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OM in the News: Measuring Health Care Quality

February 1, 2015

hospital“The goal of tying more Medicare payments to the quality—not the quantity—of health care by 2018 has intensified the debate over how ‘quality’ is defined and measured,” writes The Wall Street Journal (Jan. 31-Feb.1, 2015). Many doctors, hospitals, insurers and cost experts want to move away from the myriad quality metrics that largely measure process–toward broader measures that assess patient outcomes. This week, the National Quality Forum submitted recommendations on 199 performance measures to the U.S. Dept. of Health and Human Services. The goal is to better align measures among various programs and replace narrow process-oriented metrics with “measures that matter.”

Some doctors question whether the measures that exist can adequately measure quality. And there is little agreement on what measures matter most or are more likely to produce good value. “Measurement fatigue is a real problem in hospitals,” said a Dartmouth medical prof. “But, to me, the only metric that matters is, did you get better?”

As of last year, 33 federal programs asked providers to submit data on 1,675 quality measures. State, local and private health plans use hundreds more. Hospitals and doctors stand to lose millions in Medicare payments for missing filing deadlines or improvement benchmarks in programs that track hospital-acquired infections, readmissions and electronic-record use. The Centers for Medicare and Medicaid Services wants to move toward more quality measures “that matter most to patients and clinicians,” and note that some already had an impact on outcomes. Central-line bloodstream infections have dropped by 50% since hospitals were required to report them, and 150,000 fewer Medicare patients were readmitted to hospitals within 30 days of discharge in 2012-2013 under a federal program holding them accountable. More than 2,600 hospitals will see their Medicare payments cut 1- 3% this year—a total of $428 million— for not reducing 30-day readmissions sufficiently.

Classroom discussion questions:

1. What are the advantages and disadvantages of setting quality metrics?

2. Why do doctors oppose some of the quality measures?

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4 Comments leave one →
  1. Terry Boardman permalink
    February 1, 2015 6:22 pm

    “But, to me, the only metric that matters is, did you get better?”

    more like:

    To The Patient

    “do you perceive that you are getting better?”

    Like everything else, its the perception that determines quality and measuring healthcare quality is as difficult as determining education quality. Ask the recipient.

    Metrics on infections are important for determining if the hospital is operating properly, but if I do not get an infection as a patient , I am happy if the surgery went well and I perceived I got better.

    As far as 199 metrics are concerned there is so much manipulation of the numbers and little auditing of the reportable numbers that they are worthless.

    Set up a system to ASK THE PATIENT !! Then you will get an answer on quality.
    The answers may surprise you. And do not tell me the patient will not know- trust me they will know- its their body- they will know.

    All the other metrics are mental gymnastics by bureaucrats.

  2. February 4, 2015 12:48 am

    Terry, As always, your observations are excellent! Interestingly, yesterday’s WSJ (Feb. 3, 2015, page D1) reports on more hospital stats. Here is an excerpt indicating why these are important:

    In November, a large study by UNC researchers based on 62,000 patients at 303 hospitals in California appeared in the Journal of the American Medical Association. The study found that 34% of the in-hospital heart-attack patients died before they could be discharged. By comparison, there was a 9% fatality rate among people who showed up at the ER with heart-attack symptoms. While 65% of the ER patients received treatment to unblock an artery, just 22% of the in-hospital patients did. Cardiologists at UNC and the Minneapolis Heart Institute have already developed new protocols to address the problem, borrowing significantly from the successful initiatives that have sharply reduced time to treatment for out-of-hospital heart-attack patients.

  3. terry boardman permalink
    February 4, 2015 12:32 pm

    Re above- having been in healthcare consulting for years, one must look at the difference in the patient’s health or lack thereof when doing any general analysis as above. Foremost, patients in the hospital are,well, sicker, than those than come into the ER. Difficult to understand, but let me put it this way- a heart attack where death does not occur immediately is a viable fix mechanically -e.g. bypass for ER patients , patients IN the hospital have bad hearts- congestive heart failure, the heart is just massively diseased. Therefore more hospital heart deaths.

    Patient acuity is higher for IN hospital heart patients than ER patients in the longer term, therefore more deaths of hospital patients.

  4. Andrew Cochrane permalink
    February 6, 2015 1:41 pm

    As a doctor and a current student of OM (I am doing a Commerce degree), this is clearly an interesting and very complex subject.
    (1) The higher death rate for MI affecting patients already in hospital is well known. In most cases it is related to peri-operative MI, i.e. a heart attack in a patients having surgery for some other problem, such as a hip replacement. This has long been known to have a higher mortality than an MI in a patient out of hospital. Since many of these patients have just had surgery, the usual clot-dissolving drugs that would be used in the ED are not safe to use. Also, as Terry points out, many of these patients have higher levels of co-morbidity, i.e. they are sicker, which is why they are already in hospital.

    (2) Measurement of quality is often very difficult. In many cases process measures are used as a surrogate measure, but often become “tick box” measures. The problem with just asking the patient is that often issues of quality are not apparent for months or years.
    I am involved in heart surgery. I see coronary bypass surgery done with very differing levels of quality by different surgeons. But in the short-term 99% or patients get through and out of hospital alive – often the surgeons with poorer technique are very quick and the patients recover quite quickly. However, whether their bypass grafts are working properly may not be evident until months or years down the track.
    Similarly with orthopaedic surgery. The real long-term result is not known for quite some time.

    Andrew Cochrane, MBBS, FRACS

    Melbourne, Australia

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