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Method of the Study

This assessment was prompted by congressional interest in whether valid information on hospital and physician quality could be developed and distributed to the public to assist their choice of health care providers. The study was requested by the House Committee on Energy and Commerce, and endorsed by the Senate Committee on Finance, the Senate Special Committee on Aging, the Subcommittee on Consumer of the Senate Committee on Commerce, Science, and Transportation, and the House Committee on Science, Space, and Technology. The interest of the committees was primarily in measures of quality that could be applied to acute care hospitals and physicians, but the committees were also interested in evaluating the quality of health plans. On September 23, 1987, the OTA project Technology Assessment Board approved the proposal for this project.

During the early part of the project, OTA staff consulted with consumer organizations, professional organizations, unions, employers' associations, third-party payers, health services researchers, and methodologists for suggestions of candidates for the study's advisory panel. The advisory panels for OTA studies guide OTA staff in selecting material and issues to consider and review the written work of the staff, but the panels are not responsible for the content of final reports. The advisory panel for this study consisted of 21 members from parties with expertise or an important perspective: consumer advocacy, medical practice, nursing, hospital management, health insurance, rural health, corporate health benefits, unions, law, health maintenance organizations, quality assessment organizations, State health departments, quality assessment research, information dissemination, and health policy analysis. Frederick Mosteller from the Department of Health Policy and Management at the Harvard School of Public Health chaired the advisory panel for the study.

The first meeting of the advisory panel was held on February 3, 1987. Before the meeting, the OTA project staff began preliminary research into the issues involved in selecting and evaluating indicators for quality assessment and prepared a draft outline for the study. During the meeting, panel members were asked to discuss a framework for consumers to assess the quality of care and methods of presenting quality information to consumers. In addition, the panel members discussed the relevant issues relating to quality assessment so as to narrow the scope of OTA's task.

As a result of the panel meeting and discussions with congressional staff, the scope of the study was limited to physicians and hospitals.

On March 3, 1987, a workshop was held to consider the procedure that OTA should use to evaluate the reliability, validity, and feasibility of the selected indicators of the quality of medical care. The workshop, chaired by Frederick Mosteller, included members experienced in evaluative research methods (see app. B). On the basis of the comments received from this workshop, the OTA staff revised the evaluation procedure to give more emphasis to measurement issues and developed a checklist to apply to specific studies.

An additional workshop was held on March 23, 1987, for the purpose of developing a list of quality indicators to evaluate for the OTA study and to discuss further the framework to assess quality from a consumer's perspective. This workshop was chaired by R. Heather Palmer, a member of the advisory panel, and included several other panel members (see app. B for a complete list of workshop participants). After this meeting, the OTA staff selected the following eight indicators of quality for evaluation: 1) hospital mortality rates; 2) adverse events that affect patients; 3) formal State disciplinary actions, sanctions recommended by peer review organizations and imposed by the Department of Health and Human Services, and malpractice compensation; 4) the evaluation of physicians' performance as exemplified by care for hypertension; 5) volume of procedures performed by hospitals and physicians; 6) scope of hospital services, with emphasis on emergency services, cancer care, and neonatal intensive care units; 7) physician specialization; and 8) patients' assessments of their care. Also on the basis of the workshop discussion, OTA staff decided to limit the aspects of access to be considered in the report to those that overlapped with quality and pertained once a person had decided to seek care.

Using a method of evaluation developed for this study (see app. C), OTA staff began to evaluate six of the eight indicators selected for evaluation. Contractors were chosen to evaluate the two remaining indicators: volume of procedures performed by hospitals and physicians and patients' assessments of their

care.

As OTA staff began to consider the policy implications of the study's findings, it became apparent that they needed further information on certain specialized

topics. During the summer of 1987, OTA contracts were let to fill gaps related to the availability of data, legal issues surrounding peer review, the use of qualityof-care information by consumers, organizational loci for constructing and evaluating quality indicators, the validity of malpractice profiles, and legal issues regarding confidentiality of data on physicians (see list below).

The second meeting of the advisory panel was held on July 26-27, 1987, to bring the panel members up to date on the progress of the study and to review preliminary drafts of some sections of the report. OTA staff developed brief descriptions of each indicator for the panel's discussion. The panel gave advice on how to disseminate information on the quality indicators to the public.

During the rest of the summer and fall of 1987, OTA project staff reviewed the literature on the various indicators and compiled the respective evaluations. Throughout this time, draft papers were received from contractors. On the basis of comments from the OTA project staff, advisory panel members, and outside reviewers with expertise in the relevant fields, the contractors revised their papers.

In mid-January 1988, the draft report for the overall study was sent for review to the advisory panel and to a wide range of other experts and interested parties. Discussion of the draft report formed the subject of the final meeting of the advisory panel on February 2-3, 1988. During February and March 1988, the OTA staff revised the report in response to discussion at the final panel meeting and ouside reviewers' comments. The staff prepared a final draft, which was submitted in late March 1988 to the Technology Assessment Board for its approval.

In addition to the main report, other documents prepared to provide background information are available through OTA in limited quantities. Some of these stem from contractors' reports, and others present detailed technical information on specific indicators analyzed by OTA staff.

• Nancy E. Cahill, "Developing Law on Professional Standards and Peer Review in Quality

Assessment Activities," Duke University, 1987; • Denise Dougherty, "Hospital Mortality Rates as a Quality Indicator," Office of Technology Assessment, 1988;

• Karen Glanz and Joel Rudd, "Effects of Quality of Care Information on Consumer Choice of Physicians and Hospitals," University of Minnesota and University of Arizona, 1987;

• Peter G. Goldschmidt, "The Appropriate Organizational Loci for Constructing Indicators of the Quality of Hospitals and Physicians and for Evaluating the Validity of Those Indicators," World Development Group, Inc., 1987;

• Marlene Larks, "Access to Health Data by State Health Data Organizations and Quality Assessors," National Association of Health Data Organizations, 1987;

• Harold S. Luft, Deborah W. Garnick, David Mark, Stephen J. McPhee, and Janice Tetreault, "Evaluating Research on the Use of Volume of Services Performed in Hospitals as an Indicator of Quality," University of California, San Francisco, 1987;

• Mark McClellan, "Hypertension Screening and Management as an Indicator of Quality: An Evaluation of the Literature," Massachusetts Institute of Technology, 1988;

• Don Harper Mills and Orley Lindgren, "Physician Malpractice Profiles as Indicators of Quality: Reliability, Validity, and Feasibility Issues," Institute for Medical Risk Studies, 1987;

• Beth Mitchner, "Physician Specialization as an Indicator of Quality: An Evaluation of the Literature," Office of Technology Assessment, 1988; • James B. Simpson, "Release of Physician-Specific Quality of Care Information: Legal Issues," Western Consortium for the Health Professions, 1987; • SysteMetrics, "Report on Available State-Specific Data Bases," 1987; and

• John E. Ware, Jr., Allyson Ross Davies, and Haya H. Rubin, "The Suitability of Consumers' Assessments of Physician and Hospital Performance as Indicators of the Quality of Care," The Rand Corporation, 1987.

Acknowledgments

This project has benefited from the advice and review of several people in addition to the advisory panel. OTA staff would like to express its appreciation to the following people for their valuable guidance.

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State of New York Department of State of California Department of

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Karen S. Liebert

University of Virginia Hospital Charlottesville, VA

William Lohr

Division of Extramural Research National Center for Health

Services Research Rockville, MD

Lisa Looper

American Medical Peer Review
Association
Washington, DC

James Lubitz

Office of Research
Health Care Financing

Administration

Washington, DC

Karl Mangold

The Fisher-Mangold Group Pleasanton, CA

James Maroc

Iowa Foundation for Medical Care West Des Moines, IA

William McAuliffe

Department of Psychiatry
Cambridge Hospital

Cambridge, MA

Daisy McGinley

General Accounting Office

U.S. Congress

Washington, DC

Bruce McPherson

American Hospital Association
Chicago, IL

Judith Moore

Center for the Medical Consumer Prospective Payment Assessment

New York, NY

William Libercci

Office of the Inspector General U.S. Department of Health and Human Services

Baltimore, MD

Richard Lichtenstein

Health Services Management and

Policy

School of Public Health

University of Michigan

Ann Arbor, MI

Commission

Washington, DC

Michael Moran

Health Standards and Quality Bureau

Health Care Financing

Administration

Baltimore, MD

Laura Morlock

Health Services Research and

Development Center

John Hopkins University

Baltimore, MD

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