Quality Measures in Pediatric Hospital Medicine: Moneyball or Looking for Fabio?

Abstract

"What are we doing here?" Brad Pitt asks a table full of weathered scouts in a memorable scene in the movie Moneyball. Playing Oakland Athletics manager Billy Beane, he goes on to critique the scouts' traditional, subjective ranking of players as "looking for Fabio." The fi lm is based on a book of the same name that chronicles the record-breaking success of the 2002 Oakland Athletics baseball team. At the heart of this achievement was the application of novel evidence-based metrics to maximize performance in the setting of a limited supply of fi scal resources.Optimizing value has evolved into a larger movement in sports, and quality measurement in medicine would be envious of a similar trajectory. Although reporting and regulatory requirements in medicine have increased in recent years, our metrics remain crude, often with an inability to attribute value to distinct players. Within pediatrics, hospital-based measures comprise <5% of the total available measures, despite the fact that inpatient care accounts for 40% of pediatric health care spending.1 Of the specifi c pediatric measures endorsed by the National Quality Forum for use in the inpatient setting (Table 1), 2-5 few have relevance to the bulk of daily care provided by pediatric hospitalists.The measures that are the most relevant to pediatric hospital medicine (PHM), the Joint Commission's Children's Asthma Care (CAC) core measures for inpatient asthma, have recently been called into question in light of a large study that revealed no immediate link between components of the measures and readmission rates for asthma.6 Although many hospitals, over time, increased compliance with the home management plan of care requirement, readmission rates did not budge. Thus, there was systems-level process improvement but no change in outcome. Meanwhile, compliance rates for reliever and systemic corticosteroid use were too high to analyze potential relation with outcomes; measurement refl ected high performance but could not drive improvement. This study raises larger questions about the "how" and "why" of quality metrics.There are many reasons why the quality of care should be measured:• Improvement • Meeting standards • Comparisons (for consumers/purchasers of health care) www.hospitalpediatrics.org

The Creation of a Pediatric Hospital Medicine Dashboard: Performance Assessment for Improvement

“…Finally, the utility of our dashboard is limited by the current lack of evidence and consensus for quality metrics as well as benchmarks within PHM that lead to improvement in health outcomes. 22,[27][28][29][30][31][32] We anticipate that this will also be the largest barrier to PHM-wide dashboard implementation. In addition, this lack of performance benchmarks limits conversations with hospital administrations regarding the value that we add.…”

The Landscape of Quality Measures and Quality Improvement for the Care of Hospitalized Children in the United States: Efforts Over the Last Decade

“…These collaborative networks and registries share best practices in quality and safety, produce care guidelines, and serve as critical benchmarking tools. 37 Occasionally, quality indicators are derived from these registries and networks of subspecialty care. Existing clinical registries for pediatric-specific conditions and subspecialty care include the following 4 :…”

“…The standardization of transition of care at different hospital levels (including discharges) and the development of QMs for common pediatric respiratory illnesses have been addressed in recent work. 37 The Pediatric Respiratory Illness Inpatient Measurement System is a QMs tool recently developed through a multicenter collaborative for asthma, bronchiolitis, croup, and pneumonia. More than 100 indicators were developed, demonstrating significant between-hospital variation, although less than one-fourth are supported by strong evidence.…”

“…39 The authors are currently involved in a study that aims at validating and assessing usability of the indicators and their relationship with health-related, patient-reported outcomes. 37 US News and World Report Survey US News and World Report annually publishes a Top-50 list for each of 10 pediatric specialties and an honor roll for children' s hospitals. 40 The report is highly publicized and requires a significant effort of data collection and reporting from the participating institutions.…”

Measuring Handoffs: Can We Improve the Transition of Hospitalized Children?

“…However, as has been previously advocated, these new metrics are ones that should fall in the category of improvement rather than selection. 13 They should drive improvements to the system rather than pass judgment upon it.…”