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Unintended consequences of quality measurement

Although pay-for-performance programs and public reporting of the performance of health care providers - such as general practices in the UK - have become integral components of strategies to improve the quality of health care, measurement and reporting of the quality of healthcare can also have unintended consequences. In a recent article published in the Annals of Internal Medicine, I discuss 'exception reporting', a method whereby patients who will not benefit from an intervention (such as those who are terminally ill) are excluded from quality measurement and not treated inappropriately.

Exception reporting rates in the UK Quality & Outcomes Framework vary widely among general practices that take part in the scheme. When Dalton et al examined exception reporting rates among people with diabetes from 23 general practices in London, they found that patients who were exception-reported by their physicians were significantly less likely to achieve treatment targets for haemoglobin A1c, blood pressure and cholesterol control. The highest rates of exception reporting occurred among already disadvantaged groups at greatest risk for diabetes complications and poorer health outcomes, such as older patients, patients from ethnic minority groups, and patients with longer durations of diabetes and increased levels of co-morbidity.

The findings of this study - published in the journal Diabetic Medicine - highlight the importance of monitoring exclusions from pay-for-performance and public reporting programs.

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