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Recommending Caution in Patient-Reported Outcome–Based Performance Measurement

Patient-reported outcome–based performance measures (PRO-PMs) that are methodologically sound and evidence based have the potential to assess, promote, and reward patient-centered care. They are being incorporated into payment models, and the Centers for Medicare & Medicaid Services Meaningful Measures 2.0 initiative includes development of PRO-PMs that are embedded into workflow (1). Despite their appeal, PROPMs represent only 5% of the measures used in federal reporting programs and endorsed by the National Quality Forum (2). We describe several of the key challenges faced when developing and implementing PRO-PMs. As patient-centered measures proliferate, it is critical to understand the distinction among terms (Table). The Performance Measurement Committee of the American College of Physicians has described criteria that can be used to assess performance measures (4). These criteria have unique considerations for PRO-PMs, including whether the measure has an adequate evidence base that could be attributed reliably at the level of an individual physician, can differentiate the relative care provided by physicians, is appropriately risk adjusted, and is feasible without being overly burdensome. Data are needed demonstrating that PRO-PMs improve quality of care and are an effective tool to accurately compare physician performance and, as a result, can be used for accountability purposes. PRO-PMs should be based on the same rigor of evidence as any other performance measure. The use of empirical data, at a minimum, is needed to demonstrate a relationship between a patient-reported outcome (PRO) and at least one health care structure, process, intervention, or service that is actionable by the accountable entity (for example, physician, group practice, health plan). The number of physician-, system-, and patient-related factors tied to the successful management of multiple coincident chronic conditions—as is done in both ambulatory and hospitalbased internal medicine—makes developing and applying PRO-PMs particularly challenging. The results of systematic reviews have been mixed (5, 6), with some studies showing potential benefits in using PRO-PM data to assess quality of care, primarily at organizational or system levels (for example, hospital level) or when the PRO-PM is assessing an outcome that is linked to clinical procedures. Some PRO-PMs that are specified at the individual physician level are associated with procedures or processes that are clearly under the control of an individual physician. However, individual physician attribution is not appropriate for PROs that are highly dependent on patient factors (for example, access to care, family and community support). Studies have demonstrated limited correlation between PRO-PM scores and individual physician performance, citing factors that are not under the influence of the individual physician (5, 6). Consequently, PRO-PMs should not be used to measure individual physician performance unless there is evidence to show an association between the patient-reported outcome measure (PROM) and the care provided by the physician. A risk-adjustment strategy is paramount to account for patient and population characteristics that are proven to affect outcomes, independent of treatment. Patient factors selected for inclusion in risk-adjustment models should be evidence based and specific to the PRO concept. A lack of risk adjustment and accounting for variability in a patient's baseline health status and comorbid conditions can lead to unintended consequences. Risk adjustment enables outcomemeasures to more accurately reflect the quality of care provided and facilitates making comparisons across the entities being assessed. Additionally, determining how to adjust performance measures not to penalize physicians caring for patients who are chronically ill or who are most vulnerable is important.When reporting outcomes by factors such as race, ethnicity, or English proficiency, it is important to recognize that patients experience the health care system differently based on these characteristics inmost systems and practices. Consequently, to drive improvement in outcomes, it is important to acknowledge these differences and account for them with an appropriate risk-adjustmentmethod. A final set of considerations relates to usability and feasibility. Seamless collection of PROM data is not yet part of the routine practice of medical care in the United States. Studies suggest that if patients and physicians understand the value of PROM information and how it will be used, they will be more likely to participate in the PROM data collection process (5, 6). However, without new clinical and interoperability workflows, PROM data