The Department of Veterans Affairs (VA) manages the largest health care
system in the United States, and the Institute of Medicine has recommended
that many practices of VA quality measurement be applied to the US health
care system as a whole. The VA measures quality of care at all of its sites
by assessing adherence rates to performance measures, which generally are
derived from evidence-based practice guidelines. Higher adherence rates are
used as evidence of better quality of care. However, there are problems with
converting practice guidelines, intended to offer guidance to clinicians,
into performance measures that are meant to identify poor-quality care. We
suggest a more balanced perspective on the use of performance measures to
define quality by delineating conceptual problems with the conversion of practice
guidelines into quality measures. Focusing on colorectal cancer screening,
we use a case study at 1 VA facility to illustrate pitfalls that can cause
adherence rates to guideline-based performance measures to be poor indicators
of the quality of cancer screening. Pitfalls identified included (1) not properly
considering illness severity of the sample population audited for adherence
to screening, (2) not distinguishing screening from diagnostic procedures
when setting achievable target screening rates, and (3) not accounting for
patient preferences or clinician judgment when scoring performance measures.
For many patients with severe comorbid illnesses or strong preferences against
screening, the risks of colorectal cancer screening outweigh the benefits,
and the decision to not screen may reflect good quality of care. Performance
measures require more thoughtful specification and interpretation to avoid
defining high testing rates as good quality of care regardless of who received
the test, why it was performed, or whether the patient wanted it.
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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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