Consider the following scenario: You are contacted by the major health plan with which you contract and are told that your average length of inpatient stay is longer than their standard. You believe this is because your patients are more severely ill than average. How do you respond?
Consider the following scenario:
You are contacted by the major health plan with which you contract and are told that your average length of inpatient stay is longer than their standard. You believe this is because your patients are more severely ill than average. How do you respond?
It's a fact: Physicians' practices are, and will continue to be, evaluated. It is therefore important to: 1) understand what is meant by quality, why and how it is measured and the problems with measuring it; 2) review current health care quality measurement activities; and 3) appreciate why physicians should become involved with quality endeavors.
Quality measurement is a reality. Why should health care providers become involved? Because quality data can be useful for physicians. Quality data may permit health care providers to understand how errors creep into clinical practice, and allow detailed review of all steps involved in providing care. Physicians are in an excellent position to make a case for improving quality.
If physicians cannot understand, much less lead, the debate about quality in health care, the public may lose confidence in physicians' abilities to serve and protect their patients in the face of health care system changes. By showing leadership, physicians can improve outcomes for patients and retain a measure of autonomy over the practice of medicine.
Until recently, physicians could be confident that they alone had the social mandate to judge and manage quality of care. Changes in the medical marketplace have probably had the most significant influence on the increasing prominence of health care quality measurement. As cost containment pressures have increased, quality of care issues have emerged. The field of outcomes research has grown in response to concerns about cost containment and health care quality, and in response to the belief that variation in medical practice may be due to uncertainty about appropriate types and levels of care (Palmer, 1996; Epstein, 1995).
In addition, practice patterns and the quality of medical care vary more than had been previously realized. Clinicians' interest in obtaining objective information about their practices has increased, and patients and purchasers want to know more about the quality of care available (Wennberg and Gittelsohn, 1982; Brook et al., 1996; Corrigan, 1995).
There are differing views on what constitutes quality. In 1980, Donabedian defined quality care as that which is expected to maximize an inclusive measure of patient welfare, after taking into account the balance of expected gains and losses that attend the process of care. According to the American Medical Association (1984), quality care is that which consistently contributes to the improvement or maintenance of quality and/or duration of life. The Institute of Medicine defines quality as the degree to which health services increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Blumenthal, 1996).
Health professionals tend to define quality in terms of the technical quality of care and the quality of the interaction between the physician and the patient. Patients tend to take into account both traditional clinical end points and specific problems unique to a given disease or its treatment, including perceptions of physical, mental and social functioning, disability, and overall quality of life (Blumenthal, 1996; Ware, 1995).
Patients are more likely to define quality in terms of provider-patient interactions rather than clinical processes and outcomes of care (Kane et al., 1997). Health plans and organized health care purchasers emphasize the health of entire populations and those attributes of care that reflect the performance of organizational systems (Blumenthal, 1996).
There are many potential problems with quality measurement. First and foremost, the relationship between health care outcomes and the quality of care is not always clear. Many important outcomes occur long after care is provided, making it difficult to associate specific interventions or activities with those outcomes. It is difficult to relate receipt of specific health care services to a patient's quality of life or well-being.
Differences in severity of illness and patient preferences limit one's ability to make comparisons of clinical performance without some sort of adjustment method (Palmer, 1996; Epstein, 1995). In addition, distinguishing differences in outcomes requires large samples, which may not be available for a single provider (Ware, 1995; Palmer, 1996).
There are three generally accepted criteria for measurement of care quality: structure, process and outcome (Table). In the practice of medicine, the division between structure, process and outcome is not as distinct as might be theorized. In fact, process may not be an important predictor of outcomes, and differences in outcomes may be the result of factors not under the control of health care providers. If care quality criteria based on structural or process data are to be credible, one must demonstrate that variations in the attribute measured actually lead to differences in outcome.
Likewise, if outcome criteria are to be credible, one must demonstrate that differences in outcome will result if processes of care are altered. It is difficult to relate changes in patient health to specific medical care interventions. Many factors influence outcomes that are not directly attributable to the care process itself, and it is difficult to measure the individual contributions of each provider or organization to the overall care process (Brook et al., 1996; Hammermeister et al., 1995).
The challenge in designing quality measures is to decide what it is we want to measure and how we are going to measure it. First and foremost, one must have good measures: the integrity of everything that follows is driven by the measurement system. Generally, it is much better to design measures around specific questions, rather than to collect all data possible and hope to solve the problem in the process.
For data to be useful, they must have fundamental value in monitoring and improving care (O'Leary, 1995; Ware, 1995). One must understand the reliability, validity, strengths and weaknesses of different measures in order to avoid misinterpretation of the data.
Current Quality Measurement Activities
Medical report cards are standardized, publicly released reports on the quality of care that health plans, institutions (such as hospitals) and individual physicians deliver. Performance data are used to make comparisons. Report cards have been published by health plans and may be found in newspapers and popular magazines.
National Committee for Quality Assurance (NCQA). The NCQA is an independent, not-for-profit association that is the nation's leading accrediting agency for managed care organizations. It represents a partnership of purchasers, health plans, consumers and labor. NCQA accreditation is voluntary and involves a site visit during which the plan is evaluated in six areas: quality management, physicians' credentials, members' rights and responsibilities, preventive health services, utilization management and medical records. In addition, the health plan's internal quality management systems and the capacity of the organization to deliver accessible high quality care are evaluated.
Currently, more than half of all large employers use data from NCQA accreditation surveys to decide which health insurance options to purchase, and some large employers require or request that health plans obtain NCQA accreditation in order to bid for contracts (Iglehart, 1996).
Health Plan Employer Data and Information Set (HEDIS). HEDIS, developed and maintained by the NCQA, is a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of managed health care plans. It is an attempt to standardize how health care plans measure and report performance information and indicators, allowing comparisons across health care plans and evaluation of a health care plan over time. The current HEDIS reporting set measure-domains are effectiveness of care, access/availability of care, satisfaction with the experience of care, health plan stability, use of services, cost of care and health plan descriptive information.
For 1999, mental health measures include follow-up after hospitalization for mental illness, antidepressant medication management, mental health and chemical dependency utilization-inpatient discharges, average length of stay, and percentage of members receiving inpatient, day/night care and ambulatory services.
Foundation for Accountability (FACCT). FACCT is an independent, not-for-profit organization whose goal is selecting health care quality measures that are meaningful and relevant while reflecting aspects of care that can be influenced by health care organizations. FACCT's ongoing work consists of endorsing quality measurement sets, promoting their use, aiding implementation efforts and performing consumer research. FACCT measurement sets are organized around three fundamental facets of care quality: 1) steps to good care; 2) satisfaction; and 3) results. FACCT has endorsed quality measurement sets for asthma, breast cancer, diabetes, health risks, health status for the elderly, major depressive disorder and health plan satisfaction.
The FACCT report on major depressive disorder analyzes assessment tools for major depressive order, including diagnostic status, remission and relapse, severity of illness, patient functioning and quality of life, disease management, family social support and family burden, patient satisfaction, and disease progression. The authors make recommendations concerning which effective measures to use, measurement strategies and risk adjustment, and describe a number of quality measurement systems.
Physician Credentialing and Profiling. Physician credentialing refers to evaluation and documentation of physician attributes such as degrees, licensure, disciplinary actions, sanctions, malpractice coverage and claims, clinical privileges held, work history, and drug or alcohol abuse. Physician profiling produces periodic reports that compare physicians' performance to that of their colleagues or a benchmark figure to gain information about appropriateness and quality of patient care. Profiling has been utilized to evaluate length-of-stay, use of diagnostic tests and procedures, and drug prescribing. Feedback to physicians via profiling is the most widely recommended intervention for continuous quality improvement programs, and has been shown to have an effect on practice behavior (Cave, 1995; Balas et al., 1996; Evans et al., 1995). Profiling has been used to evaluate management of patients on psychotropic drugs in primary care clinics by comparing actual practice to benchmark criteria (Wells et al., 1988).
The evolution of physician credentialing dates to the 1970s when the Joint Commission for Accreditation of Healthcare Organizations revised credentialing rules in response to concerns that hospitals were not doing a sufficient job credentialing their physicians. In the 1990s, the federal government developed the National Practitioner Data Bank. Access to the National Practitioner Data Bank, including data on health care professionals who have had adverse actions taken by malpractice carriers, state medical licensure boards, professional societies and hospitals, is available to any entity that provides health care services.
Hospitals are required to query the data bank when considering new staff appointments and to check on their entire medical staff at least once every two years. The data bank is not open to the public.
The AMA has entered this arena with its American Medical Accreditation Program (AMAP), which aims to set a standard of physician excellence that will be accepted universally by hospitals, payers and other health care organizations. AMAP is a voluntary, comprehensive accreditation program that measures and evaluates individual physicians against national standards, criteria and peer performance in five areas: 1) credentials; 2) personal qualifications, including agreement to adherence with the AMA Code of Ethics, participation in continuing medical education, and participation in peer review exams; 3) environment in which physicians provide care via on-site review of offices and medical records; 4) clinical performance via standardized measures of key patient care processes; and 5) patient care results via standardized measures of clinical results, patient satisfaction and health status. A number of states have signed contracts or letters of intent to implement AMAP.
Despite the proliferation of performance measures, many problems with health care quality measurement remain. Report card measures are incomplete, and provide information for only a few of the many key aspects of health care. Ensuring comparable measurements among plans and reliable calculation of performance indicators is not easy. Risk adjustment is difficult. Indicators may be incorporated into report cards without adequate scientific proof that they are truly related to quality of care. Unless performance reports are carefully and accurately prepared, institutional and individual purchasers may make decisions based on differences that are neither statistically meaningful nor clinically important.
Given that health care quality measurement is here to stay, it is imperative to find ways to engage physicians in quality endeavors. Physicians bring unique skills to the field of quality evaluation, having training in and understanding of medical diagnostics and therapeutics, ongoing personal relationships with patients, and an ethical and professional commitment to placing patients' welfare first (Blumenthal and Epstein, 1996; Epstein, 1995).
Physicians have an important stake in quality measurement development and performance report dissemination. At present, quality reports often provide little useful clinical data. Physicians should use their clinical expertise to inform quality measure development. Without the benefit of clinical expertise, physicians may be increasingly required to report and be evaluated on the basis of data that has little actual influence on or relevance to care quality. In order to benefit their patients most, physicians should insist that performance data be provided to them in a timely and useful manner, and must demand that they have the means to implement changes necessary to improve quality.
Balas EA, Boren SA, Brown GD et al., (1996), Effect of physician profiling on utilization. Meta-analysis of randomized clinical trials. J Gen Intern Med 11(10): 584-590.
Blumenthal D (1996), Quality of health care, part 1: quality of care-what is it? N Engl J Med 335:891-893.
Blumenthal D, Epstein AM (1996), Quality of health care, part 6: the role of physicians in the future of quality management. N Engl J Med 335:1328-1331.
Brook RH, McGlynn EA, Cleary PD (1996), Quality of health care, part 2: measuring quality of care. N Engl J Med 335:966-969.
Cave DG (1995), Profiling physician practice patterns using diagnostic episode clusters. Med Care 33(5):463-486.
Corrigan JM (1995), How do purchasers develop and use performance measures? Med Care 33(suppl 1):JS18-JS24.
Epstein A (1995), Performance reports on quality-prototypes, problems, and prospects. N Engl J Med 333(1):57-61.
Evans JH 3rd, Hwang Y, Nagarajan N (1995), Physicians' response to length-of-stay profiling. Med Care 33(11):1106-1119.
Hammermeister KE, Shroyer AL, Sethi GK, Grover FL (1995), Why it is important to demonstrate linkages between outcomes of care and processes and structures of care. Med Care 33(suppl 10):OS5-OS16.Iglehart JK (1996), The national committee for quality assurance. N Engl J Med 335(13):995-999.Kane RL, Maciejewski M, Finch M (1997), The relationship of patient satisfaction with care and clinical outcomes. Med Care 35(7):714-730.
O'Leary, DS (1995). Performance measures: How are they developed, validated, and used? Med Care 33(suppl 1):JS13-JS17.
Palmer RH (1996), Quality health care. JAMA 275(23):1851-1852.
Ware JE Jr. (1995), What information do consumers want and how will they use it? Med Care 33(suppl 1):JS25-JS30.
Wells KB, Goldberg G, Brook R, Leake B (1988), Management of patients on psychotropic drugs in primary care clinics. Med Care 26(7):645-656.
Wennberg J, Gittelsohn A (1982), Variations in medical care among small areas. Sci Am 246(4):120-134.