A new report detailing concepts for shared accountability in performance measures between clinicians and patients has been released by the ACC, American Heart Association, American Association of Cardiovascular and Pulmonary Rehabilitation, American Academy of Family Physicians and the American Nurses Association in collaboration with other professional organizations. The report was published Nov. 3 in the Journal of the American College of Cardiology, and examines the use of performance measures and how their implementation may be improved for care.

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While performance measures have traditionally been clinician focused, their goal of improving patient outcomes is heavily dependent on the health care system as well as patient actions. Recognizing this, the developing organizations sought to outline the key concepts, measurements, and considerations for implementing patient-clinician shared-accountability performance measures.

The report advocates for shared accountability to be considered during the process of developing, analyzing, reporting and interpreting performance measures. Shared-accountability performance measures track patient actions that affect outcomes – such as following treatment plans, taking medications as prescribed, going to follow up appointments, and maintaining lifestyle changes – along with physician processes. The use of shared-accountability performance measures, which recognizes the “inextricably linked” nature of patient and clinician action, has been advocated by the Institute of Medicine.

In order to implement shared-accountability performance measures, patients must have “sufficient support and knowledge to actively participate in their health care,” the report says. Shared goal setting, shared decision making, and shared care planning and monitoring between patient and clinician are all important concepts to implement as part of shared-accountability performance measures, according to the report.

Further, measures should be shifted from assessing acute care processes to longitudinal outcomes, according to the report, as it is best utilized when chronic therapy is evidence-based and supported by guidelines.

“Achieving longitudinal adherence is a shared responsibility, as the clinician must discuss treatment preferences and provide proper education, while the patient must follow the regimen and communicate any adverse effects,” said P. Michael Ho, MD, PhD, FACC, staff cardiologist at the Veterans Affairs Eastern Colorado Health Care System and writing committee co-chair. “By properly acknowledging and motivating these interrelated factors, shared-accountability performance measures can help improve longitudinal treatment adherence, which a growing body of evidence has shown is quite poor.”

The report further discusses methodological challenges involved with shared-accountability performance measures. These include how to measure patient adherence, where to incorporate patients who refuse treatments, and how to specify episodes of care for longitudinal measures.

The document also examines the need to risk adjust for patient case mix, considering such factors as cultural beliefs, religion, socioeconomic status, and clinical characteristics. Moreover, the writing committee addresses the health information infrastructure necessary for tracking patients across multiple healthcare settings and highlights current payment reform policies that support the adoption of concepts behind shared-accountability performance measures.

Noting that performance should be reported back to both clinicians and patients to facilitate improvement, the report additionally cautions that careful monitoring should be conducted to ensure implementation does not result in a negative clinician-patient relationship, adverse patient selection by clinicians, or greater barriers to care. Instead, focus should be placed on uniting the various stakeholders in a collaborative effort to enhance care quality.

“The goal of performance measurement is to improve patient outcomes, including improving the patient’s health status, and reducing their morbidity and mortality. Therefore, it is important to engage everyone that can have an impact on these goals including patients, family members or caregivers, clinicians, and the health care system,” said Eric D. Peterson, MD, MPH, FACC, director at the Duke Clinical Research Institute and writing committee co-chair. “Shared-accountability performance measures explicitly acknowledge these interdependencies so that everyone can work together towards the improved health of the patient.”

Keywords: Cooperative Behavior, American Nurses' Association, Life Style, Follow-Up Studies, Decision Making, Social Responsibility, Diagnosis-Related Groups, Colorado, American Heart Association, Physicians, Family, Episode of Care, National Academies of Science, Engineering, and Medicine, U.S., Health and Medicine Division, Social Class, Caregivers, Patient Selection, Delivery of Health Care, Health Status, Patient Compliance

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