How Should We Assess and Use the Concept of Value in Clinical Practice?
Council News | Any discussion of the topic in question must begin with a clear understanding of the concept of value. Value is the quality achieved per dollar spent. The definition can be formulated into value equals quality divided by cost. Neither value nor quality, however, are unitary concepts. Both reflect the convictions and persuasions of the involved parties.
The most important of those involved is the patient. The components of quality (for example, timeliness, unfettered access, transparency and patient satisfaction) lend themselves to variable interpretations and perceived significance and can prove difficult to quantify. In focusing on quality, the core elements should be very specifically defined. Each element identified must be convincingly meaningful to both the health care professional and the patient. It should be a reflection of what both parties perceive as essential in healthcare delivery. In addition to the quality indicator being meaningful, other basic principles for performance measures are as follows:
- the measure must be valid and reliable
- the measure can be adjusted for patient variability
- the measure can be modified by improvements in the processes of care
- measurement must be feasible
The quality measures in health care are customarily evaluated using the Donabedian Trilogy. Accordingly to the Trilogy, the core measures are structure (how the care is organized), process (how care is delivered), and outcome (the results achieved).
Most publicly reported quality indicators are process measures as they are relatively easily measured and compared. Outcome measurements have the strongest appeal to the public as they are closely aligned with the patient’s goal for their health care. Measuring actual outcomes provides the most effective feedback loop for learning and improving. Comparative data on outcome, however, can be distorted by poor attention to the case mix index and sample size.
Efforts at cost reduction can threaten the economic stability of a healthcare system
Goals such as cost containment, profitability, access to services, profitability and high quality often conflict. The difficulty in adopting a true value system is that current reimbursement practices are misaligned with value and obscured by current measurement approaches. The movement from a volume to value system is in progress but by no means complete.
A challenge for physicians focused upon quality is a tendency to meld quality performance measures with practice guidelines. Guidelines are usually produced to outline a pathway for diagnostic and therapeutic interventions.
They are neither a performance floor nor ceiling, but merely an indication of an approach based upon clinical evidence. While quality measures should be linked to clinical guidelines, they should focus upon discrete, easily identified actions for whom adherence is advocated in the majority of a defined cohort. Ultimately, measuring results is imperative to sustain quality improvement.
Once quality measures are defined, there remain obstacles to good data collection. The most common source of data are administrative data. The obstacle with administrative data is that the original purpose of data collection was not for assessment of health care. Consequently, the information on the principle diagnosis might be inaccurate and certain clinical elements might be excluded.
Retrospective chart abstraction is labor intensive and data are likely to be incomplete.
Prospective data collection is expensive but will be more accessible with further refinement in the electronic medical record. An obstacle with the prospective approach (but generally a correctable one) is defining the data to be collected too narrowly, Other obstacles include patients lost to follow-up, inaccurate contact numbers, and lack of patient cooperation.
The engagement of physicians and all healthcare professionals is imperative if we are to achieve the highest quality health care. The monitoring and measuring of health care is a reality. The information gleamed is being used by the public, the federal government, the payers as well as healthcare professionals. The validity and relevance of the data being collected and measured hinges upon the active participation of physicians. Defining the patient cohorts, determining the relevant outcomes, defining the data to be collected all require the input of physicians. It is the physician’s responsibility to not only advocate for quality report cards that rank the quality of healthcare providers, but to also explain their ranking methods in any public distribution materials.
In summary, assessing the value of health care requires the identification of the elements to be evaluated, setting the standards of care to be achieved, ascertaining the accuracy of the data collected, ensuring the differences measured are attributable to quality of care, and making changes in clinical care as a consequence of findings.
- AHA/ACC Conference Proceedings. Circulation. 2000;101:1483-93.
- Schillie SF. Quality Improvement in Healthcare. Available at: www.medscape.org/viewarticle/561651.
- Porter, ME. N Engl J Med. 2010;363-2477-81.
Author: Douglas C. Morris, MD, is a professor of medicine at Emory University in Atlanta and director of the Emory Clinic.
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