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Measuring the quality of quality measurement

How good is good enough when it comes to quality of medical care? An interesting commentary tackles that question in today's online edition of the Journal of the American Medical Association.

It's crucial that we hold practitioners accountable to some standard of care, argue authors Harold C. Sox, MD, and Sheldon Greenfield, MD, but our current methods of quality measurement are "rudimentary."

Right now, a practice (or an individual physician) is not judged on an absolute standard; it is judged only in relation to others. The threshold for what constitutes quality care is fixed as a percentile of a distribution. It moves up and down as overall adherence rates shift.

That's a system that lacks consistency, Sox and Greenfield argue. But more importantly, they say, it's a system that's inequitable:

Practices differ in factors-disease severity, comorbidity, adherence, and preferences of patients-that affect the process and outcome of care. Because of these differences in case mix, ranking practices on measures of process or outcome, which is the basis of setting a threshold percentile, may not accurately reflect practice quality rankings. Said differently, process and outcome measures are driven by both case mix and practice quality. To fairly compare practices according to quality alone would require first removing differences in case mix by statistical adjustment. The inequity occurs because the system for quality measurement does not adjust for differences in case mix yet does require all practices to meet the same standard of quality.

A better way to assess quality of care, the authors argue, would be to shift the focus from process and outcome measures (such as hospital readmission rates), and zero in on decision quality. That would take into account:

The patient's knowledge of the factors involved in the decision, the match between the patient's values and the decision made (value concordance), and the patient's satisfaction with the decision process.

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