Quality Measures: Who Should Define Them?

Quality Measures: Who Should Define Them?



Most physicians believe that we practice “high quality medicine.” This is often based on our philosophy of medical care and our dedication to our profession. However…no longer is quality self-determined. It requires proof in the form of data. But who is determining how to define and interpret the data?

In adult medicine, there are many evidenced-based quality measures that have been well defined and validated. Why? Because the stakes are high in morbidity and mortality outcomes, and cost savings is always part of the discussion. Quality measures are being tied to best practice clinical pathways and the results have been clear. Implementing clinical pathways and standardizing medical care can be tied directly to improved outcomes.

Why is pediatrics so far behind?  We’re not at the same level, because we have less cost savings to offer. However, if we don’t start defining our own quality metrics based on well-defined data sets, others will do it for us. In fact they already have, and oftentimes don’t do it well.


Take for example, “no antibiotics for URI.” Many insurance payers have defined this metric with misconceptions about how clinical practice works or use mis-structured queries. They have used claims data to look for any patient who was seen in the office with the ICD9 of 465.9 and had an antibiotic prescription filled within 3,15, or 30 days of that visit. What many insurers do not account for in their metric, is the patient who gets seen for cellulitis two days after at URI and gets an appropriate antibiotic prescription. This is one of the consequences of allowing a non-clinical entity to create quality definitions.


What happens to the data after it’s gathered?  Some payers are incentivizing physicians for high quality with P4P bonuses. A more frightening development is that some payers are now starting to penalize physicians for poor performance. In parts of the country, physicians are being forced to pay money back for the original visit in which they diagnosed URI. This is the reality for some practices. What happens next? The savvy physicians stop coding URI at all. They use cough or some other diagnosis to avoid getting caught in this trap. Does this improve quality of care? Of course not.


So what is the answer? One solution is to put clinicians and physician leaders at the forefront of defining these metrics. The timing is perfect as we move towards ICD10 codes, when all measures will be recoded. Join the AAP’s Council on Quality Improvement & Patient Safety. Contact your state AAP Chapter or Pediatric Council and get involved!  Speak up and volunteer your expertise wherever you can. Now if we can only make it happen faster.