Download Editor`s Perspective Medicine in the Era of Outcomes Measurement

Editor’s Perspective
Medicine in the Era of Outcomes Measurement
Harlan M. Krumholz, MD, SM
O
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larly with the data coordinating center to review definitions
and discuss data collection improvement strategies. Clinicians from the hospitals voluntarily review records and
adjudicate variables to ensure accuracy. Committees elected
by local chapters of the professional societies in Massachusetts further address residual concerns through review of
blinded results before any data are publicly released.
The measures hold the promise of focusing our attention on
the patient and the end result of health care, which when
invisible are too easily ignored. The measures provide an
external assessment based on data from all the hospitals and
generate a perspective on performance that could not be
gleaned from any single institution. In addition, the public
nature of the data reinforces a commitment of the profession
to transparency and encourages institutions to focus quality
efforts broadly rather than on the specific processes being
reported.
The program has consequence, as was the case several
years ago when significantly higher mortality rates at a
prominent bypass surgery program prompted a temporary
closure. The senior vice president and general counsel of the
program wrote in a 2008 Boston Globe editorial that, “[suspension of their program] taught us to never accept the status
quo, to know we can always get better, and to highly value a
culture of learning and continuous improvement.”3 The measures can also serve to highlight excellent performance that
might otherwise go unnoticed.
Nevertheless, even the best outcomes measures have limitations. As noted by others, many deaths are not preventable
even by the best quality care, and a goal of zero is unattainable.4 The measure is intended to assess how a hospital
performed compared with what might have been expected
based on the performance of the entire group. Even with an
extensive list of clinical variables and an outstanding risk
model, some patients will have unmeasured conditions, unrelated to quality of care, which influence mortality risk. The
models, by design, should undergo regular examination and
refinement to include any relevant information that can
improve their risk adjustment. Finally, although small numbers of patients in some hospitals limit the inferences that can
be made about performance, proper statistical methods can
ensure that the number of patients at each hospital is
considered and that inferences about performance do not go
beyond the information available to make such inferences.
Once we account for differences among hospitals in the
risk of their patients and the likelihood of differences occurring by chance, quality of care remains as a probable
contributor to the differences in outcomes. Hospital variation
in quality of care processes is well documented, and it is thus
plausible— even likely—that quality issues contribute to
differences in outcomes measures across hospitals. Nevertheless, a common refrain from hospitals with high mortality
n February 9, 2009, the headlines of the Boston Globe
proclaimed that two hospitals in Massachusetts, including an institution considered one of the nation’s best, had
significantly higher than expected mortality rates for patients
undergoing percutaneous coronary intervention (PCI). The
story was based on the in-hospital risk-standardized mortality
rates for hospitals throughout the state, released by the
Massachusetts Department of Public Health.1 The unexpected
result raised questions, concerns, and some confusion about
hospital performance and the validity of the measures.
The recent focus on hospital outcomes measures seems
likely to intensify with the anticipated release by the Centers
for Medicare & Medicaid Services of 30-day riskstandardized mortality and readmission rates for acute myocardial infarction, heart failure, and pneumonia. After more
than a decade of focus on structure and process, there is a
growing sense that, in a health care system that strives to be
patient-centered, we need assessments of what actually happens to patients. The structural characteristics of an institution—such as equipment, certification, or procedural volume— do not guarantee higher quality of patient care or
superior outcomes, nor does its reputation necessarily reflect
actual experience. Process measures can capture key actions
by clinical teams that are strongly related to outcomes, but
they may typically focus on only a small subset of the
complex array of interactions, decisions, and activities that
contribute to the quality of patient care. Many aspects of care
that defy easy measurement contribute importantly to a
patient’s likelihood of a successful outcome. Thus, to describe the performance of the system we should also pay
attention to patient outcomes.
The approach to the mortality measures that is used in
Massachusetts improves on what was used by the Health Care
Financing Administration to report outcomes in the 1980s.2
The Massachusetts Data Analysis Center (Mass-DAC), the
data-coordinating center responsible for the measures and
directed by one of our Associate Editors, uses advanced
statistical models and uses detailed clinical data collected by
the hospitals to adjust for differences in the types of patients
treated at each hospital. Hospital data managers meet reguThe opinions expressed in this article are not necessarily those of the
American Heart Association.
From the Section of Cardiovascular Medicine and the Robert Wood
Johnson Clinical Scholars Program, Department of Medicine; the Section
of Health Policy and Administration, School of Public Health, Yale
University School of Medicine; and the Center for Outcomes Research
and Evaluation, Yale-New Haven Hospital, New Haven, Conn.
Correspondence to Harlan M. Krumholz, MD, SM, 1 Church Street,
Suite 200, New Haven CT 06510. E-mail [email protected]
(Circ Cardiovasc Qual Outcomes. 2009;2:141-143.)
© 2009 American Heart Association, Inc.
Circ Cardiovasc Qual Outcomes is available at
http://circoutcomes.ahajournals.org
DOI: 10.1161/CIRCOUTCOMES.109.873521
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rates is that they have reviewed deaths in their institution and
failed to find any that were preventable. This variation,
however, may reflect differences in the frequency of clear
proximate causes (eg, a patient is given a heparin overdose,
bleeds, and dies) of adverse outcomes or a confluence of
more subtle systematic factors that expose every patient to a
higher risk. These subtle factors, which define the risk of the
hospital environment, may provide the best opportunity for
improvement in outcomes. The goal is to reduce risk and
potentiate the actions that promote the effectiveness of
clinical interventions.
Amid concerns about poor publicity, many institutions will
unfortunately seek to protect their image rather than to
augment their investment in improvement activities. In a
study of bypass surgery deaths in high-performing hospitals,
Guru and colleagues showed that up to a third of deaths could
have been prevented had optimal care been provided.5 A prior
study of surgery in Colorado and Utah reached the same
conclusion.6 Hospital personnel need to use the methods
identified in this literature to identify preventable deaths as
part of their quality improvement efforts and translate these
insights into improvements in care.
The measures can also benefit less visible institutions that
are committed to excellent care. A strong measurement
system allows any institution, no matter how far from the
limelight, to be recognized for its performance. Moreover, the
measures present the opportunity to learn from those institutions with consistently outstanding performance. If the signal
from these institutions truly represents a manifestation of
higher quality, then we should identify and disseminate these
best practices. The experiences of institutions that demonstrate such positive deviance may lend insight into how all
institutions could improve, an approach that has been successful in other settings.7
To realize future improvements in outcomes measures,
information beyond mortality and readmission will be required. We need to refine models through improved data and
statistical techniques to better identify true variations attributable to differences in quality. We need more effective
means of communicating results to clinicians and the public
and further knowledge about how to optimally use the results.
Finally, we need to monitor practice to ensure that the measures
are not leading clinicians to limit access for high-risk patients
who have strong indications for intervention.
Scholarship is a critical component in the effort to improve
the quality of care. Circulation: Cardiovascular Quality and
Outcomes seeks content that can provide insight into performance and support for practical action. Our mission is to
provide a venue for practical science that can support practice
and policy. In our first 5 issues, we have published a
substantial amount of content that is relevant to national
initiatives to measure and improve outcomes for acute myocardial infarction and heart failure. This literature includes the
Methods paper that describes the readmission measure that
the Centers for Medicare & Medicaid Services will use for
profiling hospitals’ experiences with patients admitted with
heart failure8; articles focusing on delays in the response of
emergency medical services,9 patient delays in seeking care,10
delays in the delivery of critical services,11 and articles with
a long-term perspective about outcomes that reveal progress
and remaining challenges.12 Authors have also identified
patients who are less likely to receive guideline-based therapies,13 hospitals that are less likely to provide the therapies,14
and the likelihood that patients will cease to take such
therapies when prescribed.15 In addition, we have featured a
study that illuminates the complexity of an adverse prognostic factor such as depression, revealing differential effects in
men and women.16 We have also published a policy perspective that advocates for a payment system that is aligned with
the strength of clinical evidence, which would provide an
even greater incentive for the delivery of high quality care.17
We believe that scholarly contributions exploring innovative approaches to health care delivery are critical. In particular, our “Innovations in Care” section was created to provide
a forum for dissemination, discussion, and critique of systems
that enable outstanding performance. Although medical journals have not traditionally been a venue for this type of
content, we believe that a novel approach that is developed,
implemented, and evaluated rigorously deserves a public
forum. In this issue, one such contribution by Rinfret and
colleagues examines the effect of a multidisciplinary information technology program on the control of high blood
pressure.18 We also present several Methods papers from an
initiative sponsored by the National Heart, Lung, and Blood
Institute to improve the care of minority populations with
hypertension, as part of the agency’s ongoing efforts to
develop novel approaches to improving the quality of
care.19 –23 Each of these contributions holds great promise to
change current thought about how best to deliver care to this
high-risk population.
In an era of accountability, measures that reflect patient
outcomes are likely to remain in public view.3 We need to
dedicate our resources to understanding and improving performance. Through practical scholarship to improve measurement and practice, we can make true progress toward eliminating preventable adverse outcomes.
Disclosures
Dr Krumholz reports that he had contracts with the Colorado
Foundation for Medical Care and currently has contracts with the
Centers for Medicare & Medicaid Services to develop and maintain
performance measures.
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KEY WORD: Editorials
Medicine in the Era of Outcomes Measurement
Harlan M. Krumholz
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Circ Cardiovasc Qual Outcomes. 2009;2:141-143
doi: 10.1161/CIRCOUTCOMES.109.873521
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