Performance Assessment Chap 19

Question 1

Iatrogenesis

Answer 1

Disease resulting from medical or health care interventions.

Question 2

Risk adjustment (case mix)

Answer 2

A statistical process to make allowance for any difference in case mix between providers when comparing their performance.

Question 3

Why do we scrutinise performance?

Answer 3

Trust and accountability

Question 4

Public trust

Answer 4

‘Public trust’ embodies the notion of the expectations the public have that clinicians will be knowledgeable, skilful, competent; that they will behave in the patient’s best interest with beneficence, fairness and integrity.

Question 5

Accountability

Answer 5

Accountability can be achieved through formal accounts (e.g. annual reports) and the publication of performance data, backed up by methods of regulation such as accreditation.

Question 6

Note

Answer 6

It is essential that the health services research community continues to improve on hospital and physician quality assessments. There are many areas we need to address, including the theory underlying the statistical models, data quality and accuracy, and preventing or minimizing perverse incentives caused by public release.

Question 7

Methods for assessing quality of provider performance in developing countries

Answer 7

1. Observation of provider performance using a checklist
   Information derived from observation, when recorded on a structured checklist simultaneously with the provider’s actions by an independent observer, provides one of the most complete and reliable pictures of what providers do.
2. Exit interviews with patients or caretakers about provider performance
   The reliability of exit interview data depends on the memory of the patient or caretaker, how much attention was paid to the provider’s actions, knowledge, and expectations about what the provider should be doing, and comfort with talking to an interviewer.
3. Reviewing patient or health facility records to assess provider performance
   Record reviews, commonly used in industrialized countries, allow retrospective assessment of routine provider performance. Limited only by availability and quality of data, record review can assess a large number of cases, and enables review of severely ill cases or rarer conditions.
4. Interviews with providers about their performance
   They can, however, furnish information about how providers interpret information from the history and physical examination of the patient. and how they would manage severe cases or referrals.

Question 8

Note 2

Answer 8

In contrast, many countries use the rate of patient readmissions to hospital as a measure of quality of care. The problem is that a readmission rate appears to have no or little association with valid outcome measures

Question 9

Measuring hospital outcomes: don’t make perfect the enemy of good!

Answer 9

1. Inadequacy of risk adjustment
   Some of the justification for maintaining that the models are not good enough is that there are large changes in provider risk-adjusted mortality ranks from year to year.
2. Creation of perverse incentives for providers
3. Over-reporting of risk factors
   There are undoubtedly perverse incentives associated with reporting the risk factors used to adjust for case mix in a clinical database that is to be used for public dissemination of information, since the sicker a provider’s patients appear, the lower the provider’s riskadjusted mortality will be.
4. Can risk-adjusted outcomes indicate quality of care?
   Concerning the use of risk-adjusted outcomes for improving the quality of health care, Brook et al. (1996) state that, with exceptions, the assessment of quality should rely more on process data than outcome data. The main reason given for this opinion is that outcome data may not be sensitive enough since there is not always a poor outcome whenever there is an error in the provision of care.

Question 10

Case mix

Answer 10

The mix of cases (or patients) that a provider cares for.