2017 HSC Section 2 - Practice Management
Review Clinical Review & Education
Quality Measures in Otolaryngology–Head and Neck Surgery
ing pancreatectomy and esophagectomy, 33 provider volume canbe an effective performance measure. 34 Thedevelopmentofpatient-centeredoutcomemeasuresshould be a priority for otolaryngologists. Although performance measures focused onmorbidity andmortality are well suited for high-risk pro- cedures, low-risk procedures require patient-centered outcome measures, especiallywhen the goal of the intervention is to improve quality of life. 6 An example of such a procedure is cochlear implantation 21 ; the risk ofmortality is low, but the effect onquality of life fromapoor outcome canbe tremendous, preventing a child from attending mainstream schools or an adult from continuing to work. An advantage of alternative forms of performancemeasure de- velopment other thanusingguidelines or registries is that almost any topic canbe targetedwithin reason. The combinationof a systematic reviewandanexpert panel canprovide a similar framework toguide- linedevelopmentandresultinthecreationofhigh-qualityperformance measures. 35 A disadvantage of this method is that there are added stepsinadvancingfromaqualitymeasuretoapubliclyreportableper- formancemeasurebecauseendorsement by theAmericanAcademy ofOtolaryngology–HeadandNeck Surgerymust beobtainedprior to submitting to national quality organizations, such as the AMA-PCPI. Conclusions Performance measures are an important tool that can aid otolaryn- gologists in achieving effective, efficient, equitable, timely, safe, and patient-centeredcareasoutlinedbytheInstituteofMedicine.Theuse ofperformancemeasurement,bothforqualityimprovementandcost containment, is here to stay. As experts inour specialty, wemust take the lead in creating well-developed quality and performance measures.
in academic centers. Adisadvantage of thismethod is that the qual- ity of the data are dependent on the level of detail recorded in the registry. As seen in studies based on administrative data, at times the conclusions may be quite limited, as seen in studies of thyroid- ectomy from the National Inpatient Sample. 30 Other Methods of Developing Performance Measures We should not preclude developing quality measures for proce- dures for which there are no existing clinical practice guidelines or registries. Although these qualitymeasuresmay not be as robust as performance measures (and thus not suitable for public report- ing), solo or group practices, academic departments, and hospitals may still benefit from tracking qualitymeasures internally. Further- more, by starting the process of developing and tracking quality measures, we begin the long process of performance measure de- velopment by presenting evidence to organizations such as the AMA-PCPI to conduct more rigorous testing. 31 There is compelling evidence for provider volume as a quality measure. A study 32 of the National Inpatient Sample showed that, for certain procedures (eg, pancreatectomy), the postoperative mortality rate varied from 3.8% in high-volume centers to 16.3% in low-volume centers after adjusting for patient age, sex, race, pro- cedure year, urgency of admission, Charlson score, and socioeco- nomic status. However, the use of provider volume as a quality measure is controversial. Although differences in mortality across low- vs high-volume hospitals are observed on the aggregate level, provider volume is not a good predictor of individual hospital mor- tality rates. In addition, not all procedures are associatedwith a dif- ference in provider experience. 6 Thus, we must be careful not to overuse this measure by assuming it to be true of all surgical proce- dures and also not unfairly penalize high-performing hospitals re- gardless of their volume. However, for selected procedures, includ-
ARTICLE INFORMATION Submitted for Publication: June 5, 2015; final revision received August 8, 2015; accepted September 23, 2015. Published Online: November 25, 2015. doi: 10.1001/jamaoto.2015.2687 . Author Contributions: Drs Vila and Lieu had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Vila, Schneider, Lieu. Acquisition, analysis, or interpretation of data: Vila, Piccirillo. Drafting of the manuscript: Vila. Critical revision of the manuscript for important intellectual content: All authors. Obtained funding: Vila, Piccirillo. Administrative, technical, or material support: Vila. Study supervision: Schneider, Lieu. Conflict of Interest Disclosures: None reported. Funding/Support: This work was supported by training grant 5T32DC00022 from the National Institute on Deafness and Other Communication Disorders of the National Institutes of Health. Role of the Funder/Sponsor: The funding organization had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or
approval of the manuscript; and decision to submit the manuscript for publication. Additional Contributions: J. Gail Neely, MD, provided thoughtful discussion in the early stages of the manuscript, and Lauren T. Roland, MD (Department of Otolaryngology–Head and Neck Surgery at the Washington University School of Medicine in St Louis), offered helpful comments in reviewing the manuscript. There was no financial compensation. REFERENCES 1 . Burwell SM. Setting value-based payment goals—HHS efforts to improve US health care. N Engl J Med . 2015;372(10):897-899 . 2 . Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. 3 . Lohr KN, ed. A Strategy for Quality Assurance. Vol. 1. Washington, DC: Institute of Medicine, National Academy Press; 1990. 4 . Bonow RO, Masoudi FA, Rumsfeld JS, et al; American College of Cardiology; American Heart Association Task Force on Performance Measures. ACC/AHA classification of care metrics: performance measures and quality metrics: a report of the American College of Cardiology/American Heart Association Task Force
on Performance Measures. J Am Coll Cardiol . 2008; 52(24):2113-2117 . 5 . Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q. 1966;44(3)(suppl):166- 206. 6 . Birkmeyer JD, Dimick JB, Birkmeyer NJ. Measuring the quality of surgical care: structure, process, or outcomes? J Am Coll Surg . 2004;198(4): 626-632 . 7 . Nielsen DR. Evidence-based performance measurement. In: Flint PW, Haughey BH, Lund VJ, et al, eds. Cummings Otolaryngology–Head and Neck Surgery. 6th ed. Philadelphia, PA: Elsevier Saunders; 2015:28-42. 8 . US Department of Health & Human Services. Agency for Healthcare Research and Quality. Measures inventory. http://www.qualitymeasures .ahrq.gov/hhs/index.aspx. Accessed May 15, 2015. 9 . Eddy DM. Performance measurement: problems and solutions. Health Aff (Millwood) . 1998;17(4):7- 25 . 10 . Oxford Center for Evidence-Based Medicine Levels of Evidence Working Group. The Oxford 2011 levels of evidence. http://www.cebm.net/index .aspx?o=5653. Published 2011. Accessed March 20, 2015. 11 . Centers for Medicare & Medicaid Services. Measures codes. https://www.cms.gov/medicare
(Reprinted) JAMA Otolaryngology–Head & Neck Surgery January 2016 Volume 142, Number 1
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