The measurement conundrum in healthcare    

Dr Benjamin Van Voorhees, University of Illinois at Chicago College of Medicine, talks about the role of quantitative measurements in healthcare to ensure high standards of medical practice…

“You can’t manage what you can’t measure”. “What you can’t count, doesn’t count”.  These bromides of the corporate world found a home in the healthcare industry as it sought measures for evaluating quality of health care service provision.  Insurance plans and public insurers adopted quantitative measures as easily evaluated indicators of meeting accepted standards of medical practice.

The Department of Paediatrics at the University of Illinois is developing algorithms to enhance the measurement of quality of care in order to accommodate the new expectations that greatly expand the purview of primary care.  These new expectations include, care coordination and attention to the Social Determinants of Health (SDoH).  These variables are particularly important for publicly insured patients for whom social and supportive services may ameliorate circumstances of social and economic deprivation and lack of health literacy.   The new expectations require the development of innovative measures to capture the effect of these services on patients and their health outcomes. Sustainability of care coordination and social support services depends upon the incorporation of updated standards of care and relevant measures to document effectiveness and return on investment.

The evolution of clinical practice from a focus on acute and infectious diseases to one in which the health care provider is supporting the ability of a patient to prevent and/or manage one or more chronic diseases requires a different way of evaluating quality of care.  In the “old days” of medicine, quality of care was typically focused on the Donabedian model of structure and process, as defined by clinical measures which were then associated with outcome measures.  Current measures for tracking quality include variables such as meeting the schedules for wellness visits, vaccinations, and, in paediatrics, monitoring growth and development.  For adults, the measures typically include meeting the schedule for routine labs such as testing for cholesterol, or keeping measures such as blood pressure or blood glucose within an accepted range.  Preventive measures such as ordering mammograms or specific assessments required as a result of a chronic illness are also typical.  For example, the standard of care for a diabetic patient includes measuring the provider’s adherence to the recommended schedule for provision of HbA1C tests, foot examinations, and vision screening.  These services can be measured and counted and then used to define quality of care, both for health insurance plans and for providers.  This type of quality measurement has been the foundation of both health services research and the accreditation of service providers.

Measurable outcomes have become de rigueur in assessing the success or failure of a given endeavour.  Performance management and measurement relies on quantitative measures of process and outcomes, as do quality improvement (QI) and quality assurance (QA) measures.  However, developing appropriate measures to get at the human impact of a given endeavour can be very challenging.  The current QA measures, for example, do not reflect the change in focus of care from simple clinical measures to assessment of the impact of providing services such as care coordination, or addressing the social determinants of health in patient’s lives, or increasing patient engagement and self-management skills.

Many of the most innovative advances in bringing care coordination and attention to the SDoH into the purview of primary care have been funded by grants. In the United States, the federal government has funded a wide range of innovative models to improve the process and outcomes of patient care.  The Patient Centred Outcomes Research Institute, the Centers for Medicare and Medicaid Healthcare Innovation awards, along with funding from foundations, such as Robert Wood Johnson have allowed providers to develop and test new models of care that are designed to break down the traditional silos between primary care and specialty care, including mental and dental health.  These innovative models also develop partnerships with community resources to address critical deficiencies in the lives of patients that affect their ability to maintain a positive state of health and well-being.

The evaluation standards for most of these initiatives continue to rely on the standard measures of quality care:  number of well-child visits, currency with the schedule of immunisations, etc.  The current (voluntary) reporting requirements for publicly insured children includes some additional measures asking about consumer satisfaction with the care experience, and follow-up care after hospitalisations for mental illness.  These QA measures do not reflect the change in focus of care to more than simple clinical measures or “counts” of services.   If innovative models of service delivery are to be sustainable, they must be able to document the return on investment for providing services focused on addressing the SDoH, and expanding the range of vision for primary care to include monitoring for mental and dental health and coordinating services with those providers.

What is needed is a new conceptual model that describes the impact of these expanded services on patient well-being and success in maintaining optimal health outcomes.  New measures to assess the effectiveness of these additional activities tied to primary care must be developed and implemented to provide documentation for their contribution to health outcomes, and the attendant reduction in health care costs resulting from improving the ability of patients and families to maintain health.

Assessment of the impact of social services and support provided to patients and families must be measured by more than counts of services provided, or even patient or family satisfaction with those services.  At the patient level, quality of care requires a means of assessing the results of implementing interventions and detailing how they individually and collectively affect a range of outcomes: patient satisfaction and engagement, physical and emotional health, and ability to understand and manage health conditions.

The conundrum is that evaluation of interventions and activities, as well as the assessment of quality of care is necessarily reliant on quantitative measures for both expediency and a lack of more refined models of assessment.  In addition, the reporting requirements for grant funded health care innovation projects typically require the regurgitation of numbers of services, patients, contacts, etc.  These measures are necessary, but not sufficient to the purpose of developing a better understanding of the relationship between innovative activities and health outcomes.

UIC paediatrics is taking major steps toward moving the science of evaluation to the next level.  It is developing a conceptual model and both quantitative and qualitative measures to clearly explicate the incremental and contextual effects between increased care coordination and social support services and health outcomes.  Documenting positive and powerful changes in patient health, and the resultant return on investment in reduced health care costs, is critical to the sustainability of innovative models of care. Such evidence will support efforts to incorporate these innovations into accepted standards of medical practice and to make the case for financial support from health insurance plans, both public and private.

Capturing the return on investment requires a deep dive into understanding the total cost of the health care services provided, including care coordination and social support services, as well as the outcomes in terms of patient quality of life and state of wellbeing.  A truly sophisticated model of outcomes assessment would include variables such as improved school attendance and performance for youth.  This level of analysis would not only enhance our understanding of the human impact of services provided, but will allow us to understand how best to invest resources to improve the lives of children, particularly those who have been historically underserved.  UIC paediatrics is developing just such an assessment model.

Dr Benjamin Van Voorhees

Department of Paediatrics

University of Illinois at Chicago College of Medicine

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