Current health care quality measurement efforts focus on assessing care for individual indicators of performance for a patient with a specific clinical condition or set of risk factors at discrete points in time (e.g., percent of patients with diabetes who received an HbA1c screening test or percent of women between the ages of 18-54 who received a pap smear). The measurement typically is directed at measuring the actions of a single type of provider, such as the physician or the hospital, and emphasizes assessing the provision of discrete services rather than the full spectrum of services within an episode for any given patient. There are a few cases, more recently, where providers are being held accountable for what percentage of their patient with a particular condition received all recommended services under what is referred to as an appropriate care composite measure, such as for a patient with diabetes (Health Partners, 2007), but again these measurement efforts are limited in scope to providers in a single setting and do not cut across the trajectory of care to involve multiple care settings.
The literature includes a number of proposals for episode-based quality measurement, but most of the proposals have not been tested or implemented. One prominent exception is the use of episodes for measurement of relative resource use, which has become increasingly common in recent years (McGlynn et al., 2008).The IOM has recommended episode-based performance measurement in two recent reports as an approach to address the clinical quality, cost, and outcomes of care (Institute of Medicine Committee on Redesigning Health Insurance Performance Measures, 2006; Institute of Medicine Committee on Redesigning Health Insurance Performance Measures, 2007). The IOM suggested that currently available point-in-time quality measures could be aggregated to the episode level to provide a composite assessment of the quality of care for that episode. An illustration is a Geisinger Health System program where patients undergoing CABG surgery are guaranteed to receive a set of 40 recommended processes of care (Casale et al., 2007). However, significant limitations exist in the number and types of measures for many clinical conditions, specialties and settings of care. Gaps identified by the IOM include transitions across care settings (e.g., hospital to long-term-care facility), patient outcomes over time (e.g., complications of chronic conditions), and measures of the oversupply of services (Institute of Medicine Committee on Redesigning Health Insurance Performance Measures, 2006). The gaps in measures vary by condition, provider type and setting. For example, many currently available diabetes-related measures could be applied to a one-year episode of diabetes care, but most hip fracture-related measures would apply to only the acute portion of the episode of hip fracture care. - -
The NQF is currently examining the joint measurement of quality and cost using episodes as the basis of assessment (National Quality Forum, 2007). In a preliminary report, the NQF recommended development of accountable care entities - either integrated providers or virtual groups - which would be held accountable for the quality and cost of episodes of care instead of individual providers. The NQF's work on how performance would be measured at the episode level is still in development.
MedPAC tested the feasibility of assigning quality indicators related to episodes of care to individual physicians (MedPAC, 2006). However, they did not explicitly perform the quality measurement at the episode level. The quality of care for patients with specific diagnoses was attributed to physicians, and resource use for episodes of care related to the same diagnoses were independently attributed to individual physicians. Both quality measures and resource use measures were attributed based on the number of E&M visits. Using an attribution threshold of 35 percent of E&M visits, the quality of care for 93 percent of patients was attributed to a physician (MedPAC, 2006).