work with older Veterans surrounding their perceptions of home time versus the value of health care contact [12, 13]. Delphi panel methodology was employed here because the team's prior work revealed discordance between prior qualitative and quantitative findings about how stays in different healthcare settings (e.g., hospital, emergency department, and skilled nursing facilities) affected patients' quality of life. To reconcile these past contradictions, the Delphi panel was charged with: (1) determining whether to include, in addition to hospital and post-acute facilities, the emergency department as a setting in time away from home; (2) creating relative “weights” to capture varying effects of stays in different healthcare settings on quality of life; and (3) establishing the timeframe over which to most meaningfully assess days away from home.

Perhaps the most striking finding of this careful approach was that—like the prior mixed methods study—this panel of experts was unable to come to consensus. While 75% of panelists rated as acceptable the inclusion of emergency department (ED) stays in time away from home, panelists had significant disagreement on establishing relative weights or an appropriate timeframe. Even the rating of ED visits was conditional, with some panelists recommending limiting inclusion to ED visits that led to inpatient stays and the most endorsed response being an acceptance of ED inclusion “with reservations.”

This thoughtful evaluation by Van Houtven et al. points out that the enthusiasm for home time measures may be racing ahead of the evidence behind them. Initial evaluations suggest these measures may be relatively insensitive to interventions, perhaps because even in populations with multimorbidity, most older adults spend most of their days at home [2]. The Van Houtven et al. paper therefore raises a critically important question: is it possible (or even the right goal) to derive a pragmatic, person-centered quality of life measure using administrative data?

History suggests even well-meaning efforts in this regard frequently meet with failure. An individual's experiences, preferences, and needs will affect their perceived quality of life. This complex interplay changes over time, while, unfortunately, our assessment of older adult's goals too often remains static. Claims-based metrics have limited ability to account for patient factors such as access to a caregiver, living arrangements, cognitive and functional limitations, symptom burden, social roles, beliefs, and socioeconomic factors that impact health and healthcare. This information is not readily available in administrative claims databases, but it is needed to understand both quality and the lens through which a patient views their care [14]. Ultimately, endpoints like “days at home” may be best considered a pragmatic endpoint as part of a bundle of relevant outcomes, rather than a single clear “good” to be achieved.

How, then, do we capture this type of nuance? An effective universal measure would need to allow for personalization. Van Houtven and colleagues suggest additional methods to capture the variation in patient preferences, such as using discrete choice experiments to inform weighting across time frames and settings. This approach would require obtaining input from patient populations across multiple care settings and at multiple time points—a challenging feat. The Age-Friendly Health System's focus on capturing What Matters regularly in clinical encounters provides another opportunity, but to our knowledge no systems have been developed to ensure this measure is used longitudinally across care settings and over time [15].

Instead of using an easily calculated proxy measure, we believe refocusing on longitudinal capture and use of patient-reported outcome measures is a worthy goal. If CMS initiatives like the Guiding an Improved Dementia Experience (GUIDE) model [16] are successful, we may see greater clinical implementation of patient and caregiver-centered outcome measures, but to date it is not standard widespread practice to collect such surveys or document them in a way that facilitates easy assessment of outcomes [17]. Major practical challenges to overcome with obtaining patient and caregiver reports include potential low response rates, missing data, and potential to add to clinical demands. However, significant costs are also associated with claims-based metrics and with building, documenting, and extracting required data elements in electronic health records [18]. Investing in infrastructure to reliably and validly capture patient-reported quality of life and goal-concordant care measures could improve the efficiency of obtaining quality measures. If efficiency is viewed as the potential gain in meaningful data relative to health system and provider costs, such assessments could be as, if not more, cost effective for health care providers than claims-based metrics. The Veterans Affairs (VA) Clinical Assessment Reporting and Tracking (CART) Program is one example of this type of infrastructure. The CART Program, a quality assessment initiative for percutaneous coronary intervention, captures measures through the Patient Reported Health Status Assessment (PROST) system. These automated assessments are collected during routine clinical care and embedded into the electronic health record, reducing the burden of data capture, while potentially enhancing clinical decision making and individualized care [19].

There still may be value in using administrative claims data to assess some, but not all, care metrics. Healthcare costs and utilization, among other metrics, are still meaningful to payers and health systems. Though costs and use may not be perfect indicators of care quality, it remains reasonable to include these measures in a more comprehensive assessment of care. One could envision a portfolio of measures by which to capture the impact of a medical intervention or care model. For example, CMS has incorporated both patient-reported outcome performance measures and claims-based care utilization metrics to evaluate programs such as GUIDE and the Comprehensive Care for Joint Replacement Model [20]. A multidimensional approach to quality of life and home-time assessment may be the best way to capture what matters in the patient experience while also meeting the needs of policymakers and researchers.

While home time may be an appealing and easily quantifiable metric, Van Houtven's careful work reminds us to be circumspect in its use, recognizing that it may not capture the nuances of patient preferences, variability in the meaning of “home,” and the complex social and medical factors that shape an older adult's experience. Without meaningful integration with other patient-reported outcomes, a home time metric will oversimplify and risk inaccurately conveying the experience it aims to reflect. As we strive to create useful measures, perhaps home time should be viewed as one piece of a broad framework for evaluating care, rather than as a universal proxy measure for quality of life.

K.O., R.E.B., and D.S. contributed equally to manuscript preparation.

The authors declare no conflicts of interest.

This publication is linked to a related editorial by Van Houtven et al. To view this article, visit https://doi.org/10.1111/jgs.19506.