Often over the past decade we have decried the rush to measurement. For those who believe that we can measure quality easily.
Enthusiasts have advocated for pay-for-performance (P4P) without any data supporting this intrusion. Now Annals of Internal Medicine has published a review that features this conclusion: “Pay-for-performance programs may be associated with improved processes of care in ambulatory settings, but consistently positive associations with improved health outcomes have not been demonstrated in any setting.”
Will this end the P4P madness? Any practicing physician can explain the negatives of P4P programs: data collection, focus on what is being measured rather than what the patient prioritizes.
The Journal of the American Board of Family Medicine has this wonderful essay, “It Matters What Is Measured.” In this essay, author Michael LeFevre, MD, MSPH, addresses several important issues. First he discusses the idiocy of recording a review of systems at each outpatient visit (and this also relates to inpatient visits). His entire discussion is worthwhile, but I will highlight this sentence: The third and perhaps most important reason to reconsider the ROS is that payers are assigning value to it, when its value has not been demonstrated.
This is a recurrent them in the world of “quality”. Someone, usually not a practicing physician, develops a rationale for a measure. But they almost never test the measure to see its impact on patients. They have forgot Hippocrates admonition. Quality measures do influence practice and thus we should require evidence prior to adoption. Why is this such a difficult concept to understand? Why do bureaucrats (in and out of government) like these measures so greatly?
LeFevre writes this wonderful paragraph: “Adding a component for value is admirable, but the continued expansion of disease-focused process and intermediate outcome measures threatens to replicate the mistakes of the past. In the recently released list of quality measures for family medicine to be used in the Medicare Merit-based Incentive Payment System, only 2 of 55 measure a health outcome. And aside from patient satisfaction, none attempt to measure the value of the basic pillars of primary care that are widely viewed as essential to maintaining and improving health: (1) first-contact care; (2) longitudinal continuity over time; (3) comprehensiveness, with the capacity to provide care for the majority of health problems; and (4) coordination of care with other parts of the health care system.”
Often it seems that we are shouting into the wilderness. We feel like the tree that fell in the forest; was there a sound? Everyone wants to pay for value, but unfortunately we cannot really define value yet. Perhaps we will make advances with more research. Perhaps we will not. In the meantime, please decrease measurement that has not significant benefit, and potential harm.
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.