Quality Metrics—What Should We Be Measuring?
A month ago CMS and America’s Health Insurance Plans (AHIP) announced they had come together to “align and simplify” quality measures by agreeing on a number of metrics and how to capture them. There were seven sets of such measures in the initial release and more are anticipated in the future. The stated purpose was to simplify data capture and reporting for providers and to standardize the metrics. The government is obligated to go through a public rule-making process including a comment period, so we don’t know what the criticisms from the provider community will be. However, another article suggests some.
Interestingly, the week before, Porter and associates published an editorial in the New England Journal of Medicine called “Standardizing Patient Outcomes Measurement.” They started by asking the question, “Why has arriving at the essential measures of performance been so difficult in health care, when it seems to occur naturally in other fields?” Their first answer is that we have been defining quality as compliance with guidelines rather than improving outcomes. In a rather striking data point, they note “Of the 1,958 quality indicators in the National Quality Measures Clearinghouse, for example, only 139 (7%) are actual outcomes and only 32 (<2%) are patient-reported outcomes.” They go on to note, as I have discussed in other articles, that process measurement has limited effect on value. They also observe that improving compliance from 95% to say 98%, does not matter much, but costs a great deal of money, time and effort, and promotes “clinician skepticism.” Count me among the latter group.
Porter and associates note that another answer to their central question is that outcomes measures focus overwhelmingly on clinical status, using surrogates such as lab tests, which are easily measured, and omit functional status,
“even though that is why patients seek care. Billing data also don’t capture suffering due to the delays, chaos, confusion, and complications that often characterize health care.”
Certainly all persons, clinical and otherwise, can attest to the added stresses encountered trying to access health care either for themselves or their families. I think a lot of the distress I encounter daily in my practice is engendered by “the system” as much as by the disease and its effects. I wonder sometimes about why we expect patients to engage in preventive care and engage in early and aggressive care for chronic conditions when we make the whole thing so needlessly unpleasant. Maybe we are our own worst enemy.
So what do Porter and associates recommend? The cite the work of the International Consortium for Health Outcomes Measurement, which has used a multidisciplinary and international approach to outline minimum standard outcome sets for various diseases. To date they have completed 13 such sets, and by their own estimate, have covered a third of the global disease burden.
Using coronary artery disease as an example, they define cardiovascular disease progression, patient reported health status, survival, and acute complications that patients being treated for coronary artery disease experience. I did not download the file to review the specifications for each of these, but it is obviously different from current clinical guidelines which focus on indications for interventions, survival, and acute complications, largely in isolation. Clearly, this is an ambitious project, and the implications for data collection and processing are substantial, without any clear evidence yet that there is measurable patient benefit.
I was at a recent meeting at the hospital where the CMO presented some information from the CMS/AHIP initiative. While the measures themselves are not particularly controversial, there was a conspicuous absence of performance measures on most of them. (Some were “never” events.) During the discussion, I felt obliged to point out that to date, “quality” to CMS and AHIP usually means finding ways to pay less for services provided, so we could anticipate the performance level to be set so that at least 50% of providers would lose money on the deal. When I pointed out the efforts of the Consortium though, the administrative burden, costs, and IT issues were immediately apparent, and there was nothing to suggest that there would be any financial reward from the effort. Certainly no one was willing to consider the effort seriously.
I wish I could offer a simple solution to the dilemma—we are spending a lot of time and money refining a system we know does not improve the quality of the care we provide to patients, and aren’t able/willing to try something different unless there is a predictable financial payoff.
While it is possible CMS might decide to cut the Gordian knot, it is also possible patients will decide to opt out. Lawyers are worrying about the impact of “LegalZoom” and other such sites on their bread and butter business. What happens when patients start using “DoctorZoom”? Maybe the urgent care business is just a way station to do it yourself primary care. Of course, that is the way it was done for all generations before mine. Back to the future anyone?
15 March 2016
 Porter ME, Larsson S, Lee TH. Standardizing Patient Outcomes Measurement. N Engl J Med 2016;374(6):504-506. doi: 10.1056.NEJMp1511701. (11 February 2016).
 http://www.ichom.org/. Accessed 15 March 2016.
Confronting The Quality Paradox - Part 1
Confronting The Quality Paradox - Part 2
Accounting is not simply a matter of recording reality objectively, it makes things up and changes the definition of what really matters.
Confronting The Quality Paradox - Part 3
Confronting The Quality Paradox - Part 4
There will never be authentic quality within healthcare unless the word explicitly accommodates the truth that a human being is simultaneously both a subject and an object.
Confronting The Quality Paradox - Part 5
Measuring teamwork is difficult, but important if healthcare systems are to invest in their development. This article reviews the literature and provides suggestions for action now.
A consideration of the interactions of patient preferences, evidence-based medicine and peer review.