Institute: ONC | Component: 2 | Unit: 7 | Lecture: c | Slide: 17
Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Quality Measurement and Improvement
Lecture:Role of IT and informatics Results of current approaches to quality assessment
Slide content:Measurement Issues Elderly patients often have complex comorbidities that render recommendations in guidelines (and performance measures) inappropriate (Boyd et al., 2005) Experience to date in England (Doran et al., 2008) and US ( Persell et al., 2010) show most physician-recorded exceptions appropriate Medicare patients care dispersed among many physicians, so it s hard to attribute quality (Pham et al., 2007) New results in clinical trials can render some measures obsolete (e.g., lowering cholesterol, diabetes) ( Krumholz & Lee, 2008) Some measures have unintended consequences, (e.g., time to first antibiotic dose in pneumonia) ( Wachter et al., 2008) Multiplicity of measures leads to conflict reports (e.g., in stroke care) (Kelly et al., 2008) Most physicians dont have large enough practice caseloads to reliably measure differences ( Scholle et al., 2008; Nyweide et al., 2009) Need to focus on multiple measures and all payers (Berwick et al., 2009) 17
Slide notes:There are a number of challenges related to quality measurement. One of these issues, for example, is in elderly patients, who often have complex comorbidities [ koh - mohr - bid - ihd - eez ] with multiple diseases present. These may render recommendations and guidelines, which sometimes work their way into performance measures, as inappropriate. The UK P4P system, for example, allows exclusions based on various factors. One analysis addressed the issue of whether this practice might result in practitioners trying to game the system by trying to get patients excluded when they should not be, and this was found not to be the case. Another issue is that the care of patients in Medicare tends to be dispersed among many physicians. A patient may have a primary care physician and then see a specialist affiliated with a different hospital, so its difficult to attribute quality to a physician or hospital when the patients care is shared by several practitioners. New results in clinical trials can render some measures obsolete. Given the recent changes in recommendations for lowering cholesterol and the treatment of diabetes, if the results from a clinical trial dont support the recommendations of current quality measures, then these measures can become obsolete. Some measures have unintended consequences. Robert Wachter [ wok - tr ] , a well-known writer and quality expert, gives the somewhat funny, although concerning, example of patients who come into his hospital at the University of California, San Francisco, with CHF and get treated with antibiotics inappropriately. Why do they get treated with antibiotics when they come in with CHF? When an acutely ill patient presents at the hospital, a clinician first applies diagnostic efforts to determine whether the patient has pneumonia. The diagnosis of CHF is not always immediately clear, and the clinician may choose to observe the patient; however, some physicians may prescribe antibiotics to ensure that they meet the quality measure, only to discover later that the patient has CHF. It has also been shown that the multiplicity of measures leads to conflict reports, such as in stroke care, where some measures used for other types of patients may not be appropriate for all stroke patients. Additional analysis has found that most physicians dont have large enough practice caseloads to reliably measure differences. Berwick has suggested a need to focus on multiple measures and on all payers, not just Medicare or one insurer. 17