Evaluates the effectiveness of Hospital Quality Alliance standards, and identifies specific activities hospitals can work on to improve performance and deliver higher quality health care

Anthony Shih

Stephen C. Schoenbaum

English

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Measuring Hospital Performance:The Importance of Process MeasuresAnthony Shih and Stephen C. SchoenbaumThe Commonwealth FundABSTRACT: Providers and patients agree that high-quality care is an essentialcomponent of a high performance health system, a position supported byThe Commonwealth Fund’s Commission on a High Performance HealthSystem. However, recent debate has focused on how best to define “high qual-ity” in the hospital setting. Recent journal articles have found only a “modestrelationship” between performance on Hospital Quality Alliance (HQA)process measures and short-term mortality. Despite the lack of a more robustconnection, the authors of this data brief contend that these HQA measuresrepresent actionable items that can have an impact on quality and health out-comes and identify specific activities hospitals can work on to improve per-formance. Developing new process measures to reduce mortality and otherpoor outcomes, while improving performance on the current measures, canhelp move the nation toward achieving higher-quality health care and a highperformance health system.*    *    *    *    *IntroductionWhile most providers and patients agree that high-quality care is an essentialcomponent of a high performing health system, there has been much recentdebate regarding how to best define “high quality” in the hospital setting.Much of the discussion focuses on whether the process measures of theHospital Quality Alliance (HQA)—a national public–private collaborationdesigned to encourage hospitals to voluntarily collect and report hospitalquality performance information—are valuable.This data brief reviews thefindings of recent studies on the HQA measures, and finds that while addi-tional quality measures are necessary, providers should not hesitate to takeaction to improve performance on the current measures.The CommonwealthFor more information about thisstudy, please contact:Anthony Shih, M.D., M.P. H.Assistant Vice President, QualityImprovement and EfficiencyThe Commonwealth FundTel 212.606.3856Fax 212.606.3500E-mail ts@cmwf.orgThis and other CommonwealthFund publications are online atwww.commonwealthfund.org.Tolearn more about new publicationswhen they become available, visitthe Fund’s Web site and register toreceive e-mail alerts.Commonwealth Fund pub. 1046Vol. 6Data BriefJULY 2007COMMISSION ON A HIGH PERFORMANCE HEALTH SYSTEM2 The Commonwealth Fund Commission on a High Performance Health SystemFund’s Commission on a High Performance HealthSystem—launched in 2005 to develop strategiesto promote a health system that provides allAmericans with affordable access to high-quality,safe care while maximizing efficiency—has identi-fied high-quality care as one of the core goals ofa high performing health system.1Since 2005, the Centers for Medicare andMedicaid Services (CMS) has been publiclyreporting hospital-specific HQA performancemeasures on processes of care.These process meas-ures assess whether certain care processes recom-mended in clinical guidelines are administered,such the administration of an aspirin within 24hours of a heart attack (Table 1). As demonstratedin the Commission’s national and state scorecards,there is wide variation on these measures acrossthe country (Figure 1).2,3This variation in performance indicates anopportunity for providers to improve, and alsoallows consumers to identify higher- and lower-performing hospitals. However, the benefit isdependent on the validity of the measures—that is,whether they truly reflect quality of care. In con-trast to mortality rates, which directly measure aTable 1. Current Hospital QualityAlliance Process MeasuresHeart attack Aspirin at arrival Aspirin at discharge ACE inhibitor or ARB for LVS dysfunction Beta blocker at arrival Beta blocker at discharge Fibrinolytic medication within 30 minutesof arrival PCI received within 90 minutes ofhospital arrival Smoking cessation advice/counselingHeart failure Evaluation of LVS function ACE inhibitor or ARB for LVS dysfunction Discharge instrucctions Smoking cessation advice/counselingPneumonia Oxygenation assessment Initial antibiotic timing Pneumococcal vaccination Influenza vaccination Blood culture performed in the emergencydepartment prior to initial antibioticreceived in hospital Appropriate initial antibiotic selection Smoking cessation advice/counselingSurgical care improvement/surgical infection prevention Prophylactic antibiotic received within onehour prior to surgical incision Prophylactic antibiotics discontinuedwithin 24 hours after surgery end time Prophylactic antibiotic selectionNotes: Starter set of 10 measures are italicized.ACE = angiotensin-converting enzyme; ARB = angiotensin-receptor blocker; LVS = left ventricular systolic;PCI = percutaneous coronary intervention.Source: Centers for Medicare & Medicaid Services HospitalCompare Web site: http://www.hospitalcompare.hhs.gov.Measuring Hospital Performance: The Importance of Process Measures 3vital patient outcome, it is more difficult to tellwhether a process measure is an appropriate meas-ure of quality of care.In June 2007, CMS and HQA began pub-licly reporting hospital performance on 30-dayrisk-adjusted mortality for patients admitted forheart attacks and heart failure, publishing thisinformation on the Medicare Hospital CompareWeb site (www.hospitalcompare.hhs.gov).Theappeal of mortality rate data is clear: it is easy tounderstand that a patient is better off at a hospitalwith a low mortality rate than a high one.However, when CMS separated hospitals into per-formance categories of:“better than U.S. nationalrate” (i.e., better than the national average),“worsethan U.S. national rate,” and “no different thanU.S. national rate,” more than 98 percent of thehospitals fell into the “no different” category(Figure 2).Examining the Hospital Quality AllianceProcess MeasuresAlthough the evidence supporting the individualcare processes captured in the HQA quality meas-ures is strong, there is a need to evaluate thesemeasures in the field, as they become widelyadopted for public reporting programs such asHospital Compare, as well as for pay-for-perform-ance programs. Over the past year, there have beentwo journal articles that examined the relationshipbetween the HQA measures and mortality.The most recent article, written by AshishJha and colleagues and supported by TheCommonwealth Fund, was published in HealthAffairs in July 2007.4 The article compared per-formance on HQA process measures for heartattack, heart failure, and pneumonia with risk-adjusted mortality for those areas.The authors cre-ated an aggregate performance score for eachcondition for each hospital. Examining the fullrange of performance by quartiles, their analysisrevealed a consistent relationship of higher per-formance on the process measures with lower risk-adjusted mortality (Table 2).In the Journal of the American MedicalAssociation, Rachel Werner and Eric Bradlow per-formed a similar but more limited analysis, alsousing the HQA database, with findings consistentwith Jha and colleagues.5 Across all three condi-tions, the authors found that hospitals performingin the top quartile on each composite score hadlower risk-adjusted mortality rates than those per-forming in the lowest quartile.Two other recent studies examined the rela-tionship between process measures and patientoutcomes, using measures closely related to theHQA measures. Elizabeth Bradley and colleaguesexamined the relationship between heart attackprocess measures from the National Registry ofMyocardial Infarction and mortality, and foundthat the measures explained a small proportion ofthe variation in mortality.6 Gregg Fonarow andcolleagues examined the relationship between theAmerican College of Cardiology/American HeartAssociation heart failure performance measuresand mortality, and found no relationship with in-hospital mortality risk for each individual measure.Only the use of angiotensin-converting enzymeinhibitor/angiotensin-receptor blocker for leftventricular systolic dysfunction and beta-blockeruse at discharge were associated with mortality orrehospitalization at 60 to 90 days.7 Fonorow foundno relationship between other measures, such asdischarge instructions or smoking cessation coun-seling (both of which are part of the current set ofHQA measures), with the outcomes they studied.CommentaryAcross these studies, it appears that performanceon the initial set of HQA process measures has amodest relationship to short-term mortality, andthat some individual measures included in the cur-rent HQA data set are not related to short-termmortality at all. Some of the more vocal responsesto these findings are troubling, particularly the crit-icism that since the HQA measures do not have alarge effect on mortality, they also have limitedusefulness for informing consumers about quality ofcare, helping providers improve outcomes, or guid-ing payers seeking value in pay-for-performance4 The Commonwealth Fund Commission on a High Performance Health Systemprograms.8 We believe this line of argument is mis-guided. Instead, we offer the following response: Although the relationship between theHQA measures and mortality is modest andthere are clearly other factors that predictmortality, the HQA measures representactionable items that can have an impact. Asper Jha et al., if hospitals in the lowest quar-tile of performance had the mortality ratesof the top quartile, approximately 2,200deaths could have been avoided. Moving allhospitals to the top decile of performancewould improve this rate substantially. Eventhough the measures included in the HQAdo not represent all the process steps thatmight reduce mortality, they are an impor-tant foundation for reductions in mortality.Although we should continue to search foradditional performance measures, we believethat these measures should continue to beused by providers, consumers, and payers.Table 2. Adjusted Mortality Rates, Stratified by Hospital Performanceon Hospital Quality Alliance (HQA) Summary ScoresPredicted mortality rate (95% confidence interval)HQA performance AMI CHF PneumoniaFirst quartile 10.0% 4.6% 7.1%(9.7, 10.4) (4.4, 4.8) (6.9, 7.4)Second quartile 10.2% 4.9% 7.4%(10.0, 10.5) (4.8, 5.1) (7.2, 7.6)Third quartile 10.6% 5.0% 7.5%(10.3, 10.9) (4.8, 5.2) (7.2, 7.7)Fourth quartile 10.8% 5.0% 7.9%(10.5, 11.2) (4.8, 5.1) (7.6, 8.1)p value for trend <0.001 0.005 <0.001Notes: Adjusted for patient age, sex, race, and the presence or absence of each of 30 comorbidities.AMI = acute myocardial infarction; CHF = congestive heart failure.Source: A. K. Jha, E. J. Orav, Z. Li et al.,“The Inverse Relationship Between Mortality Rates andPerformance in the Hospital Quality Alliance Measures,” Health Affairs, July/Aug. 2007 26(4):1104–10.Measuring Hospital Performance: The Importance of Process Measures 5 Demonstrating that a process measure has arelationship to reduction in short-term mor-tality is desirable, but it not the only criteriaby which we should judge whether it is use-ful. For instance, Fonarow et al. found noassociation between mortality and indicatorsthat measure whether heart failure patientsreceived smoking cessation counseling.However, we would argue that theseprocesses should nevertheless be performed.Even minimal counseling (less than threeminutes) by a physician has been shown tobe effective in reducing smoking,9 andsmoking cessation is related to risk reductionfor heart disease, lung cancer, and stroke.10Decreased mortality is not the only desiredoutcome of good medical care. Otherimportant outcomes for patients and payersare decreased morbidity, including fewerin-hospital and post-hospital complications;fewer rehospitalizations; improved under-standing of conditions, leading to betterlonger-term care and outcomes; anddecreased costs.ConclusionBoth outcomes measures, such as mortality rates,and process measures are useful for improvingquality of care.11 Mortality rates may seem to rep-resent “the bottom line,” but there are numerousfactors, many beyond providers’ control, that con-tribute to mortality. Risk-adjustment methods toaccount for these factors are improving, but as therecent public reporting effort for heart attack andheart failure mortality demonstrates, it is difficultto discriminate among providers using only mor-tality rates. In addition, mortality rates alone donot point to the specific actions providers mustundertake to improve care. Process measuresderived from clinical guidelines, such as those inthe HQA, identify specific activities hospitals canwork to improve. Guidance for improving theseprocesses is available through private entities suchas the Institute for Healthcare Improvement orthrough government-sponsored programs such asMedicare’s Quality Improvement Organizations,which operate in each state.The real “bottom line” means not taking asimplistic approach to measurement and improve-ment.We must continue to generate evidence toevaluate new process measures that may helpreduce mortality and other poor outcomes; workhard to improve performance in the current suiteof HQA measures; and periodically check toassess the impact of improved implementation ofexisting and new measures on outcomes.Thisapproach will put us well along the path to achievinghigher-quality health care and a high performancehealth system.NOTES1 The Commonwealth Fund Commission on a HighPerformance Health System, Framework for a HighPerformance Health System for the United States (NewYork:The Commonwealth Fund, Aug. 2006).2 The Commonwealth Fund Commission on a HighPerformance Health System, Why Not the Best?Results from a National Scorecard on U.S. Health SystemPerformance (New York:The Commonwealth Fund,Sept. 2006).3 J. C. Cantor, C. Schoen, D. Belloff, S. K. H. How, andD. McCarthy, Aiming Higher: Results from a StateScorecard on Health System Performance (New York:The Commonwealth Fund, June 2007).4 A. K. Jha, E. J. Orav, Z. Li et al.,“The InverseRelationship Between Mortality Rates and Performancein the Hospital Quality Alliance Measures,” HealthAffairs, July/Aug. 2007 26(4):1104–10.5 R. M.Werner and E.T. Bradlow,“RelationshipBetween Medicare’s Hospital Compare PerformanceMeasures and Mortality Rates,” Journal of the AmericanMedical Association, Dec. 13, 2006 296(22):2694–2702.6 The Commonwealth Fund Commission on a High Performance Health System6 E. H. Bradley, J. Herrin, B. Elbel et al,“HospitalQuality for Acute Myocardial Infarction: CorrelationAmong Process Measures and Relationship withShort-Term Mortality,” Journal of the American MedicalAssociation, July 5, 2006 296(1):72–78.7 G. C. Fonarow,W.T. Abraham, N. M. Albert et al.,“Association Between Performance Measures andClinical Outcomes for Patient Hospitalized withHeart Failure,” Journal of the American MedicalAssociation, Jan. 3, 2007 297(1):61–70.8 S. D. Horn,“Commentary: Performance Measuresand Clinical Outcomes,” Journal of the AmericanMedical Association, Dec. 13, 2006 296(22):2731–32.9 M. C. Fiore, D.W.Wetter,W. C. Bailey et al., SmokingCessation Clinical Practice Guideline (Rockville, Md.:Agency for Health Care Policy and Research, U.S.Dept. of Health and Human Services, 1996).10 The Health Benefits of Smoking Cessation: A Report ofthe Surgeon General. DHHS Publication No. (CDC)90-8416 (Rockville, Md.: Centers for Disease Control,U.S. Department of Health and Human Services, 1990).11 S. C. Schoenbaum,“Outcomes Measurement:TheEnd or the Beginning?” in S. C. Schoenbaum, ed.,Measuring Clinical Care: A Guide for PhysicianExecutives (Tampa, Fla.: American College ofPhysician Executives, 1995), pp. 169–74.Measuring Hospital Performance: The Importance of Process Measures 7ABOUT THE AUTHORSAnthony Shih, M.D., M.P. H., is assistant vice president at The Commonwealth Fund, overseeing theProgram on Quality Improvement and Efficiency. Dr. Shih came from IPRO, an independent not-for-profit health care quality improvement organization (QIO), where he held a variety of positions since2001, most recently as vice president, quality improvement and medical director, managed care. In thisposition he developed and managed large-scale quality improvement projects for the Medicare popula-tion and designed quality measures and quality improvement studies for Medicaid managed care mar-kets. Previously, Dr. Shih was the assistant medical director for a community-based mental health clinicin Northern California serving immigrant and refugee populations. He is board-certified in publichealth and preventive medicine, and has expertise in epidemiology, health services research, and in theprinciples and practice of health care quality improvement. Dr. Shih holds a B.A. in economics fromAmherst College, an M.D. from New York University School of Medicine, and an M.P.H. fromColumbia University Mailman School of Public Health.Stephen C. Schoenbaum, M.D., M.P. H., is executive vice president for programs of The CommonwealthFund and executive director of The Commonwealth Fund Commission on a High PerformanceHealth System with responsibility for coordinating the development and management of the Fund’sprogram areas. He is also a member of the Fund’s executive management team. Prior to joining theFund in February 2000, he was president of Harvard Pilgrim Health Care of New England and seniorvice president of Harvard Pilgrim Health Care, responsible for delivery system operations in a mixedstaff and network model HMO with approximately 150,000 members. Prior to joining HarvardCommunity Health Plan in 1981, Dr. Schoenbaum was a member of the Department of Medicine atBrigham and Women’s Hospital and did epidemiologic research in obstetrics and infectious diseases.He is a lecturer in the Department of Ambulatory Care and Prevention, Harvard Medical School, theauthor of more than 125 scientific articles and papers, and the editor of a book on measuring clinicalcare. Dr. Schoenbaum received an A.B. from Swarthmore College with honors, an M.D. from HarvardMedical School (cum laude), and an M.P.H. from Harvard School of Public Health. He also completedthe Program for Management Development at Harvard Business School.The mission of The Commonwealth Fund is to promote a high performing health care system.The Fund carries out this mandate by supporting independent research on health care issues andmaking grants to improve health care practice and policy.The views presented here are those of theauthors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff, orof The Commission on a High Performance Health System or its members.

Measuring Hospital Performance: The Importance of Process Measures

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