The failure of performance measures

Understanding of performance is beset by obfuscation of the language. For purposes of clarity it is helpful to remind readers of recent deceptive changes in health care terminology reminiscent of Orwell's Newspeak Dictionary.  Important to this discussion are “quality” which is gradually replacing the more meaningful and descriptive term “performance” and “value based purchasing” which has all but replaced “pay for performance.”

A recent review of performance measure failure suffers from some of this confusion but is otherwise a useful read. Here are a few important points to keep in mind in reading this article:

Performance, considered by many to be a surrogate for quality, has never been validated as such.

Attempts to use performance for leverage have come in two forms: payment incentive and public reporting.

Originally, officially promulgated performance measures (by Joint Commission and CMS) were limited in number. Many more were adopted voluntarily, “in-house,” by various local health systems. A large number of those are being added to the list of nationalized (and mandatory) measures under the Affordable Care Act.

Some performance measures failed because they were adopted based on somebody's big idea and scant evidence, only to be later refuted by higher level trials. Those are the focus of the article.

Others were based on good evidence but still failed to help patients because the unintended consequences of “report cards” countered any benefits inherent to the measures themselves (eg heart failure core measures, the pneumonia antibiotic rule).

Not all of the measures have been proven harmful (some have) but none have been proven to benefit patients.