Werner Rachel M, Greenfield Sheldon, Fung Constance, Turner Barbara J
Center for Health Equity Research and Promotion, Philadelphia VAMC, Philadelphia, PA, USA.
J Gen Intern Med. 2007 Aug;22(8):1206-11. doi: 10.1007/s11606-007-0230-4. Epub 2007 May 22.
Performance measurement has been widely advocated as a means to improve health care delivery and, ultimately, clinical outcomes. However, the evidence supporting the value of using the same quality measures designed for patients with a single clinical condition in patients with multiple conditions is weak. If clinically complex patients, defined here as patients with multiple clinical conditions, present greater challenges to achieving quality goals, providers may shun them or ignore important, but unmeasured, clinical issues. This paper summarizes the proceedings of a conference addressing the challenge of measuring quality of care in the patient with multiple clinical conditions with the goal of informing the implementation of quality measurement systems and future research programs on this topic. The conference had three main areas of discussion. First, the potential problems caused by applying current quality standards to patients with multiple conditions were examined. Second, the advantages and disadvantages of three strategies to improve quality measurement in clinically complex patients were evaluated: excluding certain clinically complex patients from a given standard, relaxing the performance target, and assigning a greater weight to some measures based on the expected clinical benefit or difficulty of reaching the performance target. Third, the strengths and weaknesses of potential novel measures such change in functional status were considered. The group concurred that, because clinically complex patients present a threat to the implementation of quality measures, high priority must be assigned to a research agenda on this topic. This research should evaluate the impact of quality measurement on these patients and expand the range of quality measures relevant to the care of clinically complex patients.
绩效评估已被广泛倡导为改善医疗服务提供并最终改善临床结果的一种手段。然而，支持将针对单一临床病症患者设计的相同质量指标用于患有多种病症患者的价值的证据并不充分。如果临床上复杂的患者（此处定义为患有多种临床病症的患者）对实现质量目标带来更大挑战，那么医疗服务提供者可能会回避这类患者或忽视重要但未被衡量的临床问题。本文总结了一次会议的议程，该会议探讨了衡量患有多种临床病症患者的医疗质量所面临的挑战，目的是为质量评估系统的实施及关于该主题的未来研究项目提供信息。会议有三个主要讨论领域。首先，研究了将当前质量标准应用于患有多种病症患者所导致的潜在问题。其次，评估了三种改善对临床上复杂患者质量评估策略的优缺点：将某些临床上复杂的患者排除在特定标准之外、放宽绩效目标，以及根据预期临床效益或达到绩效目标的难度对某些指标赋予更大权重。第三，考虑了潜在新指标（如功能状态变化）的优缺点。与会人员一致认为，由于临床上复杂的患者对质量指标的实施构成威胁，必须高度优先安排关于该主题的研究议程。这项研究应评估质量评估对这些患者的影响，并扩大与临床上复杂患者护理相关的质量指标范围。
