Performance measures offer a head start

The physician-developed standards could form the basis for building consensus in a national quality initiative.

By Andis Robeznieks — Posted May 24, 2004

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The National Quality Forum has hit the ground running in its five-year mission to create a national, consensus-built set of ambulatory care performance measures. Instead of blindly going where no one has gone before, NQF is considering using the measure sets already developed by an AMA-led consortium as voluntary national standards until its consensus-building process is completed.

There is pressure coming from politicians, consumers and employer health care purchasers to speed adoption of such measures. So AMA Immediate Past President Yank Coble, MD, called the NQF action significant.

"It means that these measures -- that were developed by the profession -- can get out and be used more rapidly than those measures that might not be as suitable," Dr. Coble said.

"It's clear that there are going to be measures and attention to the cost of care, so the more the profession maintains its leadership, the better off it will be," he added. "If physicians develop measures based on science and their expertise, it's better than someone else doing it who doesn't have the best interest of patients at heart."

The NQF board voted April 29 in Boston to conduct an expedited review of the AMA-led Physician Consortium for Performance Improvement's existing performance measure sets.

A decision is expected in about three months about whether these sets will get the endorsement of the Washington, D.C.-based NQF, which is comprised of more than 200 member groups, including the AMA.

NQF and AMA officials were hesitant to call the consortium's measure sets "interim standards," but that's roughly how they would be used.

"They would be viewed as honest-to-goodness standards, but they would be only the first step in the process," said NQF spokesman Phil Dunn. "Eventually, they would be superseded by whatever goes through the full consensus process."

While the consensus-building process will include three to five years of back-and-forth comment and revision, the expedited review of the consortium's measures will be compressed into about three months. It will include a 30-day comment period, about two weeks for member organizations to submit a vote and then a final vote by the NQF board.

The consortium, convened by the AMA, includes medical experts representing some 60 organizations. It already has gone through a similar process to develop performance measure sets that primary care physicians can use to chart prenatal testing, preventive care and screening, and to treat patients with adult diabetes, chronic stable coronary artery disease, heart failure, hypertension, major depressive disorder and osteoarthritis of the knee.

"They've already had a vetting process," Dunn said. "We're saving a step that's already been taken."

Still some physician resistance

Although the consortium might be winning over the NQF, it still needs to win over doctors such as Dean Economous, MD, a family physician from Salem, Ohio, who worries that performance measures will "just create more headaches."

"Some are good, but some are detriments to patient care," said Dr. Economous, president of the Columbiana County Medical Society. "They're supposed to improve efficiency, but I think sometimes there is more concern for the bottom line."

He also feared that measures will be used for public reporting formulas that seek to put physicians under an unflattering light.

AMA Interim Vice President of Professional Standards Clair Callan, MD, and AMA Director for Clinical Quality Improvement Margaret Toepp, PhD, said they were aware of physician concerns, and the consortium's measure sets had been designed to address them.

"It's not telling them what to do," Dr. Toepp said. "As with all clinical recommendations, the AMA has long-standing policy that the final decisions are made at the patient-physician level."

Dr. Callan said many measure sets don't allow for explanations when standard procedures are not followed, but the consortium's sets do. When standard practice calls for giving a patient an influenza vaccine or aspirin, the physician can mark on flow sheets if these were not given for medical reasons (such as allergies) or because the patient refused them.

Dr. Callan added that public reporting of physician performance appears to be inevitable, and the consortium's measures are designed in such a way that they should ease the fears physicians have about this.

" 'Public' and 'reporting' have always been two words that raise the anxiety level of physicians very, very high, but I think they're slowly getting used to it," Dr. Callan said. "It's going to happen, and we would much rather that the measures that are used when it does happen are the ones that we have defined as being the most clinically appropriate."

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For good measure

The AMA-convened Physician Consortium for Performance Improvement -- with experts from more than 60 medical societies and the Centers for Medicare & Medicaid Services -- has developed evidence-based performance measures for:

  • Adult diabetes
  • Chronic stable coronary artery disease
  • Heart failure
  • Hypertension
  • Major depressive disorder
  • Osteoarthritis of the knee
  • Prenatal testing
  • Preventive care:
    • Adult influenza immunization
    • Colorectal cancer screening
    • Mammography screening
    • Screening for alcohol abuse
    • Screening for tobacco use

Source: American Medical Association

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External links

"National Voluntary Consensus Standards for Ambulatory Care Quality Measurement and Reporting: Phase I," project summary, in pdf (link)

AMA on advancing quality improvement in patient care (link)

Physician Performance Measurement Sets (link)

Centers for Medicare & Medicaid Services on physician-focused quality initiatives (link)

Quality measures from the Doctors' Office Quality Information Technology (link)

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