For years I have argued that performance measurement has significant potential for unintended consequences. But today, I read an article that crystallized my concerns in an important new light. The article is written about the ethics of studying work hours, “Leaping without Looking — Duty Hours, Autonomy, and the Risks of Research and Practice.” As I read the article, the implications of the ethical arguments stimulated my thoughts about performance measurement.
While I hope you will read the entire article, these lines have particular relevance here: “Bioethicist and legal scholar Michelle Meyer has described our ‘tendency to view a field experiment designed to study the effects of an existing or proposed practice as more morally suspicious than an immediate, universal implementation of an untested practice.’ She argues that people in power often rely on intuition in creating and implementing wide-reaching policies.”
Most physicians would argue that people in power (Centers for Medicare and Medicaid Services and insurance companies) have relied on intuition in creating and implementing performance measures. Please reread the above paragraph and consider seriously the problem here. Performance measures have had serious untoward consequences. Patients have suffered because of overly aggressive diabetes control, overly aggressive hypertension control and the 4 hour pneumonia rule. In the Britain's NHS P4P program care improved only slightly for targeted care but deteriorated for unmeasured parameters.
With respect to performance measurement, I have long argued that we need prospective randomized controlled trials prior to adopting any performance measure. Advocates will argue that we cannot afford the time or money needed to perform such studies. But if we accept a non-0 probability of adverse patient outcomes due to a performance measure, how can we ethically adopt such a measure?
Imposing a performance measure can have a similar impact as a new pharmaceutical agent. If we really believe the dictum primum non nocere then we have a moral obligation to object to the potential that a policy could induce negative patient outcomes.
We should not consider this concept as radical or only hypothetical, as we have clear examples of measurement impacting patient care, outcomes and even access to care. We could argue that performance measurement raises important concerns about professionalism, if indeed concern about our report cards changes how we provide patient centered care.
These ideas are important. I thank Dr. Rosenbaum for writing a brilliant piece that made me think. If only we could get “people in power” to think.
db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.