Standardizing Patient Outcomes Measurement.

ffihe arc of history is increasingIL clear; health care is shifting focus from the volume of services delivered to the value created for patients, with "value" defined as the outcomes achieved relative to the costs.1 But progress has been slow and halting, partly because measurement of outcomes that matter to patients, aside from survival, remains limited. And for many conditions, death is a rare outcome whose measurement fails to differentiate excellent from merely competent providers. Experience in other fields suggests that systematic outcomes measurement is the sine qua non of value improvement. It is also essential to all true value-based reimbursement models being discussed or implemented in health care. The lack of outcomes measurement has slowed down reimbursement reform and led to hesitancy among health care providers to embrace accountability for results. If we're to unlock the potential of value-based health care for driving improvement, outcomes measurement must accelerate. That means committing to measuring a minimum sufficient set of outcomes for every major medical condition — with well-defined methods for their collection and risk adjustment — and then standardizing those sets nationally and globally. Why has arriving at the essential measures of performance been so difficult in health care, when it seems to occur naturally in other fields? First, in health care we've allowed "quality" to be defined as compliance with evidence-based practice guidelines rather than as improvement in outcomes. Of the 1958 quality indicators in the National Quality Measures Clearinghouse, for example, only 139 (7%) are actual outcomes and only 32 (<2%) are patient-reported outcomes (see bar graph).2 Defaulting to measurement of discrete processes is understandable, given the historical organization of health care delivery around specialty services and fee-for-service payments. Yet process measurement has had limited effect on value. Such measures receive little attention from patients, who are interested in results. Process measures don't truly differentiate among providers, so incentives for improvement are limited. Nor does improving process compliance from 95% to 98% matter much for outcomes. Yet the effort required to measure processes and ensure compliance consumes organizations' resources and attention, leading to clinician skepticism about the value of measurement, which spills over to outcomes measurement. Second, the limited outcomes measurement that has occurred has been led overwhelmingly by specialty societies. But outcomes are not strictly related to individual specialties or procedures; they reflect the overall care for a patient's medical condition, in which multiple specialties are usually involved. What generally matters to patients are outcomes that encompass the whole cycle of care — including health status achieved (e.g., survival, functional status, quality of life); the time, complications, and suffering involved in getting care; and the sustainability of benefits achieved (e.g., time until recurrence). Specialty societies naturally