The value of measuring complex outcomes

Feb. 1, 2016 / By L. Gordon Moore, MD

Improving the rate of mammography or colorectal cancer screening for appropriate individuals is a good thing. I suspect that my experience in practice was similar to others: Our group would gather each year to work on quality improvement projects and achieve better rates on certain indicators, but the next year our focus would shift. We didn’t have ongoing data, but I suspect that the rates of the previous year’s focus went back to baseline.

This is what the U.K. found even when they provided billions of pounds funding, a common electronic record and significant support for improvement in their pay-for-performance program. “Observed improvements in quality of care for chronic diseases in the framework were modest, and the impact on costs, professional behavior, and patient experience remains uncertain.”¹

If our goals include significant improvement in health outcomes for populations while reducing cost trajectories, we should consider outcome variables that are more consistent with the goals. While continuing to value improvement to completion rates (mammography, well child visits, etc) we might consider the rate of hospitalization for people with ambulatory sensitive conditions.

The rate of potentially preventable hospitalizations is more likely to reflect a system of care. Persistent high performance on a risk-adjusted basis likely means that the group/organization has developed processes, people and infrastructure that is demonstrably better serving their attributed population than a group with persistently low performance. The high-performing group may have invested in technology that makes information available in real-time to their primary care physicians (PCPs), hospitalists and ED staff. They are likely to have developed processes around outreach, identification of high-risk population segments and managing care transitions. They likely have means to immediately recognize and address signs of distress.

When PCPs look at their rates of potentially preventable readmissions or admissions, they point out why a particular admission was not preventable and miss the opportunity to think about the measure as an indicator of a system of care delivery. The point of the metric is to identify a systematic over/underperformance relative to peers on a risk-adjusted basis.

A PCP might point out that a hospitalization for congestive heart failure (CHF) could not be prevented by them alone; that the ED doc called the cardiologist, that the patient hasn’t been to see the PCP in 10 months, that the patient was not picking up their prescriptions, etc. This is the reality in which we currently practice, but the premise of better population health management requires we identify these issues as failings in our system of care. The solutions are complex. The PCP needs tools that enable real-time communication, alerts when patients are not picking up necessary medication, support for outreach and time to coordinate care for people with complex illnesses. In short the PCP needs resources to do the work and the time in which to do it well.

While the rate of mammography reflects the system of care within a PCP’s practice, the risk-adjusted rate of hospitalization, ED visits, readmissions, and use of services all reflect a system of care that includes specialists, facilities and the people we all serve. We should think about what we are striving to accomplish and consider the metrics more likely to reflect our goals.

L. Gordon Moore, MD, is senior medical director for populations and payment solutions at 3M Health Information Systems.

¹ Gillam, S. J., A. N. Siriwardena, and N. Steel. “Pay-for-Performance in the United Kingdom: Impact of the Quality and Outcomes Framework–A Systematic Review.” The Annals of Family Medicine 10, no. 5 (September 10, 2012): 461–68. doi:10.1370/afm.1377.