The Relationship between Medicare's Process of Care Quality Measures and Mortality

By Ryan, Andrew M.; Burgess, James F., Jr. et al. | Inquiry, Fall 2009 | Go to article overview

The Relationship between Medicare's Process of Care Quality Measures and Mortality


Ryan, Andrew M., Burgess, James F., Jr., Tompkins, Christopher P., Wallack, Stanley S., Inquiry


Using Medicare inpatient claims and Hospital Compare process of care quality data from the period 2004-2006, we estimate two model specifications to test for the presence of correlational and causal relationships between hospital process of care performance measures and risk-adjusted (RA) 30-day mortality for heart attack, heart failure, and pneumonia. Our analysis indicates that while Hospital Compare process performance measures are correlated with 30-day mortality for each diagnosis, after we account for unobserved heterogeneity, process of care performance is no longer associated with mortality for any diagnosis. This suggests that the relationship between hospital-level process of care performance and mortality is not causal. Implications for pay-for-performance are discussed.

**********

Medicare spending totaled $374 billion in 2006 and is expected to grow at a rate of almost 8% over the next decade (Kaiser Family Foundation 2007). The massive outlays for Medicare and well-documented deficiencies in health care quality in the United States (Institute of Medicine [IOM] 2000, 2001; McGlynn et al. 2003) have raised pressing concerns about the value of medical care received by Medicare beneficiaries. In an attempt to address these concerns, Congress enacted legislation as part of the 2005 Deficit Reduction Act calling for hospital value-based purchasing (VBP), a combination of pay-for-performance (P4P) and public quality reporting, to be implemented for Medicare hospital care by fiscal year 2009 (U.S. Congress 2005). While this deadline was missed, a recent report by the Senate Finance Committee shows strong, continued support for VBP (U.S. Senate 2009).

A critical question is how health care quality will be assessed in VBP. Process of care performance measures, which attempt to assess whether "what is now known to be 'good' medical care has been applied" (Donabedian 1966), have been the cornerstone of Medicare's existing hospital-based P4P demonstration, the Premier Hospital Quality Incentive Demonstration (PHQID), and its public quality reporting program, Hospital Compare; they are likely to be prominent, or possibly exclusive, metrics of quality in VBP. This analysis evaluates the usefulness of process performance measures in VBP by assessing the correlational and causal associations between process of care measures and 30-day mortality, a prominent and commonly used measure of patient outcomes.

The potential relationships between hospital processes and outcomes of care may vary substantially by condition and the nature of the evidence base supporting the process measures. Since our focus is Medicare VBP, this analysis employs data that are part of the current experiments. Consequently, our study is limited to examining hospital care for acute myocardial infarction (AMI), heart failure, and pneumonia, the clinical conditions for which data are widely reported in Hospital Compare and which are part of Medicare's current pay-for-reporting program.

Background

Quality in health care is frequently defined by process, outcome, and structure measures (Donabedian 1966), with process and outcome measures being the most common. Process of care measures are often preferred to outcome measures on the grounds that providers have greater control over their performance on these measures, and that the measures offer "actionable" information for quality improvement (Birkmeyer, Kerr, and Dimick 2006; Mant 2001). However, the attribution of "quality" to performance on process of care measures is contingent on the nature of the measures. Performance on process of care measures that exhibit minimal clinical significance or a weak causal relationship with patient health will be of little value, even as effort is expended in achieving and documenting them. Absent the causal relationship between process performance and patient outcomes, process measures are compromised as a metric of individual provider improvement and as a means of selective referral to high-quality providers, since measure responsiveness by patients would not result in better outcomes. …

The rest of this article is only available to active members of Questia

Sign up now for a free, 1-day trial and receive full access to:

  • Questia's entire collection
  • Automatic bibliography creation
  • More helpful research tools like notes, citations, and highlights
  • Ad-free environment

Already a member? Log in now.

Notes for this article

Add a new note
If you are trying to select text to create highlights or citations, remember that you must now click or tap on the first word, and then click or tap on the last word.
One moment ...
Default project is now your active project.
Project items

Items saved from this article

This article has been saved
Highlights (0)
Some of your highlights are legacy items.

Highlights saved before July 30, 2012 will not be displayed on their respective source pages.

You can easily re-create the highlights by opening the book page or article, selecting the text, and clicking “Highlight.”

Citations (0)
Some of your citations are legacy items.

Any citation created before July 30, 2012 will labeled as a “Cited page.” New citations will be saved as cited passages, pages or articles.

We also added the ability to view new citations from your projects or the book or article where you created them.

Notes (0)
Bookmarks (0)

You have no saved items from this article

Project items include:
  • Saved book/article
  • Highlights
  • Quotes/citations
  • Notes
  • Bookmarks
Notes
Cite this article

Cited article

Style
Citations are available only to our active members.
Sign up now to cite pages or passages in MLA, APA and Chicago citation styles.

(Einhorn, 1992, p. 25)

(Einhorn 25)

1

1. Lois J. Einhorn, Abraham Lincoln, the Orator: Penetrating the Lincoln Legend (Westport, CT: Greenwood Press, 1992), 25, http://www.questia.com/read/27419298.

Cited article

The Relationship between Medicare's Process of Care Quality Measures and Mortality
Settings

Settings

Typeface
Text size Smaller Larger Reset View mode
Search within

Search within this article

Look up

Look up a word

  • Dictionary
  • Thesaurus
Please submit a word or phrase above.
Print this page

Print this page

Why can't I print more than one page at a time?

Full screen

matching results for page

Cited passage

Style
Citations are available only to our active members.
Sign up now to cite pages or passages in MLA, APA and Chicago citation styles.

"Portraying himself as an honest, ordinary person helped Lincoln identify with his audiences." (Einhorn, 1992, p. 25).

"Portraying himself as an honest, ordinary person helped Lincoln identify with his audiences." (Einhorn 25)

"Portraying himself as an honest, ordinary person helped Lincoln identify with his audiences."1

1. Lois J. Einhorn, Abraham Lincoln, the Orator: Penetrating the Lincoln Legend (Westport, CT: Greenwood Press, 1992), 25, http://www.questia.com/read/27419298.

Cited passage

Welcome to the new Questia Reader

The Questia Reader has been updated to provide you with an even better online reading experience.  It is now 100% Responsive, which means you can read our books and articles on any sized device you wish.  All of your favorite tools like notes, highlights, and citations are still here, but the way you select text has been updated to be easier to use, especially on touchscreen devices.  Here's how:

1. Click or tap the first word you want to select.
2. Click or tap the last word you want to select.

OK, got it!

Thanks for trying Questia!

Please continue trying out our research tools, but please note, full functionality is available only to our active members.

Your work will be lost once you leave this Web page.

For full access in an ad-free environment, sign up now for a FREE, 1-day trial.

Already a member? Log in now.