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Published on Monday, November 03, 2014

Measuring the right things

By Douglas L. Wood, M.D.

Measuring health care has itself become a multi-billion dollar industry with multiple goals. Some measurement is intended to improve clinical care, some is used as a basis for awarding bonuses or imposing penalties, and some is used to help guide Medicare payment.  Now, Medicare and other groups want even more measures.  

Does all of this measurement really help people better understand their health? Does it help them understand how the care they receive will help them achieve better health?

Health to most people is not measured simply in clinical terms.  Rather, it more often refers to a balance of things that allow them to function in the way they would like. For example, rather than considering a complex measure of clinical elements for diabetes and being labeled a diabetic, people with diabetes are more interested in how they can live their lives without their ailment becoming a burdensome intrusion.  

Or consider the limitations of disease-specific measures for people with multiple conditions. That same person with diabetes may have an entirely different perspective about what is important to their health if they suffer a heart attack or learn they have cancer.  Clinical measures developed for one disease do a rather poor job of capturing the impact of multiple diseases on the way a person functions.  

Perhaps it is time to critically reassess our measurement strategies, especially when it comes to trying to understand the various dimensions of health. Rather than try to collect and report dozens of measures that are disease-specific and then struggle to explain the problems with their interpretation, it is time for us to be more purposeful and parsimonious in our measurement activities.

We should start with a basic approach to measurement of health that includes four dimensions for all patient-reported outcomes:

1.    role functioning
2.    physical health
3.    mental health
4.    pain

This approach would force us to reframe our perspective from health care to health.  

Douglas L. Wood, M.D., is medical director for the Mayo Clinic’s Center for Innovation. He is also a consultant on cardiovascular diseases and chair of the MMA’s board of trustees.
Comments (8)Number of views (1468)

Author: Mary Canada

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8 comments on article "Measuring the right things"

Donald Kammerer

11/3/2014 5:16 PM

I completely agree. Nicely put.


Neil Shah

11/4/2014 9:13 AM

Excellent perspective. We should also make sure that instead of constantly adding measurements, we also remove measurements that have shown no value. For example, if a given intervention, like measuring a PHQ-9 on all patients, fails to improve meaningful endpoints like hospitalization for depressive illnesses or suicide rates then we should question the time and expense of continuing to obtain that data. We measure to improve things, not simply as an end unto itself.


Keith

11/4/2014 11:22 AM

SF-36 or other functional measure could be used. Also goals of care should be PATIENT centered and agreed upon rather than "best medical practice" as the only metric to consider


joe bocklage

11/4/2014 6:11 PM

This is the most thoughtful response to the issue that I have read. This opinion should be championed by the MMA and all other medical organizations.

Joe Bocklage


Steve Mattson

11/5/2014 11:01 PM

Great perspective. We clearly need a more "balanced" approach to measurement and reporting, including both process measures of adherence to best clinical practices (to the extent they exist) and patient-reported measure of their own health, the most meaningful of all outcomes measures.


Dean Myers

11/6/2014 10:17 AM

Finally, common sense may be returning in the approach to patient care. Measuring discrete parameters for separate conditions does not work well to promote health in patients with multiple chronic disease. It has been especially onerous with our compensation tied to these results. Wonderfully stated and should be the framework for a a new model of care.


David Power

11/20/2014 9:55 PM

I too appreciate this common sense perspective. If we are to practice patient-centered medicine, we need to work entirely around what health goals the patient is willing to set. If the patient wishes to make informed, unhealthy choices, I believe we need to enthusiastically work with that. With this approach, there will always be a 'cap' on the % of desirable outcomes that can ever realistically be acheived - beyond coercing our patients.

As many medical students have shared with me, improvement is not a categorical 'all / none' variable but is better measured on a continuous scale where moving from an A1C of 10.0 to 8.5 should be congratulated - and rewarded - even when it is does not reach ideal goals.


Richard Morris, M.D.

11/24/2014 10:55 AM

Thanks, Dr. Wood, for trying to bring some rational perspective to this onerous measurement process. I have extensive experience with the asthma measure designed by MNCM, and to their credit, I was able to convince the measurement review committee to change something that was unscientific. I agree with how you frame your recommendation to streamline the measurements to four domains of importance to the only people that count, the patients. Physicians shouldn't let measurement be an end in itself; the real end game is to ensure patient outcomes and satisfaction. I'm told that primary care practices have to comply with about fourteen separate measurements, when your four would accomplish more. Many advocates of the measurement industry (including the Dept of Health) defend the current plethora by saying "measurement is in its infancy". Insurance companies provide much, or most, of the financial support for MNCM, and they have a vested interest in penalizing a percentage of physicians so they can save money. In any other business environment that would be called a conflict of interest. MMA, of which you are the Board Chair, has also supported MNCM. MMA needs to re-think just what it wants MNCM to be and what it will support. Thank you for putting the patient first in your proposal.

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