When Quality Indicators Undermine Quality: Bias in a Quality Indicator of Follow-Up for Alcohol Misuse
When Quality Indicators Undermine Quality: Bias in a Quality Indicator of Follow-Up for Alcohol Misuse
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DOI：
10.1176/appi.ps.201200449
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发表时间：
2013-10-01
影响因子：
3.8
通讯作者：
Kivlahan, Daniel R.
中科院分区：
文献类型：
--
作者：
Bradley, Katharine A.;Chavez, Laura J.;Kivlahan, Daniel R.
目的：需要有效的质量指标来监测和鼓励对精神健康和物质使用状况（行为状况）的识别和管理。由于行为状况经常被低估，质量指标经常评估筛查阳性的患者比例，这些患者也有适当的后续护理记录。然而，这些“基于阳性筛查”的行为状况随访质量指标可能会因不同筛查质量导致的分母差异而产生偏倚（“分母偏倚”），并且可能会奖励识别出更少的具有感兴趣行为状况的患者。本研究评估了退伍军人健康管理局（VHA）网络对酒精滥用随访质量指标的性能的分母偏差，该指标使用酒精筛查阳性患者的数量作为分母。研究方法：通过对219，119份医疗记录的回顾，在21个VHA网络中比较了酒精滥用随访的两个质量指标-基于阳性筛查的质量指标和基于人群的质量指标。结果：两项质量指标结果不一致。例如，两个网络在质量指标上的表现相似（随访率分别为64.7%和65.4%），尽管一个网络识别和记录的随访患者数量几乎是另一个网络的两倍（每10万名合格患者中分别有5，411名和2，899名）。在基于阳性筛选的质量指标上表现更好的网络比在基于人群的质量指标上表现更好的网络识别出更少的酒精滥用患者（分别为平均4.1%和7.4%）。结论：酒精滥用随访的基于阳性筛查的质量指标优先奖励识别出更少酒精滥用患者的网络。
Objective: Valid quality indicators are needed to monitor and encourage identification and management of mental health and substance use conditions (behavioral conditions). Because behavioral conditions are frequently underidentified, quality indicators often evaluate the proportion of patients who screen positive for a condition who also have appropriate follow-up care documented. However, these "positive-screen-based" quality indicators of follow-up for behavioral conditions could be biased by differences in the denominator due to differential screening quality ("denominator bias") and could reward identification of fewer patients with the behavioral conditions of interest. This study evaluated denominator bias in the performance of Veterans Health Administration (VHA) networks on a quality indicator of follow-up for alcohol misuse that used the number of patients with positive alcohol screens as the denominator. Methods: Two quality indicators of follow-up for alcohol misuse-a positive-screen-based quality indicator and a population-based quality indicator-were compared among 21 VHA networks by review of 219,119 medical records. Results: Results for the two quality indicators were inconsistent. For example, two networks performed similarly on the quality indicators (64.7% and 65.4% follow-up) even though one network identified and documented follow-up for almost twice as many patients (5,411 and 2,899 per 100,000 eligible, respectively). Networks that performed better on the positive-screen-based quality indicator identified fewer patients with alcohol misuse than networks that performed better on the population-based quality indicator (mean 4.1% versus 7.4%, respectively). Conclusions: A positive-screen-based quality indicator of follow-up for alcohol misuse preferentially rewarded networks that identified fewer patients with alcohol misuse.