ArticleJournal of general internal medicine2016
Are Improvements in Measured Performance Driven by Better Treatment or "Denominator Management"?
Article in Journal of general internal medicine, 2016. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 10 papers, 1 of them a synthesis that pooled it.
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Who cites it
10 citing papers in PubMed, 1 synthesis or guideline pooled it.
- Pay-for-Performance and Veteran Care in the VHA and the Community: a Systematic Review.Journal of general internal medicine · 2018Pooled it
- From exception to insight: a phenomenological study of quality managers' perspectives on the individual appeals in the National Healthcare Quality Program.Israel journal of health policy research · 2026Article
- Improving diagnosis-based quality measures: an application of machine learning to the prediction of substance use disorder among outpatients.BMJ open quality · 2025Article
- Conceptual and methodological recommendations for assessing the empirical validity of process measures of health care quality.Health services research · 2024Article
- Healthcare quality measures in implementation research: advantages, risks and lessons learned.Health research policy and systems · 2022Article
- Incentivizing performance in health care: a rapid review, typology and qualitative study of unintended consequences.BMC health services research · 2022Review
- Assessing the postdeployment quality of treatment for substance use disorders among Army enlisted soldiers in the Military Health System.Journal of substance abuse treatment · 2020Article
- Facility-level changes in receipt of pharmacotherapy for opioid use disorder: Implications for implementation science.Journal of substance abuse treatment · 2018Article
- Promoting Adoption of Medication for Opioid and Alcohol Use Disorders Through System Change.Journal of studies on alcohol and drugs · 2017Article
- The Next Generation of Clinical Performance Measures.Journal of general internal medicine · 2016Article
Corrections and comments
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Authors and funding
6 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundProcess measures of healthcare quality are usually formulated as the number of patients who receive evidence-based treatment (numerator) divided by the number of patients in the target population (denominator). When the systems being evaluated can influence which patients are included in the denominator, it is reasonable to wonder if improvements in measured quality are driven by expanding numerators or contracting denominators.
objectiveIn 2003, the US Department of Veteran Affairs (VA) based executive compensation in part on performance on a substance use disorder (SUD) continuity-of-care quality measure. The first goal of this study was to evaluate if implementing the measure in this way resulted in expected improvements in measured performance. The second goal was to examine if the proportion of patients with SUD who qualified for the denominator contracted after the quality measure was implemented, and to describe the facility-level variation in and correlates of denominator contraction or expansion.
designUsing 40 quarters of data straddling the implementation of the performance measure, an interrupted time series design was used to evaluate changes in two outcomes.
participantsAll veterans with an SUD diagnosis in all VA facilities from fiscal year 2000 to 2009. MAIN MEASURES: The two outcomes were 1) measured performance-patients retained/patients qualified and 2) denominator prevalence-patients qualified/patients with SUD program contact. KEY
resultsMeasured performance improved over time (P < 0.001). Notably, the proportion of patients with SUD program contact who qualified for the denominator decreased more rapidly after the measure was implemented (p = 0.02). Facilities with higher pre-implementation denominator prevalence had steeper declines in denominator prevalence after implementation (p < 0.001).
conclusionsThese results should motivate the development of measures that are less vulnerable to denominator management, and also the exploration of "shadow measures" to monitor and reduce undesirable denominator management.
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