Performance measures are the specific care choices that are evaluated when judging the quality of care a doctor provides. Guiding quality of care with performance measurement was one of the greatest successes of the VHA transformation of the 1990s; reinvigorating performance measurement is a primary goal of today's VHA transformation. Current performance measures have known limitations. They do not personalize treatments' risks and benefits to individual patients. Some do not measure particularly important care or do not allow for appropriate patient- centered exceptions, such as for very ill patients. They create a burden for doctors. Doctors and clinical leaders have rarely had say in helping make scores useful and understandable. There is currently a push to summarize multiple performance measures into composite scores that measure a clinic's overall care. The best way to accomplish this, however, is unknown. Most health organizations and insurers use an approach that prioritizes simplicity. Medicare is developing an approach that prioritizes being able to distinguish one clinic from another ? have fewer ties. Here, we lay out a new ?benefit-based? approach; one that prioritizes the amount care can improve patient outcomes. Prevention of cardiovascular disease (CVD) is an ideal case for testing the performance measurement issues discussed above. It has an exceptionally strong clinical evidence base; CVD is the leading cause of morbidity and mortality in VA, and there has already been extensive work on developing individual performance measures. Furthermore, our work and that of others has already laid the groundwork for how care could be better personalized, and we already have a strong ongoing partnership with the VA Center for Analytics and Reporting. In this project, we propose examining alternative approaches to constructing composite performance measures for the medicines of CVD prevention, including statin, blood pressure, and anti-platelet therapies like aspirin. Can a more personalized, benefit-based CVD performance approach improve on conventional approaches to composite construction in reliability, validity, or usability? Is it feasible to create a composite that incorporates more clinical nuance, is preferred by VA leadership and frontline PACT members, and can be communicated in ways that help users improve their performance? This project focuses on CVD prevention, but the model being explored could be generalized to other conditions.
In Aim 1, we will develop composite performance measures for cardiovascular disease prevention using three different techniques, including our new benefit-based approach. We will also explore the impact of different exclusions or improving data quality on performance measurement.
In Aim 2, we will test and compare these new composite measures for reliability, validity, and their potential impact.
In Aim 3, we will test the measures' acceptability and utility with clinicians and clinical and national leaders. This will include working with separate local and national stakeholder advisory groups and conducting formal semi-structured interviews. This will inform the measures themselves and how they are communicated to stakeholders.

Public Health Relevance

Performance measures are how VA leadership evaluates the care provided to Veterans. They can be used to guide care ? such as when a clinician realizes that he is not providing ideal care because a new performance measure recommends something he had not been doing ? or grade it ? such as when physician report cards inform a clinic director that one doctor is particularly skilled. Combining performance measures into composites is the most established way to summarize and guide care. In this project, we will develop new performance measures and new ways of creating composites that will be aimed directly at improving care in ways that are effective and less burdensome to providers.

National Institute of Health (NIH)
Veterans Affairs (VA)
Non-HHS Research Projects (I01)
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Health Care System Organization and Delivery (HS5A)
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Veterans Health Administration
Ann Arbor
United States
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Sussman, Jeremy B; Heisler, Michele (2018) Of Barbershops and Churches. Circ Cardiovasc Qual Outcomes 11:e005149