Category Archives: Quality Measurement

Adjusting the Adjustment

Measuring the quality of care and improving it over time is a fundamental obligation of healthcare providers. Increasingly, quality is also tied to reimbursement and is reported publicly. While I strongly agree with both trends, three recent articles point out some of the challenges ahead.

The common theme among them is that “risk-adjustment” is a hard thing to do. A brief diversion to provide some context.

There are two main ways to measure and compare quality. One is to assess processes of care, such as adherence to established best practices and evidence-based treatment guidelines. This is relatively easy to do, but is by definition highly reductionist. Clinicians understand that “good care” is more than the sum of a handful of isolated activities. Does anyone really think that good diabetes care is equivalent to measuring the HgbA1c level annually and making sure that everyone is screened for diabetic retinopathy? The other way to me is to assess patient outcomes, or how patients actually fare at the hands of different providers. This allows for comparison of endpoints that providers and patients find important, and frees providers to innovate. The challenge is that it is very difficult to separate the relative impacts of patients’ baseline characteristics from the care received in determining the outcomes.

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No Kidding

I tend to “batch read” medical journals. I usually set aside some time on Sunday mornings, after the New York Times and before the Giants kick-off to skim the cardiology journals that I still get. This past Sunday I saw something in Circulation that caught my eye.

The title of the article was “Medication initiation burden required to comply with heart failure guideline recommendations and hospital quality measures” and it was apparently deemed important enough by the editors to have an accompanying editorial called “Rethinking the focus of heart failure quality measures.” Both were authored by luminaries in the field. The punch-line? Lots of patients admitted to the hospital with heart failure need to start one or more new medications to meet guideline recommendations and hospital heart failure quality measures. This is, of course, hard to pull off, because of the challenges associated with “managing polypharmacy” and “heart failure transitional care.”

Continue reading No Kidding