Harris Alex H S, Kivlahan Daniel R, Bowe Thomas, Finney John W, Humphreys Keith
Center for Health Care Evaluation, VA Palo Alto Health Care System, Stanford University School of Medicine, Menlo Park, CA 94025, USA.
Med Care. 2009 Dec;47(12):1244-50. doi: 10.1097/MLR.0b013e3181b58882.
Health care process quality measures usually are designed by expert panels attempting to synthesize nuanced clinical evidence and subsequently operationalized using administrative data. Many quality measures are then adopted without directly validating their presumed links with outcomes. Later efforts to validate process measures often yield negative results, leaving policy makers without a defensible means of measuring quality. This article presents an alternative strategy for developing and validating process quality measures. The development of an alcohol use disorder (AUD) treatment quality measure is used as an example.
An expert panel generated a range of candidate process quality measures of AUD treatment derivable from administrative data that were then tested to determine which had the strongest associations with facility- and patient-level outcomes. Outcome and process data were from 2701 US Veterans Health Administration patients starting a new episode of care at 54 VA facilities.
Several of the candidate process-of-care quality measures predicted facility- and patient-level outcomes. Having at least 3 visits during the first month of specialty AUD treatment was correlated with improvement on the Addiction Severity Index Alcohol composite at the facility level, r = 0.41 (95% Confidence Interval 0.16-0.61), and at the patient level, r = 0.07 (CI: 0.03-0.11).
These "prevalidated" quality measures can now be judged for the extent they map onto the extant clinical literature and other design requirements. The development and validation strategy we describe should aid in efficiently producing quality measures in other areas of health care.
医疗保健过程质量衡量标准通常由专家小组制定，他们试图综合细微的临床证据，随后使用行政数据将其实施。然后，许多质量衡量标准在未直接验证其与结果的假定联系的情况下就被采用了。后来验证过程衡量标准的努力往往产生负面结果，使政策制定者没有一种合理的质量衡量方法。本文提出了一种制定和验证过程质量衡量标准的替代策略。以酒精使用障碍（AUD）治疗质量衡量标准的制定为例。
一个专家小组生成了一系列可从行政数据中得出的AUD治疗过程质量衡量标准候选指标，然后对其进行测试，以确定哪些与机构层面和患者层面的结果有最强的关联。结果和过程数据来自美国退伍军人健康管理局的2701名患者，他们在54个退伍军人事务（VA）机构开始新的治疗阶段。
几个护理过程质量衡量标准候选指标预测了机构层面和患者层面的结果。在AUD专科治疗的第一个月至少进行3次就诊，与机构层面成瘾严重程度指数酒精综合指标的改善相关，r = 0.41（95%置信区间0.16 - 0.61），在患者层面相关性为r = 0.07（置信区间：0.03 - 0.11）。
现在可以根据这些“预先验证”的质量衡量标准与现有临床文献和其他设计要求的契合程度来对其进行评判。我们描述的制定和验证策略应有助于在医疗保健的其他领域高效地制定质量衡量标准。
