Pitfalls of converting practice guidelines into quality measures: lessons learned from a VA performance measure

Area of Science:

• Health Services Research
• Quality Improvement
• Clinical Practice Guidelines

Background:

• The Department of Veterans Affairs (VA) operates a large US healthcare system, with its quality measurement practices influencing national standards.
• VA quality measurement relies on adherence to evidence-based practice guidelines, with higher adherence indicating better care.
• Converting clinical guidelines into performance measures for quality assessment presents conceptual challenges.

Purpose of the Study:

• To delineate conceptual problems in converting practice guidelines into quality measures.
• To illustrate how adherence rates to guideline-based performance measures can be poor indicators of actual cancer screening quality.
• To advocate for a more balanced perspective in using performance measures to define healthcare quality.

Main Methods:

• Conceptual analysis of guideline-to-measure conversion.
• Case study analysis of colorectal cancer screening at a VA facility.
• Identification of pitfalls in performance measure design and interpretation.

Main Results:

• Performance measures may inaccurately assess quality due to unaddressed illness severity in patient populations.
• Failure to distinguish screening from diagnostic procedures can skew target screening rates.
• Ignoring patient preferences and clinician judgment in scoring performance measures can misrepresent care quality.

Conclusions:

• Adherence rates to performance measures do not always equate to quality of care, especially in colorectal cancer screening.
• Factors like patient comorbidity and preferences against screening can make non-screening a high-quality decision.
• Performance measures need more nuanced specification and interpretation to accurately reflect quality, avoiding conflation of high testing rates with good care.