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Alternative Pay-for-Performance Scoring Methods: Implications for Quality Improvement and Patient Outcomes

Glickman, Seth W. MD, MBA*†; Boulding, William PhD‡; Roos, Jason M. T. BA‡; Staelin, Richard PhD‡; Peterson, Eric D. MD, MPH§¶; Schulman, Kevin A. MD*‡¶

doi: 10.1097/MLR.0b013e3181a7e54c
Original Article

Background: Pay-for-performance programs typically rate hospitals using a composite summary score in which process measures are weighted by the total number of treatment opportunities. Alternative methods that weight process measures according to how hospitals organize care and the range for possible improvement may be more closely related to patient outcomes.

Objectives: To develop a hospital-level summary process measure adherence score that reflects how hospitals organize cardiac care and the range for possible improvement; and to compare associations of hospital adherence to this score and adherence to a composite score based on the Centers for Medicare and Medicaid Services scoring system with inpatient mortality.

Research Design and Subjects: Hospital-level analysis of 7 process measures for acute myocardial infarction (AMI) and 4 process measures for heart failure at 4226 hospitals, and inpatient mortality after AMI at 1351 hospitals in the United States. Data are from the Hospital Compare and Joint Commission Core Measures databases for October 2004 through September 2006.

Measures: Associations between composite scores based on Centers for Medicare and Medicaid Services methodology and alternative adherence scores with inpatient survival after AMI.

Results: In principal components analysis, hospital cardiac care varied between hospitals largely along the lines of “clinical” (ie, pharmacologic interventions) and “administrative” (ie, patient instructions or counseling) activities. A scoring system reflecting this organization was strongly associated with inpatient survival and fit the mortality data better than the composite score. Higher administrative activities scores, holding the clinical activities score fixed, were associated with lower survival.

Conclusions: In-hospital cardiac care is organized by clinical and administrative processes of care. Pay-for-performance schemes that incentivize hospitals to focus on administrative process measures may be associated with decreased adherence to clinical processes. A pay-for-performance scheme that acknowledges these factors may be associated with improved inpatient mortality.

From the *Center for Clinical and Genetic Economics, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; †Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina; ‡The Fuqua School of Business, Duke University, Durham, North Carolina; §Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; and ¶Department of Medicine, Duke University School of Medicine, Durham, North Carolina.

Supported in part by a gift from the Douglas and Stefanie Kahn Charitable Gift Fund (to S.W.G.).

Reprints: Kevin A. Schulman, MD, Center for Clinical and Genetic Economics, Duke Clinical Research Institute, Duke University School of Medicine, PO Box 17969, Durham, NC 27715. E-mail: kevin.schulman@duke.edu.

© 2009 Lippincott Williams & Wilkins, Inc.