Medicine in the Era of Outcomes Measurement

Abstract

On February 9, 2009, the headlines of the Boston Globe proclaimed that two hospitals in Massachusetts, including an institution considered one of the nation’s best, had significantly higher than expected mortality rates for patients undergoing percutaneous coronary intervention (PCI). The story was based on the in-hospital risk-standardized mortality rates for hospitals throughout the state, released by the Massachusetts Department of Public Health.1 The unexpected result raised questions, concerns, and some confusion about hospital performance and the validity of the measures. The recent focus on hospital outcomes measures seems likely to intensify with the anticipated release by the Centers for Medicare &Medicaid Services of 30-day risk-standardized mortality and readmission rates for acute myocardial infarction, heart failure, and pneumonia. After more than a decade of focus on structure and process, there is a growing sense that, in a health care system that strives to be patient-centered, we need assessments of what actually happens to patients. The structural characteristics of an institution—such as equipment, certification, or procedural volume—do not guarantee higher quality of patient care or superior outcomes, nor does its reputation necessarily reflect actual experience. Process measures can capture key actions by clinical teams that are strongly related to outcomes, but they may typically focus on only a small subset of the complex array of interactions, decisions, and activities that contribute to the quality of patient care. Many aspects of care that defy easy measurement contribute importantly to a patient’s likelihood of a successful outcome. Thus, to describe the performance of the system we should also pay attention to patient outcomes. The approach to the mortality measures that is used in Massachusetts improves on what was used by the Health Care Financing Administration to report outcomes in the 1980s.2 The Massachusetts Data Analysis Center (Mass-DAC), the data-coordinating center responsible for …