Measuring quality of care with routine data: avoiding confusion between performance indicators and health outcomes

BMJ 1999;319:94-98 ( 10 July )

General Practice

Measuring quality of care with routine data: avoiding confusion between performance indicators and health outcomes

Editorial by Jankowski

Antonio Giuffrida, research fellow, ^a Hugh Gravelle, professor of economics, ^a Martin Roland, professor of general practice. ^b

^a National Primary Care Research and Development Centre, Centre for Health Economics, University of York, Heslington, York YO10 5DD, ^b National Primary Care Research and Development Centre, Williamson Building, University of Manchester, Oxford Road, Manchester M13 9PL

Correspondence to: M Roland m.roland{at}man.ac.uk

Objective: To investigate the impact of factors outsidethe control of primary care on performance indicators proposedas measures of the quality of primarycare.
Design: Multiple regression analysis relating admissionrates standardised for age and sex for asthma, diabetes, and epilepsyto socioeconomic population characteristics and to the supplyof secondary careresources.
Setting: 90 family health services authorities in England,1989-90 to 1994-5.
Results: At health authority level socioeconomic characteristics,health status, and secondary care supply factors explained 45%of the variation in admission rates for asthma, 33% for diabetes,and 55% for epilepsy. When health authorities were ranked, onlyfour of the 10 with the highest age-sex standardised admissionrates for asthma in 1994-5 remained in the top 10 when allowancewas made for socioeconomic characteristics, health status, andsecondary care supply factors. There was also substantial yearto year variation in therates.
Conclusion: Health outcomes should relate to crude ratesof adverse events in the population. These give the best indicationof the size of a health problem. Performance indicators, however,should relate to those aspects of care which can be altered bythe staff whose performance is beingmeasured.

Key messages

The NHS executive has proposed that admission rates for asthma, diabetes, and epilepsy could be used at health authority level as indicators of the quality of primary care
There is considerable year to year variation in the ranking of health authorities by admission rates for these conditions, even when rates are aggregated. This makes it hard to interpret a single year's data: a 3 year average would be more reliable
Morbidity, socioeconomic characteristics, and secondary care supply are important confounding factors that explain between a third and a half of the variation in admission rates across health authority areas
Performance indicators should relate to aspects of care that can be controlled by decision makers. Confounding factors have a clear impact on admission rates and must therefore be taken into account if such rates are to be used as performance indicators

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