All that glitters in the fabled New England Journal of Medicine is not gold. A recent article by Dale and colleagues is a masterclass in producing pleasing-sounding statements, and truisms that go precisely nowhere, but impress the undiscerning reader. They write an article in favour of using quality metrics to improve care. Then they show that process measures may focus attention on things that can be counted at the expense of more important things that cannot. So they say we should count “what’s important to patients”. Then they point out that the signal to noise ratio will not emerge in most cases where outcomes are used – patients value not dying from cancer, but you can never judge your clinician’s performance in screening by cancer death rates. They advocate a ‘balanced mixture’ of measures and advertise their own. But they do not say or prove that they have the right balance. And they admit that using payment to change behaviour is effete. But they say it is a good idea. The whole thing is a muddle. Truth is, no one knows how to use metrics in performance management. But we advocate for task-based (clinical process) measures to ensure that the essentials are in place. We think outcome measures are a poor idea except for patient satisfaction and maybe outcomes of a very small number of highly technical procedures.
— Richard Lilford, CLAHRC WM Director
- Dale CR, Myint M, Compton-Phillips AL. Counting Better – the Limits and Future of Quality-Based Compensation. New Engl J Med. 2016; 375(7): 609-11.
- Lilford RJ. Risk Adjusted Outcomes – Again! NIHR CLAHRC West Midlands News Blog. 24 April 2015.