Process of Care and Health Outcomes

The Medicare program has been an advocate of increased measurement of provider quality and reporting of that measurement to the public to aid beneficiaries in selecting hospitals and physicians from whom they are most likely to get good care.  The linchpin in this approach is that what is being measured, particularly in regard to processes of care, is truly related to, if not causative of, good health outcomes, such as mortality.  One of the pay-for-reporting programs operated by CMS relates to hospital surgical care processes.  New research in the Archives of Surgery examines the level of compliance by hospitals with these measures and its relation to health outcomes.   (Arch. Surg. Article)

The researchers categorized hospitals by their level of compliance and then examined the hospitals’ thirty-day post-operative mortality, venous thromboembolism and surgical site infection rates.  In the first year examined, 2005, only about 40% of hospitals reported their compliance with the process of care measures, but by 2006 almost all hospitals reported.  The data was adjusted for a variety of hospital, patient and other factors.  Compliance rates had significant variability, from 54% in the lowest quintile to 91% in the highest.

There was, however, little association between the variation in process of care compliance and the health outcome measures.   Simply put, hospitals with the lowest levels of compliance had no worse outcomes than hospitals with high levels.  The only apparent benefit to patients for going to a hospital with high compliance was the likelihood of not having an extended stay.  In fact, in several cases hospitals in the lowest quintile of compliance had fewer complications than those in the highest quintile.    One can conclude that the rates of process compliance provide little useful information for patients and probably impose an unnecessary cost on hospitals to collect and report the data.  There may be issues with the completeness and accuracy of hospital reporting, but it would have to have been systematically bad to affect the study results.  That is unlikely.  The results are another warning that measuring true quality that results in actual better care outcomes is not simple and programs designed to require reporting or to pay-for-performance need to be based in very solid research.