• NormandSharon-Lise TSTDepartment of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA; Department of Biostatistics, Harvard Chan School of Public Health, Boston, Massachusetts, USA. Electronic address: sharon@hcp.med.harvard.edu., Katya Zelevinsky, Haley K Abing, and Marcela Horvitz-Lennon.
• Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA; Department of Biostatistics, Harvard Chan School of Public Health, Boston, Massachusetts, USA. Electronic address: sharon@hcp.med.harvard.edu.
• World Neurosurg. 2022 May 1; 161: 331342.e1331-342.e1.

BackgroundQuantifying quality of health care can provide valuable information to patients, providers, and policy makers. However, the observational nature of measuring quality complicates assessments.MethodsWe describe a conceptual model for defining quality and its implications about the data collected, how to make inferences about quality, and the assumptions required to provide statistically valid estimates. Twenty-one binary or polytomous quality measures collected from 101,051 adult Medicaid beneficiaries aged 18-64 years with schizophrenia from 5 U.S. states show methodology. A categorical principal components analysis establishes dimensionality of quality, and item response theory models characterize the relationship between each quality measure and a unidimensional quality construct. Latent regression models estimate racial/ethnic and geographic quality disparities.ResultsMore than 90% of beneficiaries filled at least 1 antipsychotic prescription and 19% were hospitalized for schizophrenia during a 12-month observational period in our multistate cohort with approximately 2/3 nonwhite beneficiaries. Four quality constructs emerged: inpatient, emergency room, pharmacologic/ambulatory, and ambulatory only. Using a 2-parameter logistic model, pharmacologic/ambulatory care quality varied from -2.35 to 1.26 (higher = better quality). Black and Latinx beneficiaries had lower pharmacologic/ambulatory quality compared with whites. Race/ethnicity modified the association of state and pharmacologic/ambulatory care quality in latent regression modeling. Average quality ranged from -0.28 (95% confidence interval, -2.15 to 1.04) for blacks in New Jersey to 0.46 [95% confidence interval, -0.89 to 1.40] for whites in Michigan.ConclusionsBy combining multiple quality measures using item response theory models, a composite measure can be estimated that has more statistical power to detect differences among subjects than the observed mean per subject.Copyright © 2022 Elsevier Inc. All rights reserved.

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