Thoughts on the 4 hour rule and other core measures

Bob Wachter’s post on the 4 hour pneumonia rule lists these lessons to apply to future quality measure development:

First, results from studies of patients with known diagnoses should be extrapolated cautiously, if at all, to patients who lack a diagnosis.

Second, or some measures, “bands” of performance (i.e., 80-100% adherence) may make more sense than “all-or-nothing” expectations.

Third, representative end users of quality measures (in this case, ED docs and hospitalists) should participate in measure development.

Fourth, quality measurement and reporting programs should build in mechanisms to reassess measures over time. In this case, CMS and the Joint Commission are to be praised for listening to the chorus of criticism: in response, the measure has been revised from a 4-hour to a 6-hour standard. Even though a 6-hour TFAD rule is still not evidence-based, it should cause less harm.

Finally, biases, both financial and intellectual, that may influence quality measure development should be minimized. The TFAD measure was proposed and endorsed by many of the same people who conducted the foundational studies. None of us can be completely unbiased when evaluating our own research results.

These are important lessons for developers of quality measures. But I think there may be an even larger lesson for us “end users.” One of Wachter’s observations is telling:

As I’ve discussed previously, the biggest surprise of the last decade in the quality field has been this: public reporting alone (even without pay-for-performance) leads to huge changes in the behavior of providers and healthcare organizations… even though there is virtually no evidence that patients are reading or acting on the reports.In other words, shame and pride are powerful forces for change.

The lesson? Shame and pride are about me, us, our institutions. Shame and pride motivate us to play for the test. It’s called performance. I would submit that real quality is something different. Real quality is not about us or our public reports; it’s about the patient. Yes, shame and pride get results, but are they may not be the results we want.

The 4 hour pneumonia rule is just one example of the conflict between what performs well and what really works for patients. Last year I commented on the disappointing results for heart failure core measures:

The rush by hospitals to get a good report card may have diverted attention from other life saving therapies such as devices and aldosterone receptor antagonists.The first quality measure was the provision of discharge instructions on medications, diet and other aspects of heart failure care. In one study on which this recommendation was based the instructions included a full hour of one-on-one verbal counseling. The intervention was associated with improved outcomes. The “core quality” measure, in contrast, required only that written instructions be given to the patient. It’s one thing to hand patients a ream of paper as they are rushed out the door and quite another to provide detailed counseling. Nominal compliance may earn the hospital a perfect report card while doing little of substance to help patients.

DB weighed in here.