Quality Improvement is Not Easy

Heart failure is one of the most expensive conditions for Medicare and other payers.  Medicare for several years has promulgated and measured performance against several quality of care measures for heart failure.  A recent Journal of the American Medical Association commentary suggests this effort hasn’t made any real difference in outcomes or cost.  (JAMA Commentary) After several years of measuring, resulting in apparent improved compliance with recommendations, key outcomes like 30-day and one year mortality, rehospitalizations and heart failure costs were relatively constant over a five year period.

There are several possible reasons, some benign.  Hospitals could have been doing a good job on the measured items and were now just better documenting what they did; thus there wasn’t much room for improvement in ultimate outcomes.  Hospitals could have documented that they were meeting the measured items, but not really been doing so.  But it appears that the best explanation may be that the selected measures really didn’t have much to do with improving outcomes and thus only served to focus providers away from other measures that might have been more important.  An unintended negative consequence of most performance measurement is that it limits more wide-ranging exploration and experimentation around care improvement.  The commentary notes that perhaps all performance measures should be considered provisional until they are validated in very rigorous followup research.

In addition to the effort’s failure to improve health or financial outcomes, it costs hospitals a lot of time and money to comply with the requirements, so the effort may actually have a negative return.  As with many concepts discussed recently in health reform debates–comparative effectiveness and resulting guidelines, more health information technology, pay for performance–actually getting in practice what is advanced in theory is very difficult and complex.    The need for intensive, ongoing research to test theory against reality is vital.  This is not a cause for discouragement, but for realistic expectations about how fast we can identify the best care for each patient and how quickly, if ever, we see savings from widespread adoption of that best care.  Delivering good quality, appropriate care is an extremely worthy end in itself; probably the most important goal of the health system.