Measuring quality or something else?

The latest issue of Journal of the American Medical Association examines performance measures being enforced by insurers and regulators, reportedly to improve clinical outcomes.

Medpundit looks at the study in JAMA led by Drs. Rachel Werner and Eric Bradlow. This study found that those “quality measures” mandated by third party payers don’t necessarily translate into quality care or better patient outcomes. In fact, the measures predicted small, insignificant improvements in mortality rates. Medpundit insightfully concludes:

Here's what counts for quality in hospitals - cleanliness and good nursing care. Hospitals don't measure those parameters, though. It's much harder to measure the worth of a nurse than to send someone around to check off documentation points on a chart. You can enact every principle of evidence based guidelines and it won't do squat for the patient if they are only attended by a nurse's aid with six weeks of training who can't recognize a turn for the worst, while the fully trained nurses are pre-occupied with fulfilling the documentation requirements.

We have vastly over-rated the improvements we get from easy pharmacological fixes while simultaneously under-rating the value of basic medical care and judgment. And with the coming of pay for performance, the mismeasure will only get worse.

And Dr. James Gaulte at Mdredux continues.

He discusses Dr. Susan Horn’s editorial appearing in the same JAMA issue which asked: “If these performance measures are not strongly associated with outcomes, why should we bother with them either as basis for P4P [pay-for-performance] or for consumers to use as tools for judging hospitals?” Dr. Horn noted that improving outcomes in actual real world practice is much more complex and multidimensional than using a few, discrete interventions that seemed efficacious and safe in randomized clinical trials. In part, it is the question of efficacy versus effectiveness. Measuring quality of care is much more complex and slippery than the ten measures measured.

In an earlier article, Dr. Werner pointed out some possible unintended consequences of hospital “report cards” including treating the chart and excluding sicker patients. Mdredux concludes:

One message should be: we have no business using simple and simplistic measures as a basis for pay for performance or for claiming to be able to distinguish between different hospitals quality of care. Not only may they not deliver on what they promise, they may be harmful.

A related Mdredux post on December 8 quotes the president of the American Medical Association, voicing his concerns of P4P measures being increasingly imposed on doctors, saying:

I will point out that-reminiscent of the managed care debacle-P4P will allow insurers to dictate the treatment that we give our patients and will publicly label any physician foolish enough to contract with them and not follow their dictates as nonpreferred, substandard or some such label.

This is not just speculation, wrote Mdredux, as physicians in Washington state had exactly that happen to them.

Medical professionals (this one included) are increasingly concerned that, like many of today’s clinical practice guidelines, these performance measures are heavily influenced by vested interests and not necessarily based on careful, proven science. Yet compliance with these clinical measures is also being imposed upon patients. Everyone is affected.

The news over recent years has been filled with discoveries of conflicts of interest among those establishing obesity and weight loss, diabetes and cholesterol guidelines. Health Care Renewal has posted frequently about allegations of conflicts of interest affecting top scientists and managers at the National Institutes of Health. Their most recent post noted that the US Food and Drug Administration (FDA) panel assessing drug-eluting stents for coronary artery disease includes six members with conflicts of interest.

Coming Monday: A review of the “Guide to Clinical Preventive Services” recently released for employers. Companies use it to help determine what health services to cover, as well as support “wellness” programs and health measures being imposed on increasing numbers of employees and recipients of government health benefits.