Entete 3

Quality indicators for functional status and quality of life in people with multimorbidity: Are we ready?

Sydney Dy, Elizabeth Pfoh, and Cynthia Boyd

Patients with multimorbidity suffer from multiple concurrent diseases that may affect their functional status and quality of life. Quality measurement that incorporates functional status and quality of life domains could be a valuable approach to complement the many disease-centered quality measures, and might help guide improvement in care. However, since multiple factors can influence functional status and quality of life, incorporating these outcomes into measures of the quality of health care may be challenging, especially in the population with multimorbidity.  To address this concern, we published a review in the Journal of the American Geriatrics Society [1] that aimed to inform initiatives that are developing quality indicators addressing functional status and health-related quality of life for patients with multimorbidity.  

We reviewed key sources of indicators (such as the National Quality Forum and Agency for Healthcare Research and Quality) to find quality indicators for quality of life and functional status relevant to this population in the outpatient arena. We also interviewed key informants who are using these outcomes in quality indicator projects that include or focus on the population with multimorbidity.

We found few relevant quality indicators for people with multimorbidity; existing indicators are used only for specific populations or settings, are challenging to implement, and have issues with validity. Key informants discussed concerns about the validity of existing indicators for differentiating quality of care between systems, and concerns about their use in a population where physical function for many people is naturally declining over time. Additionally, they raised concerns about consistent documentation for these quality indicators across providers.  Another challenge is defining the appropriate sampling population for the indicators.  

Across countries, quality measurement is used for varied purposes, ranging from financial incentives to accountability and quality improvement.  Avoiding unintended consequences through the use of such quality indicators is essential, as it may be most challenging to improve these outcomes in the most vulnerable populations.  Fundamental to the consideration of using quality indicators that focus on functional status and quality of life is improving the evidence base for how to improve these outcomes for people with multimorbidity – and this is still a limited, albeit growing, evidence base.

A potential first step to better integrate these outcomes into quality initiatives might be to implement standards for infrastructure to routinely collect this data from patients in clinical care.

1. Dy SM, Pfoh ER, Salive ME, Boyd CM. Health-Related Quality of Life and Functional Status Quality Indicators for Older Persons with Multiple Chronic Conditions. Epub, J Am Geriatr Soc. 2013 Dec 9.

One comment

  • 1
    Ross Upshur
    December 17, 2013 - 11:14 am | Permalink

    This is a great step forward. It is important to recognize the significant limitations in indicator development. We need to pay very close attention and think very clearly about what we are measuring and how we measure it, making concern for measurement theory and its relation to the ontology of multi-morbidity important. Given the considerable heterogeneity in this patient population, we also need to pay close heed to what we consider outcomes. I think greater clarity with respect to what we mean by outcomes in the first place is a necessary first step.

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