Tussles on the Healthcare Quality Data Battleground

Today has been a tough in the world of healthcare quality metrics.

First, US New and World Report's "Best Hospitals" list is slammed for being entirely subjective in an article published in the Annals of Internal Medicine, then a report in the British Medical Journal calls for the use of inpatient mortality rates as part of hospital quality "report cards" to be scrapped, as they "can mislead the public into thinking a hospital offers poor care when it does not."

Finally, a physicians are denouncing a new rating system put together by Blue Cross of California and the Pacific Business Group on Health.

Reputation trumps all

Seeking to "quantify the role of reputation in determining the relative standings of the top 50 hospitals in the 2009 edition of US News & World Report's rankings," Ashwini Segal, MD of Case Western Reserve University and MetroHealth Medical Cente, found that reputation score alone agreed with the report's rankings "100% of the time for the top hospital in each specialty, 97% for the top 5 hospitals, 91% for the top 10 hospitals, and 89% for the top 20 hospitals."

Though Seghal concludes that "little relationship exists between subjective reputation and objective measures of hospital quality among the top 50 hospitals," Avery Comarow, US News & World Report's health rankings editor, believes that this is a philosophical difference between Dr. Seghal and the news magazine. Speaking with Bloomberg, Comarow said that the reputation scores reflect the fact that the top hospitals have a nationwide reputation for excellence in their particular specialties.

More bluntly, Comarow told the Cleveland Plain Dealer: "'I think it's a reasonably good analysis with a fundamental misunderstanding going in' of what reputation means. 'He doesn't look at reputation the same way we do.'"

When we said you failed, we might have made a slight error...

According to Peter Pronovost, MD, PhD, professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine, and Richard Lilford, PhD, professor of clinical epidemiology at the University of Birmingham in England, the use of inpatient mortality rates to determine quality of hospital care is done largely because it's easy.

The path of least resistance, though, is not usually the most effective. Pronovost and Lilford claim that hospitals should be judged only by the number of preventable deaths that occur within their walls, while the inpatient mortality rate considers all deaths. Pronovost and Lilford, for example, say that rates of death after elective procedures or from blood stream infections are effective yardsticks.

"[I]f you want to look at preventing deaths, why on Earth would you look at all deaths, when it’s only a small percentage that fall into that category?” Pronovost asks.

Where's my blue ribbon?

Meanwhile, California physicians are protesting the California Physician Performance Initiative, a physician performance measurement initiative created by Blue Cross of California and the Pacific Business Group on Health, a business coalition of 50 purchasers.

"The organizations worked together to measure the performance of 13,000 high-volume physicians on evidence-based healthcare quality standards" and "will publicly recognize physicians who scored above average in up to eight measures in preventive screening, diabetes, and other categories.

The effort is all well and good, says the CMA, except that the they have serious concerns "about the validity and accuracy of the underlying data" which they feel is in "blatant disregard for the irreparable harm it will have on physicians’ reputations."

At issue is the fact that the CPPI "relies solely on claims data" which the CMA claims "fails to comprehensively document the care a patient receives or the reasons a patient may not receive the care that is the focus of a quality measure." Further, they feel that the awarding of digital blue ribbons to physicians that score in the top 50th percentile will imply that those without ribbons are not "quality doctors," which could hurt their practices.

CMA claims that it has been working for more than two years to try to address its concerns, but to no avail, hence the groups withdrawal from the initiative. In that case, it seems that none of the parties will be able to agree on anything, so, rather than dwell on the institutional back and forth, it's probably best to wait and see how the initiative plays out with the Blue Cross insured.