REPLY
Scorecard Medicine—Measuring Process and Outcome
Robert H. Brook, MD, ScD
1 June 1994 | Volume 120 Issue 11 | Pages 971-972
IN RESPONSE:
I agree with Dr. Clement that, unless publicly released data on quality are accurate, untoward events may occur. In particular, physicians who perceive that outcome-based systems do not adequately adjust for sickness at the time of treatment may stop caring for sick patients to improve their performance profiles. One solution is to build severity adjustment models that "overadjust" for sickness (that is, give physicians who care for sicker patients extra credit in terms of expected mortality).
Patients' habits that affect outcome, such as smoking [1], weight [2], and even exercise, can be measured and included as adjustors in outcome models. Because self-reports would be anonymous, confidential, and not used for determining eligibility for life or health insurance, patient responses should not be biased.
Finally, I did not intend to leave the impression that outcome data are the only or even the best ways to compare health plans or physicians. Process comparisons are often preferable and have been useful for comparing plans on quality of prenatal care [3], use of hysterectomy [4], and treatment of myocardial infarction [5]. Process measures are better for these purposes because they are more directly under the control of the physician or plan and can be measured contemporaneously. By contrast, it might take 10 years to judge a surgeon by the hernia recurrence rate. Furthermore, for example, only a few cases need to be reviewed to determine whether physicians differ in their use of influenza vaccine in the elderly. Many more persons must be included to determine whether differences occurred in the pneumonia death rate because physicians failed to provide a medically indicated influenza vaccination. Only process measures for which good scientific evidence supports a relation to outcome should be included in quality scorecards. Otherwise, we may encourage the use of processes that will not improve or protect a person's health and that will result in a distortion of our investment in health care.
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Author and Article Information
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University of California, Los Angeles, Center for the Health Sciences; Los Angeles, CA 90024
1. Stewart AL, Brook RH, Kane RL. Conceptualization and Measurement of Health Habits for Adults in the Health Insurance Study. Vol. I, Smoking. Santa Monica, CA: RAND; 1979. R-2374/1-HEW.
2. Stewart AL, Brook RH, Kane RL. Conceptualization and Measurement of Health Habits for Adults in the Health Insurance Study. Vol. II, Overweight. Santa Monica, CA: RAND; 1980. R-2374/2-HEW.
3. Murata PJ, McGlynn EA, Siu AL, et al. Quality measures for prenatal care. A comparison of care in six health plans. Arch Fam Med. 1994; 3:41-9.
4. Bernstein SJ, McGlynn EA, Siu AL, Roth CP, Sherwood MJ, Keesey JW, et al. The appropriateness of hysterectomy. A comparison of care in seven health plans. Health Maintenance Organization of Quality of Care Consortium. JAMA. 1993; 269:2398-402.
5. Carlisle DM, Siu AL, Keeler EB, McGlynn EA, Kahn KL, Rubenstein LV, et al. HMO vs fee-for-service care of older persons with acute myocardial infarction. Am J Public Health. 1992; 82:1626-30.
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