I’m feeling like a broken record on pay for performance

UPDATE: Edited cause I totally misread an indicator!

This time it’s obstetric quality metrics. “Association Between Hospital-Level Obstetric Quality Indicators and Maternal and Neonatal Morbidity“:

Importance  In an effort to improve the quality of care, several obstetric-specific quality measures are now monitored and publicly reported. The extent to which these measures are associated with maternal and neonatal morbidity is not known.

Objective  To examine whether 2 Joint Commission obstetric quality indicators are associated with maternal and neonatal morbidity.

Design, Setting, and Participants  Population-based observational study using linked New York City discharge and birth certificate data sets from 2010. All delivery hospitalizations were identified and 2 perinatal quality measures were calculated (elective, nonmedically indicated deliveries at 37 or more weeks of gestation and before 39 weeks of gestation; cesarean delivery performed in low-risk mothers). Published algorithms were used to identify severe maternal morbidity (delivery associated with a life-threatening complication or performance of a lifesaving procedure) and morbidity in term newborns without anomalies (births associated with complications such as birth trauma, hypoxia, and prolonged length of stay). Mixed-effects logistic regression models were used to examine the association between maternal morbidity, neonatal morbidity, and hospital-level quality measures while risk-adjusting for patient sociodemographic and clinical characteristics.

Main Outcomes and Measures  Individual- and hospital-level maternal and neonatal morbidity.

These researchers picked two perinatal quality measures. One was the percentage of deliveries that were elective before 39 weeks gestation. The other was c-sections for low-risk mothers. You want both to be low. Then they looked at both maternal and neonatal morbidity, and measured whether they were correlated with “quality”.

Here’s neonatal morbidity:

OB Mortality

Quality is on the x-axis. Mortality is on the y-axis. Can you see a relationship? Cause I can’t. Neither could the statistics.  The quality measures “were not associated with severe maternal complications (risk ratio [RR], 1.00 [95% CI, 0.98-1.02] and RR, 0.99 [95% CI, 0.96-1.01], respectively) or neonatal morbidity (RR, 0.99 [95% CI, 0.97-1.01] and RR, 1.01 [95% CI, 0.99-1.03], respectively).”

I don’t dislike the theory behind “pay for performance”. I just don’t think that the things we measure are often really “quality”. And the literature keeps making me feel like I’m right.


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