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Gustavson AM, Hagedorn HJ, Jesser LE, Kenny ME, Clothier BA, Bounthavong M, Ackland PE, Gordon AJ, Harris AHS. Healthcare quality measures in implementation research: advantages, risks and lessons learned. Health Res Policy Syst 2022; 20:131. [PMID: 36476309 PMCID: PMC9730563 DOI: 10.1186/s12961-022-00934-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 11/08/2022] [Indexed: 12/12/2022] Open
Abstract
Implementation studies evaluate strategies to move evidence-based practices into routine clinical practice. Often, implementation scientists use healthcare quality measures to evaluate the integration of an evidence-based clinical practice into real-world healthcare settings. Healthcare quality measures have standardized definitions and are a method to operationalize and monitor guideline-congruent care. Implementation scientists can access existing data on healthcare quality measures through various sources (e.g. operations-calculated), or they can calculate the measures directly from healthcare claims and administrative data (i.e. researcher-calculated). Implementation scientists need a better understanding of the advantages and disadvantages of these methods of obtaining healthcare quality data for designing, planning and executing an implementation study. The purpose of this paper is to describe the advantages, risks and lessons learned when using operations- versus researcher-calculated healthcare quality measures in site selection, implementation monitoring and implementation outcome evaluation. A key lesson learned was that relying solely on operations-calculated healthcare quality measures during an implementation study poses risks to site selection, accurate feedback on implementation progress to stakeholders, and the integrity of study results. A possible solution is using operations-calculated quality measures for monitoring of evidence-based practice uptake and researcher-calculated measures for site section and outcomes evaluation. This approach provides researchers greater control over the data and consistency of the measurement from site selection to outcomes evaluation while still retaining measures that are familiar and understood by key stakeholders whom implementation scientists need to engage in practice change efforts.
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Affiliation(s)
- Allison M. Gustavson
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System, 1 Veterans Drive, Mail Code#152, Minneapolis, MN 55417 USA
- Department of Medicine, University of Minnesota, Minneapolis, USA
| | - Hildi J. Hagedorn
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System, 1 Veterans Drive, Mail Code#152, Minneapolis, MN 55417 USA
- Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, MN 55455 USA
| | - Leah E. Jesser
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System, 1 Veterans Drive, Mail Code#152, Minneapolis, MN 55417 USA
| | - Marie E. Kenny
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System, 1 Veterans Drive, Mail Code#152, Minneapolis, MN 55417 USA
| | - Barbara A. Clothier
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System, 1 Veterans Drive, Mail Code#152, Minneapolis, MN 55417 USA
| | - Mark Bounthavong
- Health Economics Resource Center, VA Palo Alto Healthcare System, Palo Alto, CA 94025 USA
| | - Princess E. Ackland
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System, 1 Veterans Drive, Mail Code#152, Minneapolis, MN 55417 USA
- Department of Medicine, University of Minnesota, Minneapolis, USA
| | - Adam J. Gordon
- Vulnerable Veteran Innovative PACT (VIP) Initiative; Informatics, Decision-Enhancement, and Analytic Sciences Center (IDEAS), Salt Lake City Veterans Healthcare System, 500 Foothill Drive, Salt Lake City, UT 84148 USA
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), University of Utah School of Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84148 USA
| | - Alex H. S. Harris
- Center for Innovation to Implementation, Palo Alto Veteran Affairs Healthcare System, Palo Alto, CA 94025 USA
- Department of Surgery, Stanford University School of Medicine, Stanford, CA 94305 USA
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Li X, Evans JM. Incentivizing performance in health care: a rapid review, typology and qualitative study of unintended consequences. BMC Health Serv Res 2022; 22:690. [PMID: 35606747 PMCID: PMC9128153 DOI: 10.1186/s12913-022-08032-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 05/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Health systems are increasingly implementing policy-driven programs to incentivize performance using contracts, scorecards, rankings, rewards, and penalties. Studies of these "Performance Management" (PM) programs have identified unintended negative consequences. However, no single comprehensive typology of the negative and positive unintended consequences of PM in healthcare exists and most studies of unintended consequences were conducted in England or the United States. The aims of this study were: (1) To develop a comprehensive typology of unintended consequences of PM in healthcare, and (2) To describe multiple stakeholder perspectives of the unintended consequences of PM in cancer and renal care in Ontario, Canada. METHODS We conducted a rapid review of unintended consequences of PM in healthcare (n = 41 papers) to develop a typology of unintended consequences. We then conducted a secondary analysis of data from a qualitative study involving semi-structured interviews with 147 participants involved with or impacted by a PM system used to oversee 40 care delivery networks in Ontario, Canada. Participants included administrators and clinical leads from the networks and the government agency managing the PM system. We undertook a hybrid inductive and deductive coding approach using the typology we developed from the rapid review. RESULTS We present a comprehensive typology of 48 negative and positive unintended consequences of PM in healthcare, including five novel unintended consequences not previously identified or well-described in the literature. The typology is organized into two broad categories: unintended consequences on (1) organizations and providers and on (2) patients and patient care. The most common unintended consequences of PM identified in the literature were measure fixation, tunnel vision, and misrepresentation or gaming, while those most prominent in the qualitative data were administrative burden, insensitivity, reduced morale, and systemic dysfunction. We also found that unintended consequences of PM are often mutually reinforcing. CONCLUSIONS Our comprehensive typology provides a common language for discourse on unintended consequences and supports systematic, comparable analyses of unintended consequences across PM regimes and healthcare systems. Healthcare policymakers and managers can use the results of this study to inform the (re-)design and implementation of evidence-informed PM programs.
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Affiliation(s)
- Xinyu Li
- Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Jenna M Evans
- DeGroote School of Business, McMaster University, 1280 Main Street West, Hamilton, ON, L8S4M4, Canada.
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Adams RS, Garnick DW, Harris AHS, Merrick EL, Hofmann K, Funk W, Williams TV, Larson MJ. Assessing the postdeployment quality of treatment for substance use disorders among Army enlisted soldiers in the Military Health System. J Subst Abuse Treat 2020; 114:108026. [PMID: 32527513 DOI: 10.1016/j.jsat.2020.108026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 04/07/2020] [Accepted: 05/01/2020] [Indexed: 01/23/2023]
Abstract
Little is known about the rates and predictors of substance use treatment received in the Military Health System among Army soldiers diagnosed with a postdeployment substance use disorder (SUD). We used data from the Substance Use and Psychological Injury Combat study to determine the proportion of active duty (n = 338,708) and National Guard/Reserve (n = 178,801) enlisted soldiers returning from an Afghanistan/Iraq deployment in fiscal years 2008 to 2011 who had an SUD diagnosis in the first 150 days postdeployment. Among soldiers diagnosed with an SUD, we examined the rates and predictors of substance use treatment initiation and engagement according to the Healthcare Effectiveness Data and Information Set criteria. In the first 150 days postdeployment 3.3% of active duty soldiers and 1.0% of National Guard/Reserve soldiers were diagnosed with an SUD. Active duty soldiers were more likely to initiate and engage in substance use treatment than National Guard/Reserve soldiers, yet overall, engagement rates were low (25.0% and 15.7%, respectively). Soldiers were more likely to engage in treatment if they received their index diagnosis in a specialty behavioral health setting. Efforts to improve substance use treatment in the Military Health System should include initiatives to more accurately identify soldiers with undiagnosed SUD. Suggestions to improve substance use treatment engagement in the Military Health System will be discussed.
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Affiliation(s)
- Rachel Sayko Adams
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA, USA; Veterans Health Administration, Rocky Mountain Mental Illness Research Education and Clinical Center, 1700 N. Wheeling Street, Aurora, CO 80045, USA.
| | - Deborah W Garnick
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA, USA.
| | - Alex H S Harris
- VA Health Services Research & Development, Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025, USA; Department of Surgery, Stanford University, 291 Campus Drive, Stanford, CA 94305, USA.
| | - Elizabeth L Merrick
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA, USA.
| | - Keith Hofmann
- Kennell and Associates, Inc., 3130 Fairview Park Drive, Suite 450, Falls Church, VA 22042, USA.
| | - Wendy Funk
- Kennell and Associates, Inc., 3130 Fairview Park Drive, Suite 450, Falls Church, VA 22042, USA.
| | - Thomas V Williams
- NORC at the University of Chicago, 4350 E W Highway, Bethesda, MD 20814, USA.
| | - Mary Jo Larson
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA, USA.
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Hysong SJ, Francis J, Petersen LA. Motivating and engaging frontline providers in measuring and improving team clinical performance. BMJ Qual Saf 2019; 28:405-411. [PMID: 30824492 DOI: 10.1136/bmjqs-2018-008856] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 01/20/2019] [Accepted: 01/23/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Sylvia J Hysong
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, Texas, USA .,Medicine-Health Services Research Section, Baylor College of Medicine, Houston, Texas, USA
| | - Joseph Francis
- Office of Organizational Excellence, U.S. Department of Veterans Affairs, Washington, District of Columbia, USA
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Finlay AK, Binswanger IA, Timko C, Smelson D, Stimmel MA, Yu M, Bowe T, Harris AHS. Facility-level changes in receipt of pharmacotherapy for opioid use disorder: Implications for implementation science. J Subst Abuse Treat 2018; 95:43-47. [PMID: 30352669 PMCID: PMC6209329 DOI: 10.1016/j.jsat.2018.09.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 09/03/2018] [Accepted: 09/27/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The U.S. is facing an opioid epidemic, but despite mandates for pharmacotherapy for opioid use disorder to be available at Veterans Health Administration (VHA) facilities, the majority of veterans with opioid use disorder do not receive these medications. In implementation research, facilities are often targeted for qualitative inquiry or quality improvement efforts based on quality measure performance during a one-year period. However, sites that experience quality performance changes from one year to the next may be highly informative because mechanisms that impact facility change may be more discoverable. The current study examined changes in receipt of pharmacotherapy for opioid use disorder in a national healthcare system to determine the extent to which sites fluctuated in performance over a two-year period and illustrate how changes in quality measures over time may be useful for implementation research and healthcare surveillance of quality measures. METHODS Using national VHA data from Fiscal Years (FY) 2016 and 2017, we calculated quality measure performance as the number of patients who received pharmacotherapy for opioid use disorder (i.e., methadone, buprenorphine, and naltrexone) divided by the number of patients with a current non-remitted opioid use disorder diagnosis for each FY at each facility (n = 129) and examined change from FY16 to FY17. RESULTS The mean rate of receipt of pharmacotherapy for opioid use disorder was 38% (facility range = 3% to 74%) in FY16 and 41% (facility range = 2% to 76%) in FY17. The average facility-level change in performance was 3% and ranged from -19% to 26%. There were 32 facilities that decreased in provision of pharmacotherapy, 12 facilities with no change, and 85 facilities that increased. CONCLUSIONS For facilities with average or high performance, it was difficult to maintain their performance over time. Identifying and learning from facilities with recent fluctuations may be more informative to guide the design of future quality improvement efforts than studying facilities with stable high or low performance.
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Affiliation(s)
- Andrea K Finlay
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA; National Center on Homelessness Among Veterans, U.S. Department of Veterans Affairs, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA.
| | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO 80237-8066, USA; Division of General Internal Medicine, University of Colorado School of Medicine 12631 E. 17(th) Ave., Academic Office One, Campus Box B180, Aurora, CO 80045, USA.
| | - Christine Timko
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA; Department of Psychiatry and Behavioral Medicine, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305, USA.
| | - David Smelson
- Center for Organization and Implementation Science, Edith Nourse Rogers VA Medical Center, 200 Springs, Bedford, MA 01730, USA.
| | - Matthew A Stimmel
- Veterans Justice Outreach Program, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA.
| | - Mengfei Yu
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA.
| | - Tom Bowe
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA.
| | - Alex H S Harris
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA; Department of Surgery, Stanford University School of Medicine, Alway Building, Room M121, 300 Pasteur Drive, Stanford, CA 94305-2200, USA.
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Kondo KK, Wyse J, Mendelson A, Beard G, Freeman M, Low A, Kansagara D. Pay-for-Performance and Veteran Care in the VHA and the Community: a Systematic Review. J Gen Intern Med 2018; 33:1155-1166. [PMID: 29700789 PMCID: PMC6025676 DOI: 10.1007/s11606-018-4444-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/09/2018] [Accepted: 04/10/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Although pay-for-performance (P4P) strategies have been used by the Veterans Health Administration (VHA) for over a decade, the long-term benefits of P4P are unclear. The use of P4P is further complicated by the increased use of non-VHA healthcare providers as part of the Veterans Choice Program. We conducted a systematic review and key informant interviews to better understand the effectiveness and potential unintended consequences of P4P, as well as the implementation factors and design features important in both VHA and non-VHA/community settings. METHODS We searched PubMed, PsycINFO, and CINAHL through March 2017 and reviewed reference lists. We included trials and observational studies of P4P targeting Veteran health. Two investigators abstracted data and assessed study quality. We interviewed VHA stakeholders to gain further insight. RESULTS The literature search yielded 1031 titles and abstracts, of which 30 studies met pre-specified inclusion criteria. Twenty-five examined P4P in VHA settings and 5 in community settings. There was no strong evidence supporting the effectiveness of P4P in VHA settings. Interviews with 17 key informants were consistent with studies that identified the potential for overtreatment associated with performance metrics in the VHA. Key informants' views on P4P in community settings included the need to develop relationships with providers and health systems with records of strong performance, to improve coordination by targeting documentation and data sharing processes, and to troubleshoot the limited impact of P4P among practices where Veterans make up a small fraction of the patient population. DISCUSSION The evidence to support the effectiveness of P4P on Veteran health is limited. Key informants recognize the potential for unintended consequences, such as overtreatment in VHA settings, and suggest that implementation of P4P in the community focus on relationship building and target areas such as documentation and coordination of care.
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Affiliation(s)
- Karli K Kondo
- Portland VA Health Care System, Evidence-based Synthesis Program, Portland, OR, USA.
- Oregon Health and Science University, Portland, OR, USA.
| | - Jessica Wyse
- Portland VA Health Care System, Evidence-based Synthesis Program, Portland, OR, USA
| | | | - Gabriella Beard
- Portland VA Health Care System, Evidence-based Synthesis Program, Portland, OR, USA
| | - Michele Freeman
- Portland VA Health Care System, Evidence-based Synthesis Program, Portland, OR, USA
| | - Allison Low
- Portland VA Health Care System, Evidence-based Synthesis Program, Portland, OR, USA
| | - Devan Kansagara
- Portland VA Health Care System, Evidence-based Synthesis Program, Portland, OR, USA
- Oregon Health and Science University, Portland, OR, USA
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Ford JH, Abraham AJ, Lupulescu-Mann N, Croff R, Hoffman KA, Alanis-Hirsch K, Chalk M, Schmidt L, McCarty D. Promoting Adoption of Medication for Opioid and Alcohol Use Disorders Through System Change. J Stud Alcohol Drugs 2018; 78:735-744. [PMID: 28930061 DOI: 10.15288/jsad.2017.78.735] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The Medication Research Partnership (MRP), a collaboration between a national commercial health plan and nine addiction treatment centers, implemented organizational and system changes to promote use of federally approved medications for treatment of alcohol and opioid use disorders. METHOD A difference-in-differences analysis examined change over time in the percentage of patients receiving a prescription medication for alcohol or opioid use disorders treated in MRP (n = 9) and comparison (n = 15) sites. RESULTS MRP clinics experienced a 2.4-fold increase in patients receiving an alcohol or opioid prescription (13.2% at baseline to 31.7% at 3 years after MRP initiation); comparison clinics experienced significantly less change (17.6% to 23.5%) with an adjusted difference-in-differences of 12.5% (95% CI [5.4, 19.6], p = .001). MRP sites increased the patients with prescriptions to treat opioid use disorder from 17.0% (baseline) to 36.8% (3 years after initiation), with smaller changes observed in comparison sites (23.2% to 24.0%) and a 3-year post-initiation adjusted difference-in-differences of 19% (95% CI [8.5, 29.5], p = .000). Medications for alcohol use disorders increased in both MRP (9.0% to 26.5%) and comparison sites (11.4% to 23.1%). CONCLUSIONS Promoting the use of medications to support recovery required complex interventions. The Advancing Recovery System Change Model, initially developed in publicly funded systems of care, was successfully adapted for commercial sector use. The model provides a framework for providers and commercial health plans to collaborate and increase patient access to medications.
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Affiliation(s)
- James H Ford
- Center for Health Systems Research and Analysis, University of Wisconsin-Madison, Madison, Wisconsin
| | - Amanda J Abraham
- Department of Public Administration and Policy, School of Public and International Affairs, University of Georgia, Athens, Georgia
| | - Nicoleta Lupulescu-Mann
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon
| | - Raina Croff
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, Oregon
| | - Kim A Hoffman
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, Oregon
| | | | | | - Laura Schmidt
- School of Medicine, University of California at San Francisco, San Francisco, California
| | - Dennis McCarty
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, Oregon
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Rubinsky AD, Ellerbe LS, Gupta S, Phelps TE, Bowe T, Burden JL, Harris AHS. Outpatient continuing care after residential substance use disorder treatment in the US Veterans Health Administration: Facilitators and challenges. Subst Abus 2017; 39:322-330. [DOI: 10.1080/08897077.2017.1391923] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Anna D. Rubinsky
- Kidney Health Research Collaborative, University of California, San Francisco, San Francisco, California, USA
- Department of Veterans Affairs San Francisco Health Care System, San Francisco, California, USA
| | - Laura S. Ellerbe
- Center for Innovation to Implementation, Department of Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA
| | - Shalini Gupta
- Center for Innovation to Implementation, Department of Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA
| | - Tyler E. Phelps
- Center for Innovation to Implementation, Department of Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA
| | - Thomas Bowe
- Center for Innovation to Implementation, Department of Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA
| | - Jennifer L. Burden
- Department of Veterans Affairs, Veterans Health Administration, Washington, DC, USA
| | - Alex H. S. Harris
- Center for Innovation to Implementation, Department of Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA
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Hemmat S, Schillinger D, Lyles C, Ackerman S, Gourley G, Vittinghoff E, Handley M, Sarkar U. Performance Measurement and Target-Setting in California's Safety Net Health Systems. Am J Med Qual 2017; 33:132-139. [PMID: 28555507 DOI: 10.1177/1062860617708393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Health policies encourage implementing quality measurement with performance targets. The 2010-2015 California Medicaid waiver mandated quality measurement and reporting. In 2013, California safety net hospitals participating in the waiver set a voluntary performance target (the 90th percentile for Medicare preferred provider organization plans) for mammography screening and cholesterol control in diabetes. They did not reach the target, and the difference-in-differences analysis suggested that there was no difference for mammography ( P = .39) and low-density lipoprotein control ( P = .11) performance compared to measures for which no statewide quality improvement initiative existed. California's Medicaid waiver was associated with improved performance on a number of metrics, but this performance was not attributable to target setting on specific health conditions. Performance may have improved because of secular trends or systems improvements related to waiver funding. Relying on condition-specific targets to measure performance may underestimate improvements and disadvantage certain health systems. Achieving ambitious targets likely requires sustained fiscal, management, and workforce investments.
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Affiliation(s)
- Shirin Hemmat
- 1 University of California, San Francisco, San Francisco, CA
| | | | - Courtney Lyles
- 1 University of California, San Francisco, San Francisco, CA
| | - Sara Ackerman
- 1 University of California, San Francisco, San Francisco, CA
| | - Gato Gourley
- 1 University of California, San Francisco, San Francisco, CA
| | | | | | - Urmimala Sarkar
- 1 University of California, San Francisco, San Francisco, CA
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Affiliation(s)
- David Atkins
- Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs, 810 Vermont Ave., NW (10P9H), Washington, DC, 20420, USA.
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