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Measuring Quality of Care in Patients With Multiple Clinical Conditions: Summary of a Conference Conducted by the Society of General Internal Medicine

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Abstract

Performance measurement has been widely advocated as a means to improve health care delivery and, ultimately, clinical outcomes. However, the evidence supporting the value of using the same quality measures designed for patients with a single clinical condition in patients with multiple conditions is weak. If clinically complex patients, defined here as patients with multiple clinical conditions, present greater challenges to achieving quality goals, providers may shun them or ignore important, but unmeasured, clinical issues. This paper summarizes the proceedings of a conference addressing the challenge of measuring quality of care in the patient with multiple clinical conditions with the goal of informing the implementation of quality measurement systems and future research programs on this topic. The conference had three main areas of discussion. First, the potential problems caused by applying current quality standards to patients with multiple conditions were examined. Second, the advantages and disadvantages of three strategies to improve quality measurement in clinically complex patients were evaluated: excluding certain clinically complex patients from a given standard, relaxing the performance target, and assigning a greater weight to some measures based on the expected clinical benefit or difficulty of reaching the performance target. Third, the strengths and weaknesses of potential novel measures such change in functional status were considered. The group concurred that, because clinically complex patients present a threat to the implementation of quality measures, high priority must be assigned to a research agenda on this topic. This research should evaluate the impact of quality measurement on these patients and expand the range of quality measures relevant to the care of clinically complex patients.

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Acknowledgements

The authors gratefully acknowledge Greg Pawlson for his assistance as a conference leader and Robert Centor for his comments on an earlier draft of this manuscript. Funding was provided by the American Board of Internal Medicine (ABIM) Foundation and the Commonwealth Fund.

Conflict of Interest

Dr. Greenfield has received grants for research from Pfizer and Novo-nordisk and honoraria from Pfizer. Dr. Fung has received research support from a grant from Pfizer. Dr. Turner has received a grant for research from Pfizer.

Author information

Authors and Affiliations

  1. Center for Health Equity Research and Promotion, Philadelphia VAMC, Philadelphia, PA, USA

    Rachel M. Werner MD, PhD

  2. Division of General Internal Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, 19104, USA

    Rachel M. Werner MD, PhD & Barbara J. Turner MD, MSEd

  3. Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA

    Rachel M. Werner MD, PhD & Barbara J. Turner MD, MSEd

  4. Department of Medicine and the Center for Health Policy Research, University of California, Irvine, CA, USA

    Sheldon Greenfield MD

  5. Division of General Internal Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA

    Constance Fung MD, MSHS

  6. David Geffen School of Medicine at UCLA, Los Angeles, CA, USA

    Constance Fung MD, MSHS

  7. RAND Corporation, Santa Monica, CA, USA

    Constance Fung MD, MSHS

  8. 1230 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA

    Rachel M. Werner MD, PhD

Authors
  1. Rachel M. Werner MD, PhD
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  2. Sheldon Greenfield MD
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  3. Constance Fung MD, MSHS
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  4. Barbara J. Turner MD, MSEd
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Corresponding author

Correspondence to Rachel M. Werner MD, PhD.

APPENDIX

APPENDIX

Conference participants

Steve Asch

VA Greater Los Angeles Healthcare System (VAGLA), RAND, Geffen School of Medicine at University of California, Los Angeles (UCLA)

Anne Marie

Audet The Commonwealth Fund

Elizabeth Bayliss

University of Colorado Health Sciences Center, Kaiser Permanente

Chris Callahan

Indiana University, Regenstrief Institute

Christine Cassel

American Board of Internal Medicine

Robert Centor

University of Alabama, Dept. of Medicine

Timothy Cuerdon

American College of Physicians

Leslie Dunne

Society of General Internal Medicine

Dan Duffy

American Board of Internal Medicine

Carole Flamm

Blue Cross and Blue Shield Association

Martin Fortin

Université de Sherbrooke, Québec, Canada

Constance Fung

VAGLA, RAND, UCLA

Alan Glaseroff

Hulmboldt Integrated Practice Association, Eureka, CA

Mark Granoff

UCLA, Cedars-Sinai Medical Center

Sheldon Greenfield

University of California, Irvine

Rod Hayward

University of Michigan, Ann Arbor VA Medical Center

Eric Holmboe

American Board of Internal Medicine

Sherry Kaplan

University of California, Irvine

David Karlson

Society of General Internal Medicine

Bruce Landon

Harvard University

Catherine Maclean

VAGLA, RAND, UCLA

Ernie Moy

Agency for Healthcare Research and Quality

Sharon-Lise Normand

Harvard University

Patrick O’Connor

Health Partners Research Foundation

Michael Parchman

University of Texas Health Science Center at San Antonio, South Texas Veterans Healthcare System

Greg Pawlson

National Committee for Quality Assurance

Lisa Rubenstein

VAGLA, RAND, UCLA

Dana Gelb Safran

Tufts University

Jeffrey Samet

Boston University

Chris Sinsky

Medical Associates Clinic and Health Plans, Iowa

Wally Smith

Virginia Commonwealth University

Mary Tinetti

Yale University

Barbara Turner

University of Pennsylvania

Kevin Weiss

Northwestern University, Hines VA Medical Center

Neil Wenger

UCLA, RAND

Rachel Werner

Philadelphia VA Medical Center, University of Pennsylvania

Daniel Wolfson

ABIM Foundation

Albert Wu

Johns Hopkins Bloomberg School of Public Health

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Werner, R.M., Greenfield, S., Fung, C. et al. Measuring Quality of Care in Patients With Multiple Clinical Conditions: Summary of a Conference Conducted by the Society of General Internal Medicine. J GEN INTERN MED 22, 1206–1211 (2007). https://doi.org/10.1007/s11606-007-0230-4

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  • DOI: https://doi.org/10.1007/s11606-007-0230-4

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