Outpatient Process Measures Are Focused on Underuse of Care

At an attempt to improve quality of healthcare, a number of clinical performance measures have been developed to improve clinician and institutional performance. However, the influence of these measures on changing clinical practice on a large scale have been questioned. A primary question being raised, and which was the objective of the current study in JAMA Internal Medicine, is that a focus on underuse and rewarding physicians to do more would tilt the balance toward overutilization.

The authors of the study, in an attempt to understand the influence of outpatient process measures on underuse and overuse, identified all outpatient and emrgency department (ED) process measures included in major national measure programs till mid-2012. Inpatient measures were excluded from the evaluation, as were outcomes measures, settings other than outpatient or ED, and nonclinical aspects of care. A total of 521 measures of care were included in the study from across 16 measure collections.

A detailed evaluation of these measures showed that nearly 92% (477) targeted underuse while just over 6% (34) targeted overuse. Less than 3% (14) addressed misuse. Of the 16 measure collections, the authors found only 3 that included a good percentage of overuse measures (≥10%) while more than 50% did not include any overuse measures. Underuse measures, the authors write, covered all categories of clinical service, while overuse measures were restricted and addressed either diagnostic imaging or medication prescription.

According to Erika Newton, MD, MPH, one of the study's senior authors, "Our findings suggest that, by focusing almost single-mindedly on identifying and penalizing underuse, current outpatient performance measures may well foster a culture of ‘more is better’─and inadvertently encourage overuse of care." The authors believe their findings highlight the need to anticipate and monitor intended and unintended consequences of measure programs and the need for a fair balance between measureing underuse and overuse of clinical services across the spectrum.