A new brief from the Peterson-Kaiser Health System Tracking group asks what measures are most relevant to identifying performance of a health system over time and for making international comparisons. Unlike spending, where analysis is fairly straightforward, quality measures are somewhat complex and their relevance often debated. The brief focuses on those. (Peterson Brief) Requiring participants in the health system to report on large numbers of measures, as the US does, can create administrative burdens and focus quality improvement efforts on the wrong and sometimes inconsistent areas. Many of these measures are also to narrow to help get a big picture on quality. Some indicators like disease incidence, disability rates, self-reported health status and others may tell us something but is variance in those rates, over time or in comparison to other systems, due to the performance of the health system or broader socio-economic trends and factors.
By one big picture measure, mortality, the US has improved dramatically in 30 years, from about 1200 deaths per 100,000 of population in 1980 to roughly 925 in 2010. Much of this is due to improvements in treatment of diseases like arteriosclerosis, high blood pressure and cancer. But other developed countries have also lowered their mortality rates, which generally are and stay lower than in the US and some of them have lowered their rates faster. But homicides and car accidents alone may account for most of the US gap and those aren’t really due to performance of the health system. Process of care measures can also be compared over time and across systems, although many of those have unclear links to ultimate health status and outcomes. The US has shown steady improvement on many of these measures.
The authors analyze a variety of approaches to quality measurement and summarize performance on these. By most measures the US is improving. Two that have gotten worse are obesity (which actually has unclear health effects depending on how you define obesity) and self-reported days in poor health, which may be related to the aging of the population as much as anything. There have been modest improvements in reducing the number of bad things that happen during health treatment, like surgery on the wrong limb giving people the wrong drug.
With international comparisons to other developed countries, there are areas where the US is outperforming, such as survival rates for certain cancers and wait times for specialty visits, several where we perform consistent with other nations, and a number where our performance is worse, but many of those would appear to have socio-economic factors. There can also be measurement issues, because of its reimbursement systems, the US may actually do a much better job of collecting comprehensive and accurate information. Overall, as usual, one is left with the perception that the US could do a much better job of keeping its citizens in good health and effectively treating diseases, but many of the issues around this relate to societal and cultural problems, and lack of individual responsibility, that can’t be fixed by the health system.