Braithwaite R Scott, Caplan Arthur
Division of Comparative Effectiveness and Decision Science, Department of Population Health, School of Medicine, New York University, New York, NY, USA.
Division of Bioethics, Department of Population Health, School of Medicine, New York University, New York, NY, USA.
SAGE Open Med. 2014 Feb 18;2:2050312114523425. doi: 10.1177/2050312114523425. eCollection 2014.
Quality reporting is increasingly used as a tool to encourage health systems, hospitals, and their practitioners to deliver the greatest health benefit. However, quality reporting systems may have unintended negative consequences, such as inadvertently encouraging "cherry-picking" by inadequately adjusting for patients who are challenging to take care of, or underpowering to reliably detect meaningful differences in care. There have been no reports seeking to identify a minimum level of accuracy that ought to be viewed as a prerequisite for quality reporting.
Using a decision analytic model, we seek to delineate minimal standards for quality measures to meet, using the simplest assumptions to illustrate what those standards may be.
We find that even under assumptions regarding optimal performance of the quality reporting system (sensitivity and specificity of 1), we can identify a minimal level of accuracy required for the quality reporting system to "do no harm": the increase in health-related quality of life from a higher rather than lower quality practitioner must be greater than the number of practitioners per patient divided by the proportion of patients willing to switch from a lower to a higher quality provider.
Quality measurement systems that have not been demonstrated to improve health outcomes should be held to a specific standard of measurement accuracy.
质量报告越来越多地被用作一种工具，以鼓励卫生系统、医院及其从业者提供最大的健康效益。然而，质量报告系统可能会产生意想不到的负面后果，例如因对难以护理的患者调整不足而无意中鼓励“挑肥拣瘦”，或者因检测能力不足而无法可靠地发现护理方面有意义的差异。目前尚无报告试图确定应被视为质量报告先决条件的最低准确性水平。
我们使用决策分析模型，试图通过最简单的假设来阐述质量指标应达到的最低标准，以说明这些标准可能是什么。
我们发现，即使在质量报告系统最佳性能的假设下（敏感度和特异度均为1），我们也能确定质量报告系统“不造成伤害”所需的最低准确性水平：高质量而非低质量从业者带来的健康相关生活质量的提高必须大于每位患者的从业者数量除以愿意从低质量提供者转向高质量提供者的患者比例。
尚未证明能改善健康结果的质量测量系统应符合特定的测量准确性标准。
