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Table 1.  
Process Measures Endorsed by the National Quality Forum (NQF) Listed by Institute of Medicine (IOM) Category and Population to Which Each Measure Applies
Process Measures Endorsed by the National Quality Forum (NQF) Listed by Institute of Medicine (IOM) Category and Population to Which Each Measure Applies
Table 2.  
Most Common Signs and Symptoms for Which Patients Seek Care in Hospital-Affiliated Outpatient and Emergency Department Settingsa
Most Common Signs and Symptoms for Which Patients Seek Care in Hospital-Affiliated Outpatient and Emergency Department Settingsa
1.
Goitein  L.  The argument against reimbursing physicians for value. JAMA Intern Med. 2014;174(6):845-846.
PubMedArticle
2.
Institute of Medicine. Development of Methodology for Evaluation of Neighborhood Health Centers. Washington, DC: National Academy of Sciences; 1972.
3.
National Quality Forum. Providing a road map for better care.http://www.qualityforum.org/Home.aspx. Accessed June 16, 2014.
4.
US Centers for Disease Control and Prevention. Table 7: Twenty leading principal reasons for outpatient department visits: United States, 2010.http://www.cdc.gov/nchs/data/ahcd/nhamcs_outpatient/2010_opd_web_tables.pdf. Accessed August 4, 2014.
5.
US Centers for Disease Control and Prevention. Table 10: Ten leading principal reasons for emergency department visits, by patient age and sex: United States, 2010.http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf. Accessed August 4, 2014.
Research Letter
February 3, 2015

Quality Measures Based on Presenting Signs and Symptoms of Patients

Author Affiliations
  • 1Veterans Affairs/Robert Wood Johnson Clinical Scholars Program, University of California, Los Angeles
  • 2RAND Corporation, Boston, Massachusetts
  • 3Department of Medicine, University of California, Los Angeles
  • 4Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
JAMA. 2015;313(5):520-522. doi:10.1001/jama.2014.17550

Health care reform efforts, such as accountable care organizations, focus on improving value partly through controlling use of services, including diagnostic tests. Some have expressed concern that these efforts may result in delayed diagnosis and subsequent patient harm.1 Publicly reported quality measures that evaluate care provided prior to arriving at a diagnosis could prevent financial incentives from producing harm.

The Institute of Medicine (IOM) previously developed a conceptual framework for categorizing process quality measures.2 The IOM framework includes criteria related to prevention, screening, evaluation/diagnosis, management, and follow-up.2

The National Quality Forum (NQF) currently serves as the consensus-based quality-measure–endorsement entity called for in the Affordable Care Act. Measures are submitted to the NQF by professional societies, government agencies, health systems, nonprofit organizations, and industry. Multistakeholder expert committees assess proposed measures using specific evaluation criteria. Endorsed measures are often adopted by the Centers for Medicare & Medicaid Services in payment and public reporting programs.3

We determined how NQF-endorsed process measures match the entire IOM framework and concentrated on quality measures that evaluate the prediagnostic care of patients presenting with signs or symptoms. We then compared these sign/symptom-based quality measures with the most common reasons people seek care.

Methods

Based on predefined criteria (eAppendix in the Supplement), 3 of the authors categorized each NQF-endorsed process measure into 1 of the 5 IOM groups. We then subclassified the evaluation/diagnosis- and management-related measures by their NQF-designated denominator and numerator. The NQF denominator indicates the characteristic or population to which the quality measure applies. We grouped denominator statements by sign/symptom (eg, chest pain), established diagnosis (eg, diabetes), procedure (eg, coronary artery bypass grafting), medication (eg, lithium), diagnostic test (eg, carotid imaging study), or other. The numerator is the action taken by a clinician. We grouped numerator statements into use of in vitro diagnostics (IVD), which include blood, urine, and pathology tests; medical imaging; or other, which most often described a treatment (Table 1). We used 2010 National (Hospital) Ambulatory Medical Care Survey data to compare the sign/symptom-based measures with the most common reasons people seek care.4,5

Results

Of 372 process quality measures listed on the NQF website as of June 4, 2014, 360 were coded into a unique IOM category, 11 into 2 categories, and 1 into 3 categories, resulting in 385 codings. Approximately two-thirds (n = 267) targeted disease management and 12% (n = 46) targeted evaluation/diagnosis. The remaining were evenly distributed among prevention, screening, and follow-up.

Of 313 measures pertaining to evaluation/diagnosis or management, 211 (67%) began with an established diagnosis, whereas 14 (4.5%) started with a sign/symptom. The sign/symptom-based measures focused on geriatric care (eg, memory loss, falls, urine leakage) or emergency department care (eg, chest pain). In contrast, many common reasons for which patients seek care, including fever, cough, headache, shortness of breath, earache, rash, and throat symptoms, were not reflected by the quality measures (Table 2).4,5 The performance of an IVD or medical imaging study was the action required by 59 of 313 (19%) endorsed quality measures; many others required actions related to medication prescribing.

Discussion

Existing NQF-endorsed process measures focus predominantly on management of patients with established diagnoses. The prediagnostic care of patients is rarely assessed, and the 14 sign/symptom-based measures infrequently reflect the most common reasons patients seek care.

Even though we used defined coding criteria, our work is limited by subjective categorization of the measures and our focus on process measures as opposed to outcome measures. Nevertheless, we believe that using a comprehensive set of endorsed sign/symptom-based measures could help patients receive timely care as payment models are changed and may prevent financial incentives from resulting in underuse of necessary care. Efforts to develop valid sign/symptom-based quality measures will be challenging; however, as cost pressures increase, they may be necessary to maintain and improve the accuracy of patient diagnosis upon which all subsequent care depends.

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Article Information
Section Editor: Jody W. Zylke, MD, Deputy Editor.

Corresponding Author: Hemal K. Kanzaria, MD, MSHPM, Veterans Affairs/Robert Wood Johnson Clinical Scholars Program, University of California, Los Angeles, 10940 Wilshire Blvd, Los Angeles, CA 90024 (hkanzaria@mednet.ucla.edu).

Author Contributions: Dr Kanzaria had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. All authors reviewed the National Quality Forum categorization.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Kanzaria.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: All authors.

Administrative, technical, or material support: All authors.

Study supervision: Mattke, Brook.

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: This work was supported by the Robert Wood Johnson Clinical Scholars program, the US Department of Veterans Affairs, grant T32-HP-19001 (UCLA Institutional National Research Service Award) from the Health Resources and Services Administration, and funding from the RAND Corporation.

Role of the Funder/Sponsor: The funders/sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We are grateful to Mary Vaiana, PhD (RAND Corporation), for her careful review of an earlier draft of this manuscript, for which she received compensation.

References
1.
Goitein  L.  The argument against reimbursing physicians for value. JAMA Intern Med. 2014;174(6):845-846.
PubMedArticle
2.
Institute of Medicine. Development of Methodology for Evaluation of Neighborhood Health Centers. Washington, DC: National Academy of Sciences; 1972.
3.
National Quality Forum. Providing a road map for better care.http://www.qualityforum.org/Home.aspx. Accessed June 16, 2014.
4.
US Centers for Disease Control and Prevention. Table 7: Twenty leading principal reasons for outpatient department visits: United States, 2010.http://www.cdc.gov/nchs/data/ahcd/nhamcs_outpatient/2010_opd_web_tables.pdf. Accessed August 4, 2014.
5.
US Centers for Disease Control and Prevention. Table 10: Ten leading principal reasons for emergency department visits, by patient age and sex: United States, 2010.http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf. Accessed August 4, 2014.
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