Evaluation of the effect of performance monitoring and feedback on care process, utilization, and outcome.

Abstract

OBJECTIVE: We evaluated a program of performance measurement and monitoring by assessing care process, utilization of services, and outcomes. RESEARCH DESIGN AND METHODS: Information on 63,264 diabetic individuals who were continuously enrolled as members of Kaiser Permanente Southern California from 1 January 1994 to 31 December 1997 was used to evaluate the program. Time trends in testing for glycemic test and control and screening for dyslipidemia, use of lipid-lowering drugs, and microalbuminuria were evaluated as measures of care process. Time trends in hospitalization, outpatient appointments, prescriptions, and laboratory tests were evaluated as measures of utilization. Outcomes were hospitalization for myocardial infarction, ischemic stroke, and lower-limb amputation. RESULTS: Between 1994 and 1997, improvements were evident in the process measures. The mean number of hospitalizations and the mean and median number of outpatients visits did not change. The mean number of laboratory tests increased from 13.2 in 1994 to 23.6 in 1997. The mean number of prescriptions for any medication increased from 19.7 to 24.3. Hospitalization rates for myocardial infarction did not change, but rates increased for ischemic stroke and lower-limb amputation. CONCLUSIONS: Our findings suggest that measurement and monitoring of clinical performance can bring about modest improvements in measures of the processes of care in the absence of financial incentives, centrally driven interventions, and specialty care for all patients. In our setting, process improvements were associated with higher utilization of laboratory services and more prescriptions without an immediate return in terms of lower hospital utilization.

Effect of a Nurse-Directed Diabetes Disease Management Program on Urgent Care/Emergency Room Visits and Hospitalizations in a Minority Population

“…Unfortunately, most approaches used to improve diabetes outcome measures have been ineffective in practice. These include: 1) reminding patients about appointments (5,6); 2) providing feedback information on patients to their treating physicians (7)(8)(9)(10), even when treatment recommendations for the patient were included (11,12); 3) case management (when the case manager could not make treatment decisions) (13,14); 4) physician education (15,16); and 5) multifaceted quality improvement interventions in the practice setting (17,18).…”

A Controlled Trial of Web-Based Diabetes Disease Management

“…Prior research suggests beneficial effects of diabetes disease management programs or computer decision support systems (17)(18)(19)22,24,31,32), but lack of rigorous control in many of these studies prevents reliable discrimination of intervention effects from the background secular improvements in levels of HbA 1c , blood pressure, and lipids occurring nationwide (33)(34)(35)(36). The specific benefits of computer aids to diabetes care are gradually becoming rigorously documented.…”

“…The methods and findings of our intervention are potentially generalizable. The study was conducted in a pluralistic, mixed-payor group practice different than the highly integrated managed care settings in which most care improvement research has usually been conducted (18,19,22,23,31). The informatics architecture underlying the DMA is adaptable to local medical data sources and guideline implementations.…”

Impact of Population Management With Direct Physician Feedback on Care of Patients With Type 2 Diabetes

“…Prior interventions to improve quality of care by changing physician practice patterns have mostly been either physician-centered (e.g., intensive academic detailing, physician report cards) (13)(14)(15) or patient-specific and centered on clinic visits (e.g., computerized reminder systems) (12,16 -20). In contrast, population-based diabetes management takes an overview perspective to monitor and deliver patient care (21,22).…”