Clinical performance measures address underuse and overuse of care in healthcare settings

Clinical performance measures - quality indicators used to evaluate and motivate health care providers' performance - have taken center stage in efforts to improve quality in health care on a national level. Lead author Erika Newton, MD,MPH, Clinical Assistant Professor of Emergency Medicine at Stony Brook Medicine, and Brenda Sirovich, MD,MS, of the Outcomes Group, VA Medical Center, White River Junction, VT, and the Dartmouth Institute, and colleagues examined 16 national collections of performance measures and found that more than 90 percent of 521 outpatient measures targeted underuse of care and only 7 percent addressed overuse of care. Their findings are reported in the online first edition of JAMA-Internal Medicine.

"Our findings suggest that, by focusing almost single-mindedly on identifying and penalizing underuse, current outpatient performance measures may well foster a culture of 'more is better' ─ and inadvertently encourage overuse of care," said Dr. Newton, co-lead author of the study.

In the paper, titled "Undermeasuring Overuse—An Examination of National Clinical Performance Measures," the researchers looked at 16 collections of performance measures in widespread use - defined as those in major national measure programs or clearinghouses, such as the National Quality Forum. They discovered nearly half of collections contained no overuse measures at all.

On a positive note, Newton and Sirovich conclude that although the current system of clinical performance measurement may be significantly slanted toward measuring whether patients are receiving "enough" care, performance measurement is nonetheless "well positioned to address both underuse and overuse," particularly if policymakers actively monitor the aggregate effects.

They add that the development and implementation of measure collections ─ or individual measures themselves ─ that address both underuse and overuse of care could represent a "Goldilocks approach to performance measurement, . . . [which] could encourage clinicians and institutions to target a balance of care that is just right."