Patient-based outcomes measures are coming
Patient-based outcomes measures are coming
Measures change care for patient and provider
By Sharon Sokoloff, PhD
Executive Vice President
Medical Outcomes Trust, Boston
The Medical Outcomes Trust brought together eight prominent leaders of US health care and invited them to share their thoughts about the future of health-related quality of life (HRQoL) outcomes measurement through the year 2005. This article includes a summary of the major themes that emerged from that interchange. While the experts contributed a variety of perspectives, there was remarkable consensus about one central point: patient outcome measures will soon be integral to and routinely used in clinical practice as well as virtually all systems that organize, deliver, and finance care.
Patient outcomes improve accountability and choice in health care
The vast majority of the quality measures in use to date are process measures, an indicator of the still-formative stage of the field of quality measurement. Our goal is to establish a more comprehensive quality measurement strategy to include process and outcome measures. Such a system promises consumers, payers and purchasers increased: 1) accountability for the quality of care provided and 2) choice for health plans and physicians.
Purchasers will increasingly require scientifically sound information about the results of care and the health of populations over time. Already, key organizations in the field, e.g., AHCPR, NCQA, JCAHO, and FACCT, are engaged in work aimed at accelerating the quality and diversity of the outcomes measures available, the adoption of the measures and the resolution of the methodological challenges affecting progress in this field, e.g., risk adjustment and continuous enrollment in managed care settings. Notably, HCFA has demonstrated significant leadership in the field spearheading initiatives that incorporate health status and outcomes measures of HRQoL in nursing homes, home health care and managed care settings.
Several examples of how readily accessible and standardized information about the results of care will be used to increase accountability follow. Outcomes studies: 1) will be used to reveal that certain clinical modalities have no effect on health outcomes and thus, the use of those procedures, technologies, or treatments could be discontinued, 2) will be used to evaluate alternative health care practitioners and to address issues of regulation and oversight of non-physician practitioners, and 3) will impact the pharmaceutical and medical device industries holding them accountable for patient outcomes with regard to the products they develop.
Patient outcomes support the improvement of clinical practice
An important achievement in the coming years will be the acceptance of the complementary nature of process and outcomes measures in the continuous quality improvement cycle. All health care sectors will realize the debate about "process versus outcome measures" is over. Efforts will be aimed at implementing strategies that link the evaluation and improvement of processes and outcomes with the goals of such a strategy including: 1) understanding the results associated with various processes of care, specifically, which practices yield the best outcomes and 2) guiding an ongoing, iterative process of improving the value of health care. Managing clinical processes and managing patient outcomes are two integral parts of a comprehensive and sound measurement strategy.
Outcomes measurement systems must be standardized to achieve success
The need for standardized and comparable data and information is a cornerstone of the science and use of outcomes measurement. For much of our history, competing systems have been used to measure quality and clinical effectiveness. However, experts both hope for and expect a "shakedown" and consolidation favoring standardized measures that subscribe to a scientific base. Without standardization and scientific rigor the result could be years of fragmented and ineffectual efforts.
Significant progress has been made by and among purchasers in the movement toward the achievement of standardized quality performance measures in the 1990s. Specifically, purchasers have acted in a coordinated way to make buying decisions on the basis of information that is standardized and based on good science recognizing that they cannot afford not to standardize and to make information about the results of care as comparable as possible.
Patient outcomes will be linked to payment systems
As payment systems evolve they will continue to change from cost reimbursement to more and more capitated models to a range of incentive-based payments methods. Increased competition will lead to greater buyer emphasis on value, i.e., an interest in quality and benefit as well as cost. All forms of outcomes measurement will assume increasing importance in judging value including: traditional biological and clinical measures, symptoms, utilization, cost, functional status and well-being, and satisfaction with care. Our experts agreed that if payment systems are going to be dependent on the quality of outcomes information, as they believe they will be, then we will see physicians begin to accept these measures. In markets where managed care predominates, there has already been significant behavior modification on the part of physicians.
Physicians must "buy in" and contribute to outcomes measurement methodologies
Outcomes measures promise tremendous improvements in clinical care particularly for patients with chronic medical conditions such as asthma, diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, and depression. There is no doubt that cross-sectional health status and longitudinal outcomes information will be integrated into routine patient care, in all settings, as a complement to the information available through more conventional care practices, e.g., the history and physical, and analysis of laboratory data. To date, the integration of patient outcomes into clinical practice has been slow, the rare exception rather than the rule.
However, software technology designed to collect, organize and analyze standardized patient-based outcomes data in a matter of seconds is already widely available today. If medical schools, residency programs and physician organizations support the use of these measures, significant progress could be made by 2005. It is encouraging to see that the AMA and a handful of physician specialty organizations have begun to take a leadership role in this area.
Physician experts in the field of health outcomes stress that acceptance of outcomes measures by the medical profession will be predicated on two conditions: 1) physician input in the implementation process, and 2) the use of scientifically rigorous measures. There is a tremendous gap in practicing physicians’ understanding about what these measures are about, i.e., the actual challenges and benefits of their use. For some, this results in outright hostility and for others, "simply" a state of misinformation. Until we educate the people who will be using these measures about what they mean, what their strengths are, what their limitations are, and how they fit into the whole thrust of total quality management, we will be missing a major opportunity. Because the human instinct is not to be measured, it is critical that physicians are involved in the processes of systematizing outcomes measures in order to obtain their support and "buy-in" in the programs.
Outcomes measures add value to the clinical encounter
Clinicians’ acceptance and use of outcomes measures will be predicated on the availability of tools that: 1) are as simple as possible, 2) are scored in rapid time, and 3) generate information for review at the time of clinical encounters. To the extent that technology makes it so simple that the information facilitates efficient and effective patient care, it will be accepted. To the extent that it is a burden, it will not be accepted or used.
If the tools help physicians, they will use them. Thus, the real challenge is to develop tools and systems useful to physicians. There are models of successful implementation strategies for systems-wide changes, e.g., the implementation of a clinical computerization initiative, in which retired "emeritus physicians" became powerful advocates for the new tools and systems. The idea of involving physicians to carry the message to their peers, particularly physicians who are well-respected, has been demonstrated to have excellent results.
Patients must be involved to improve health outcomes
Consumers are playing an increasingly active role in the movement to improve the results and value of health care. Consumer information about the experience of their health in various domains, e.g., physical function, social functioning and energy, as well as their preferences about and satisfaction with their health care is central to maximizing the value of health care.
We have the ability today to use technology to elicit rich and detailed information from patients about their status, everything from their physical to psychosocial status, and to do so in a standardized, easy and efficient way. We have the ability to collect information from patients while they are sitting in the physician’s waiting room and to organize and analyze it so that when she walks into the doctor’s office, the doctor would know a tremendous amount about her status, how it has changed since her last visit and her preferences. The more patients are involved in their own care, the more they will be empowered to make informed choices about lifestyle and treatment.
Final note
As we approach the year 2000, the field of health outcomes measurement is at a formative and exciting stage. It is no longer a question of "if" but rather "when and how" patient-based health-related quality of life outcomes will be used on a widespread basis in virtually all health care sectors. Two key factors find us poised on the threshold of widespread implementation of these measures: 1) significant changes in public and private health policy that are requiring and/or otherwise promoting the use of patient outcomes, and 2) major advances in software technology that promise highly precise, standardized patient outcomes information in rapid turn-around time. While formidable challenges exist, particularly related to the implementation of outcomes measures in practices and systems of care, over time, a significant investment will be made and HRQoL measures will soon become integral to the way health care is delivered, evaluated, regulated and paid for in the US and abroad.
[I'd like to acknowledge my debt for the ideas presented in this column to a group of experts who participated in a Medical Outcomes Trust roundtable. They are: Wade Aubry, MD, national medical consultant, Blue Cross Blue Shield Association; Helen Darling, manager, Healthcare Strategy & Programs, Xerox Corp.; William Jacott, MD, board member of the American Medical Association, associate professor and head of the Department of Family Practice and Community Health, University of Minnesota; Jonathon Lord, MD, senior advisor for clinical affairs, American Hospital Association; Walter J. McNerney, professor of health policy, J.L. Kellogg Graduate School of Management, Northwestern University; Dennis O'Leary, MD, president, Joint Commission on Accreditation of Health Care Organizations; Cary Sennett, MD, PhD, vice president for Performance Measurement, National Committee for Quality Assurance; and Helen Smits, MD, MACP, president, Health Right, Inc., Hartford, CT.
For more information, contact Sharon Sokoloff, PhD, executive vice president, The Medical Outcomes Trust, 20 Park Plaza, Suite 1014, Boston, MA 02116. Telephone: (617) 426-4046. E-mail: [email protected].]
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