Study Examines Effect of Active versus Passive Monitoring of VA Quality Performance Measures

BACKGROUND:
Healthcare reform has placed great value on measuring clinical performance to inform patient choices and payer reimbursements. Performance also is often tied to pay-for-performance initiatives. VA uses a fully developed and universally implemented performance management system of more than 70 indicators of clinical quality, access, patient satisfaction, and value. Performance is followed over time and, in some cases, measures reach a ceiling where high-performance levels seem to be sustained. Such measures are often “retired,” or passively monitored – and no longer impact facility budgets. This longitudinal retrospective study compared the nature and rate of change in hospital outpatient clinical performance as a function of a measure’s status (active vs. passive), and examined the mean time to stability of performance after changing status. Using data for 133 VAMCs from VA’s External Peer Review Program from 2000 to 2008, investigators studied 17 measures in five clinical areas common to ambulatory care: screening, immunization, chronic care after acute myocardial infarction (AMI), diabetes, and hypertension. Using VA administrative data, organizational characteristics also were assessed, including facility size, academic mission, and primary care structure.

FINDINGS:

• Performance measure monitoring status (active vs. passive) did not significantly impact performance over time. Structural organizational characteristics, including facility size, academic mission, and primary care structure, had no impact on this finding.
• There was variability in whether or not measures stabilized after a status change, suggesting the possibility that some measures may take more than two years to stabilize. However, performance scores for measures with short stability times were no higher or lower than scores for measures with longer stability times.
• Of the 6 measures changing from passive to active monitoring, 2 (33%) stabilized after the status change (breast cancer screening and cervical cancer screening).
• Of the 11 measures changing from active to passive monitoring, 5 (45%) stabilized after the status change (tobacco use, diabetic foot inspection, beta blockers, ASA, and depression screening). All measures that stabilized did so immediately after the status change (e.g., time to stability was one quarter). Of the 6 measures that did not stabilize, 5 suggested continued improvement after the change.

LIMITATIONS:

• This study relied on outpatient measures of preventive processes and chronic conditions of high prevalence in the VA population. Measures of inpatient or surgical care, which rely much less on patient adherence, may result in different findings.

AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (CDA 07-018, SHP 08-147). Dr. Hysong was supported by an HSR&D Career Development Award. All authors are part of HSR&D’s Houston Center for Quality of Care and Utilization Studies.

Hysong S, Khan M and Petersen L. Passive Monitoring Versus Active Assessment of Clinical Performance: Impact on Measured Quality of Care. Medical Care October 2011;49(10):883-890.