| Subtheme: Validity of the Measures |
… the AMI [acute myocardial infarction] mortality measure does not risk-adjust for the most important factor influencing mortality: the time from onset of symptoms to the time the patient presents for treatment. Efforts [to measure care quality] continue to objectify subjective data … it is an uncertain area at best! Decision making should be firmly placed in the realm of the physician at the patient’s bedside and not some policy manual written by a bureaucrat. The metrics are basic—and need [to be] improved. Measures do not equal up to date EBM [evidence-based medicine]. The information now being reported is 1–2 years old when seen by the public. I’m fine with public reporting, but we need metrics that are fair and meaningful! Data that accurately refects clinical quality. My fear is that the number of metrics is now clearly out of hand. We believe we are now reporting about 200 metrics to 19 different organizations (required or otherwise). I believe the process measures and the patient satisfaction measures are good to share, however without true risk adjustment and analysis it is just data and not information. Any risk-adjustment methodology should be readily available and understood by the measured. Volumes are so low that traditional statistical measures are difficult to use. While every patient’s care should be the best able to be delivered … some of the rates appear to be affected by randomness. [Measures] should be reliable, truly drive to improve outcomes, not just fill a political agenda.
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| Subtheme: Relevance of the Measures |
“Not everything that can be counted counts, and not everything that counts can be counted.”—Albert Einstein† Restricting analysis to easily captured metrics markedly reduces the value of the measure. There is a need to accelerate the shift in focus from process of care measures to clinical outcomes. Process measures are primarily measures of documentation. I am unaware of any peer-reviewed study which has demonstrated any correlation with outcomes or improved outcomes. … [measuring and reporting quality] distracts attention from the basic reason for the patient’s presentation and care. Hospitals are managing to the data, not necessarily focusing on what may be more significant issues in their community.
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| Subtheme: Fairness of the Measures |
Until these providers are directly impacted financially and to the same degree as the hospital for core measure and patient experience data, no hospital with medical staff that is largely independent should be financially penalized. Doctors, nursing homes, home health agencies, hospice, and other providers are much more impactful on the rates of mortality/readmission than the hospital, but it is clearly convenient to place the burden on the hospital. Too many of the increasing number of process measures are easy to be gamed. The differences between top performers and average performers for many of the measures are meaningless. For core measures and patient experience, any hospital which is strapped for money is forced into the small sampling methodology. This creates … variance if the independent practitioner is not [performing at] 100%. None of the measures take into effect socioeconomic factors. I believe that variation in mortality and readmissions is NOT random but is related to factors beyond the walls of the hospital. Demographics, availability of home care, hospice, nursing home beds, local economy, etc. CMS [Centers for Medicare & Medicaid Services] does not risk-adjust on community factors. Only patient specific factors related to comorbidity. Not robust enough. Noncompliance is a huge variable in the region. We use the IHI [Institute for Healthcare Improvement] best practices, but if the patient isn’t going to follow the plan then the hospital cannot be responsible. Some hospitals have more challenging populations to serve or have a disproportionate level of poor and/or elderly patients. This can lead to lower compliance by the patient population and therefore poorer outcomes for things like readmission rates. The truth is, for instance, that both 30-day mortality and readmission have relatively little to do with care received in the hospital (in most cases) and everything to do with what happens to the patient when they leave. I believe that variation in mortality and readmissions is NOT random but is related to factors beyond the walls of the hospital. Demographics, availability of home care, hospice, nursing home beds, local economy, etc. CMS does not risk-adjust on community factors, [only] patient specific factors related to comorbidity. Not robust enough. Current CMS core measures are unnecessarily complicated which adds to cost. Unrealistic expectations defined by CMS for hospitals assume that we will be able to change behavioral attitudes and therefore, decrease mortality rates, readmission rates, etc. The burden of measuring and monitoring are becoming more and more untenable. It would be nice to develop a value analysis that looks at the marginal improvements anticipated vs. the actual costs of implementation and “holding the gains.” Many times these feel like “unfunded mandates.” Publicly reported measures are the only way hospitals can compare to each other, but I worry about the honesty of our competitors, i.e., gaming the system, while we scrupulously report the facts.
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| Subtheme: Concerns About Public Reporting |
The only “public” looking at the measures are other hospitals. The measures need to be meaningful, fair, and reported in a timely manner. The information now being reported is 1–2 years old when seen by the public. I think that many indicators can be misleading and [that] the general public [does] not understand how many factors can influence these statistics. Average person does not understand public report measures. I support public reporting, but until CMS and others are more honest with the public about the limitations of the reporting, they have lost a lot of credibility with me.
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| Theme: Positive Views of Quality Measurement |
In general, I believe public reporting does cause hospitals to focus on quality improvement. Standardization of processes can and does lead to improved outcomes and lower cost. … the transparency that we are trying to create is good … I believe the advent of pay for performance … has brought the needed attention to patient care issues. The measures allow us to focus our activities around specific disease categories, procedures and/or surgical interventions. Patient care experience measures have provided a forum to differentiate health care providers.
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| Theme: Recommendations for Improving Quality Measurement |
I think CMS should consider affecting physician compensation in relation to some of the measures, not just hospital compensation. To effectively do this we need to create measurements that are extractable electronically so we can afford to be more and more transparent. Standards should be based on clinical scientific data from medical records/medical research. Not from extrapolated MedPar‡ data. Should be reviewed and “blessed” by professional organizations. Educate the public—start earlier—schools, church, employers.
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