Many measures currently embraced by national quality assessment programs do not contain the level of clinical detail necessary to appropriately target populations at greatest risk for poor outcomes, nor do they motivate the appropriate clinical actions to improve those outcomes.
For example, quality measures for diabetes have traditionally focused on improving care processes, such as testing to document levels of glycemic control. Yet it is not the testing, but how patients and clinicians respond to poor glycemic control levels, that drive improvements in patients’ health status.
In addition, quality measures that focus on controlling risk factors (e.g., having a glycosylated hemoglobin of less than 7 percent) generally do not take into account how much a patient will benefit from lowering their current target glycemic control level.
As a result, measures that promote optimal control may instead create unintended consequences for patients, such as taking more than one drug to treat the same condition, medication side effects and patients with the poorest health status – all instead of improving the quality of care.
Service Innovation: New Quality Assessment Measures
QUICCC investigators are developing new quality assessment measures that examine the complexity of chronic illness care, such as:
- Appropriate responses to poor blood pressure, glycemic and lipid control
- How comorbidities should factor into quality assessment
- Metrics that incorporate Quality Adjusted Life Years saved to assess quality
Ongoing research and development
QUICCC investigators have received funding from the Department of Veterans Affairs to examine innovative ways to measure quality of care for diabetic patients with hypertension, and to construct quality measures based on potential QALYs for patients with diabetes.
Monitoring quality, particularly when clinically detailed measures are combined with appropriate incentives, may be one of the most effective ways to improve performance on targeted measures.
Until recently, most quality monitoring studies have demonstrated greater care process improvements rather than better outcomes.
The next challenge in performance monitoring will be to develop and implement measures that can improve outcomes, such as blood pressure control, without promoting unintended consequences.
Service Innovation: Developing Measures to Motivate QI
QUICCC investigators are working with the National Committee on Quality Assurance, the National VA Office of Quality and Performance, and investigators at the Northern California Kaiser Permanente Division of Research to develop measures likely to motivate quality improvement for persons with chronic conditions.
QUICCC investigators are partnering with investigators from Kaiser Permanente on a study funded by the Agency for Healthcare Research and Quality to implement clinical action feedback of “tightly-linked” measures for primary care teams in the Kaiser system.
Similarly, the AIM study uses measures indicating lack of medication intensification to target patients for additional medication management.