Quality of care by a hypertension expert: a cautionary tale for pay-for-performance approaches

Pay-for-performance programs may be widely implemented, but gaps remain in our understanding of the implementation of performance measurement approaches.

To compare 3 approaches to hypertension quality measurement as applied to high-quality care delivered by a hypertension expert.

Care of 23 patients treated by a single hypertension expert was assessed by 3 measurement approaches: (1) outcome, (2) a multicomponent process, and (3) "outcome-linked" process. Exemplary case studies were identified to illustrate additional challenges to applying the approaches.

Forty-four percent of patients (n = 10) had complete concordance between the outcome and outcome-linked process approaches, 22% of patients (n = 5) had complete concordance between the outcome and multicomponent process approaches, 52% of patients (n = 12) had complete concordance between outcome-linked process and multicomponent process approaches, and 22% of patients (n = 5) had uniform agreement among all 3 approaches. Case studies revealed numerous opportunities for misinterpretation or gaming by providers.

Currently available measurement approaches resulted in a varied assessment of provider performance under optimal hypertension care conditions suggesting that caution is required before their use for provider compensation.