NEJM: Quality improvement initiatives should meet four criteria

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Despite the progress made in quality measurements and hospital performance, there is room for improvement, according to an article published online June 23 by the New England Journal of Medicine.

“Measuring the quality of healthcare and using those measurements, which now involve virtually all U.S. hospitals, are migrating to ambulatory and other care settings and are increasingly evident in healthcare systems worldwide,” wrote Mark R. Chassin, MD, president of the the Joint Commission, in Oakbrook Terrace, Ill., and colleagues. Chassin and colleagues wrote as individuals and not representatives of the commission.

“For example, in 2009, a total of 98.3 percent of eligible patients with acute myocardial infarction received a beta-blocker at hospital discharge, as compared with 87.3 percent of such patients in 2002,” the authors reported.

The authors proposed a conceptual framework to guide future developments in this field, with a focus on process measures. “To address legitimate concerns about the program, we propose that such programs now focus explicitly on maximizing health benefits to patients,” they wrote.

Chassin and colleagues suggested that all quality measures used in national transparency and payment programs—both existing ones and proposed new ones—be vetted against four criteria, and that only measures that meet all four criteria be used for purposes of accountability (accreditation, public reporting or pay for performance):

  • A measure must be based on a strong foundation of research showing that the process addressed by the measure, when performed correctly, leads to improved clinical outcomes;
  • The measurement strategy must accurately capture whether the evidence-based care has been delivered;
  • The measure should address a process quite proximate to the desired outcome, with relatively few intervening processes; and
  • The measure should have minimal or no unintended adverse consequences.

“Of the 28 Joint Commission 2010 core measures that are aligned with Medicare, we believe that 22 meet all four criteria and could be deemed ‘accountability measures’,” the authors wrote.

Achieving the goal of improving health outcomes requires, of course, that hospitals make improvements in the clinical processes of care assessed by these accountability measures, according to the researchers, who analyzed improvement performance on accountability core measures from 2002 through 2009 among 3,123 hospitals. They found that that hospitals have made in improving their performance on these measures--from a performance rate of 81.8 percent in 2002 to a rate of 95.4 percent in 2009.

In addition, the percentage of hospitals whose performance across all accountability measures that exceeded 90 percent increased substantially—from 20.4 percent in 2002 to 85.9 percent in 2009.

The authors acknowledged that challenges will exist, but said they believed those challenges are manageable.

“Fortunately, we have a surfeit of measures that meet all four accountability criteria with which to populate accreditation, public reporting and pay-for-performance programs,” the report concluded. “Eliminating measures that do not pass these accountability tests and replacing them with ones that do will reduce unproductive work on the part of hospitals, enhance the credibility of the program with physicians and other key stakeholders and increase the positive effect that all these programs will have on health outcomes for patients.”