Developing indicators for the Medicare Quality Indicator System (MQIS): challenges and lessons learned

The Medicare Quality Indicator System (MQIS), initiated in 1993, was intended to form the basis for the Health Care Financing Administration's (HCFA's; Washington, DC) hospital-based quality measurement system. The MEDSTAT Group (Washington, DC) established quality indicator development methods for five clinical conditions, including early-stage breast cancer, diabetes mellitus, and upper gastrointestinal and lower intestinal bleeding.

Five national expert panels were convened to identify scientifically based hospital processes of care related to positive patient outcomes, as described in research studies and/or broadly accepted by the medical and allied health professions as indicators of high-quality care.

One of the most important lessons learned was the need for a narrow clinical focus for each quality indicator module. If the focus was adequately narrowed, all other tasks could be accomplished more efficiently and less ambiguously. Also, selection of the expert panel chair should occur early because of the chair's pivotal contributions to the clinical focus selection, literature review, and development of draft quality indicators. Perhaps the most starting finding and biggest challenge was the paucity of scientifically sound literature to support the clinical topics; except for the breast cancer studies, most of the available literature was categorized as flawed to some degree. A critical challenge for development of quality indicators is to translate what has been learned from the best scientific efficacy studies into indicators of effective rather than efficacious care.

In choosing quality indicators, disease incidence and potential for quality improvement are important parameters. Although the former is relatively easy to define, the latter is not.