In Reply: Dr Loeb and Ms Foster suggest that well-constructed evidence-based sets of process measures and outcome measures should both be used in conjunction to achieve better care. They also state that process measures are not intended to be static and should be revised as the science evolves. We support both of these stances. However, as our Commentary noted, 3 of the 4 process measures from the Centers for Medicare & Medicaid Services and The Joint Commission were based on expert opinion alone, and these 4 measures remained essentially static for the past 13 years, despite the major evolution in heart failure clinical trials and guidelines. As an example, the beneficial role of discharge β-blocker therapy in eligible patients with systolic dysfunction has been supported by several randomized trials and community-based studies1 yet still has not been included in the core process measure set. Thus, while we concur that process measures have a vital role in performance evaluation, should be based on evidence, and need to be revised as the science evolves, we suggest that the system of developing and selecting performance measures may also benefit from process improvement.
Fonarow GC, Peterson ED. Process Measures, Outcome Measures, and Heart Failure—Reply. JAMA. 2010;303(1):35–36. doi:10.1001/jama.2009.1938
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