David W. Baker, MD, MPH; Amir Qaseem, MD, PhD, MHA; for the American College of Physicians' Performance Measurement Committee
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AzeemMajeed, Professor of Primary Care
Imperial College London
November 5, 2011
Unintended Consequences of Quality Measurement
In recent years, pay for performance programs and public reporting of provider performance have become integral components of strategies to improve the quality of health care in many countries. However, as highlighted by David Baker and Amir Qaseem, quality measurement can also have unintended consequences. Among the measures that Baker and Qaseem advocate to reduce such unintended consequences is the ability of physicians to report exceptions for not following a recommendation. Although 'exception reporting' should be an essential component of quality measurement to ensure that patients who will not benefit from an intervention (such as those who are terminally ill) are not treated inappropriately, at the same time, it is important to monitor the use of exception reports at both patient and provider level.
In the United Kingdom, the Quality and Outcomes Framework, a major pay-for-performance scheme introduced into UK primary care in 2004, permits primary care physicians to 'exception report' patients from the quality targets in the framework. One potential disadvantage of allowing exception reporting is that physicians might exclude patients in whom they have difficulty reaching targets to increase their quality achievement scores. Excluded patients may then receive suboptimal care and, if so, pay-for-performance programs and quality measurement could worsen existing disparities in health care if already disadvantaged groups of patients are more likely to be excluded from measurement of achievement of quality targets.
Analysis of data on exception reporting rates at provider level in the UK Quality & Outcomes Framework shows a wide variation between primary care practices, particularly for indicators more closely linked to clinical outcomes, such as HBA1c control in people with diabetes. At patient level, when we examined exception reporting rates amongst people with diabetes from 23 primary care practices from a socio-economically and ethnically diverse part of London, we found that patients who were exception reported by their physicians were significantly less likely to achieve treatment targets for HbA1c, blood pressure and cholesterol control. There was considerable variation in exception reporting by patient characteristics (such as age, ethnicity, co-morbidity, and duration of illness). Highest rates of exception reporting occurred among already disadvantaged groups at greatest risk of diabetes complications and poorer health outcomes such as older patients; and patients from ethnic minority groups, with longer duration of diabetes and with increased levels of comorbidity.
The experience from the United Kingdom highlights the importance of monitoring exclusions from pay-for-performance and public reporting programmes. Failure to adequately monitor exception reporting and the reasons why physicians and providers exclude patients from public reporting may lead to the patients who are most at risk of adverse health outcomes being excluded from these schemes and thus from receiving evidence-based care. This in turn may exacerbate current health disparities and worsen health outcomes in these vulnerable groups of patients.
1. Baker DW, Qaseem A. Evidence-Based Performance Measures: Preventing Unintended Consequences of Quality Measurement. Annals of Internal Medicine 2011; 155: 638-640.
2. Ashworth M, Millett C. Quality improvement in UK primary care: the role of financial incentives. J Ambul Care Manage 2008; 31: 220-225.
3. Doran T, Fullwood C, Reeves D, Gravelle H, Roland M. Exclusion of patients from pay-for-performance targets by English physicians. N Engl J Med 2008; 359: 274-284.
4. Dalton ARH, Alshamsan R, Majeed A, Millett C. Exclusion of patients from quality measurement of diabetes care in the UK pay-for-performance programme. Diabetic Medicine 2011; 28: 525-531.
5. Millett C, Gray J, Saxena S, Netuveli G, Khunti K, Majeed A. Ethnic disparities in diabetes management and pay-for-performance in the UK: The Wandsworth Prospective Diabetes Study. PLoS Med 2007; 4: e191.
I am a general practitionerin the primary care practice of Dr Curran & Partners in Clapham, London. The Department of Primary Care & Public Health at Imperial College London has received funding from the NHS for research on pay for performance.
Dale W.Bratzler, DO, MPH, Jerod M. Loeb, PhD, Denise Krusenoski, MSN, RN, The Joint Commission, Oakbrook Terrance, IL
University of Oklahoma Health Sciences Center, College of Public Health, Oklahoma City, OK
November 16, 2011
VTE Prophylaxis Performance Measures
Venous thromboembolism (VTE) remains a common complication of hospital care (1, 2). Multiple medical record audits of high-risk medical and surgical patients have consistently shown underuse of VTE prophylaxis (2). Most patients who are sick enough to require hospitalization have risk factors for VTE. Pulmonary embolism is a common and potentially preventable cause of death from hospital care (1, 2).
In their editorial, Baker and Qaseem (3) criticize The Joint Commission's performance measure on VTE prophylaxis (VTE-1) for hospitalized patients because it purportedly encourages use of VTE prophylaxis for hospitalized patients unless there is documentation in the medical record showing that the patient is not at risk for VTE. We believe this measure construct, using a permissible exclusion remains appropriate.
In 2006 and 2007, the National Quality Forum (NQF) convened a steering committee and a technical advisory panel to evaluate existing and develop new measures to address prevention and treatment of VTE (4). These panels included representation from multiple stakeholders including two authors of the American College of Chest Physicians (ACCP) clinical practice guideline. The measures were tested by The Joint Commission in multiple hospitals and were posted for comment during the consensus development process at NQF.
The decision to promote routine VTE prophylaxis or require documentation that no prophylaxis was needed was based on careful consideration of the ACCP guideline recommendations. The ACCP did not advocate patient-specific assessment for VTE risk due to the lack of appropriately-derived and validated risk assessment tools, and stated that "there is sufficient evidence to recommend routine thromboprophylaxis for most hospitalized patient groups (2)." The ACCP also noted that "we are not able to confidently identify the small population of patients in the various groups who do not require thromboprophylaxis (2)."
While the ACCP highlighted the lack of clinically-validated risk- assessment models to guide thromboprophylaxis, a careful review of the performance measure specifications for VTE-1 shows that the measure construct allows documentation of the lack of need for VTE prophylaxis based on completed hospital risk assessment forms (5). The specifications also give complete discretion to the clinician at the bedside to decide if prophylaxis is indicated for their patient, and to chose the type of thromboprophylaxis (pharmacologic or mechanical) if indicated for their patients based on an assessment of the potential risks (5). This approach is consistent with the ACCP and NQF recommendations for each hospital to develop written, institution-wide thromboprophylaxis policies (2, 4).
1. Qaseem A, Chou R, Humphrey LL, Starkey M, Shekelle P; American College of Physicians. Venous thromboembolism prophylaxis in hospitalized patients: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2011;155:625-632. [PMID: 22041951]
2. Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, et al; American College of Chest Physicians. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133:381S-453S. [PMID: 18574271]
3. Baker DW, Qaseem A. Evidence-based performance measures: preventing unintended consequences of quality measurement. Ann Intern Med. 2011;155:638-640. [PMID: 22041954]
4. National Quality Forum. National Voluntary Consensus Standards for Prevention and Care of Venous Thromboembolism: Phase II. Accessed at http://www.qualityforum.org/Projects/s- z/VTE_Phase_II_(2008)/VTE_Phase_II.aspx on 8 November 2011.
5. The Joint Commission. Specifications Manual for National Hospital Inpatient Quality Measures. Accessed at http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures/ on 8 November 2011.
Baker DW, Qaseem A, . Evidence-Based Performance Measures: Preventing Unintended Consequences of Quality Measurement. Ann Intern Med. 2011;155:638–640. doi: 10.7326/0003-4819-155-9-201111010-00015
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Published: Ann Intern Med. 2011;155(9):638-640.
Healthcare Delivery and Policy, High Value Care, Prevention/Screening, Venous Thromboembolism.
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