Converting Practice Guidelines Into Quality Measure
Performance incentives have been recently adopted in France by the national health care insurer to remunerate French Doctors. In Health care, when one can not measure outcomes one measures process. But a good process for an individual patient doesn’t reflect necessarily a good process for the average patient studied by the evidence-based medical research. In a precedent post I presented what the heterogeneity of treatment effect means. In the present post I will try to highlight where stands the fundamental difference between professional guidelines and quality assessment tools of physician practice. Guidelines stem from the average patient. A quality assessment tool assesses the individual patient dealing with the heterogeneity or deviation around the mean value. From now on, given the use of guidelines made by health policy makers to evaluate health care professionals, it becomes a priority goal for searchers to take into account this use when writing their guidelines. For that purpose they should more insist on the heterogeneity of their results and perform sub group analysis across the different risk level of disease to which their studied subjects are exposed. They should accurately determine if their recommendations are applicable to subjects with multiple co morbidities. That is only at this condition that guideline will coincide with a sound balanced quality assessment tool for physician practice.
The thoughts here above were inspired to me by the reading of the two following interesting papers authored by physicians working for the Department Veterans Affairs which manage the most important health care system in the United States:
Garber AM. Evidence-Based Guidelines As a Foundation For Performance Incentives. Health Affairs. 2005 Jan;24(1):174-179. Available from: http://dx.doi.org/10.1377/hlthaff.24.1.174.
Walter LC, Davidowitz NP, Heineken PA, Covinsky KE. Pitfalls of Converting Practice Guidelines Into Quality Measures. JAMA: The Journal of the American Medical Association. 2004 May;291(20):2466-2470. Available from:http://dx.doi.org/10.1001/jama.291.20.2466.