Original Articles
Developing a Clinical Performance Measure

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Abstract

Background:

Clinical performance measurement is an increasingly important way for public and private purchasers alike to compare the value of health services provided by competing health delivery systems. The widespread use of performance measures has increased the demand for development of new measures that cover previously unevaluated aspects of care.

Methods:

Four steps required to develop a clinical performance measure that is suitable for making comparisons among health delivery systems are discussed: (1) choosing clinical areas to measure, (2) selecting performance indicators within each area, (3) designing specifications for consistent implementation of a measure, and (4) evaluating the scientific strength of a measure.

Results:

The application of these steps to developing measures of quality for hypertension is provided, with an emphasis on a measure of adequacy of control of blood pressure.

Conclusions:

Developing useful clinical performance measures requires careful attention to methodologic issues. Following the steps outlined in this paper should enhance the quality of future measurement development.

Section snippets

Choosing Areas to Measure

The choice of areas for assessment is based on three criteria: (1) the importance of the condition, (2) the potential for quality improvement, and (3) the degree to which health care professionals control the mechanisms for improving care.

Selecting Indicators of Performance

Multiple indicators can be used to evaluate the quality of care for most conditions. An indicator is a statement about the process or outcomes of care. A performance measure evaluates the extent to which health plans provide or achieve the element of care included in the indicator. Indicators are often based on guidelines issued by specialty societies, government agencies, or others, but require greater specificity to be implemented.

Two criteria to consider when selecting process indicators are

Designing Specifications for a Measure

Once a potential quality-of-care indicator has been selected, the next step is to construct a reliable and valid measure that can be implemented consistently across different organizations. The six elements of designing specifications are described here.

Testing the Scientific Strength of a Measure

Testing should be done in multiple plans that vary on key factors of interest such as: characteristics of the enrolled population, geographic location, organizational structure, sophistication of the data processing environment, and anticipated variation in performance on a measure. A major purpose of the evaluation is to determine whether the measure is reliable and valid. For measures that pass the tests of reliability and validity, an assessment of the interpretability of results should be

Summary

The major steps in developing a measure for making comparisons among health plans have been reviewed: choosing areas for measurement, selecting indicators of performance within each area, designing the specifications for consistent implementation of a measure, and testing the scientific strength of a measure. A general review of the recommended approach within each step was provided along with a more specific discussion of the application to one measure of quality for hypertension care.

Acknowledgements

This paper was prepared under funding from The Commonwealth Fund and was presented at a conference titled “Prevention and Managed Care: Joining Forces for Value and Quality,” in Atlanta, Georgia. The views expressed in this paper are those of the authors and do not represent the official positions of their institutions, The Commonwealth Fund, or the sponsors of the conference. The authors are indebted to Sally Morton, PhD, who did the power calculations for this paper.

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