The Feasibility and Usefulness of Applying a Health Economic Framework to Prioritize Quality Indicators: A Demonstration with Chronic Obstructive Pulmonary Disease

The modern quality movement has placed increased attention on health care performance. As a result, quality indicators, which are quantitative measurements of health care performance, have become increasingly prevalent in health care systems. Although many health systems define improving population health and reducing health care costs as priorities, many quality indicators are selected using criteria that do not always align with these priorities. Health economics offers a framework for explicitly bringing considerations of population health and health care costs into the process of prioritizing quality indicators. This research sought to demonstrate the feasibility of operationalizing the health economic framework to prioritize quality indicators and explore the usefulness of this method. Quality indicators for smoking cessation and oxygen therapy in chronic obstructive pulmonary disease were used as examples to demonstrate the feasibility of associating variations in indicator values with variations in quality-adjusted life years (QALYs) and costs. The joint variation in QALYs and costs was represented as incremental net health benefit (INHB), which represents the QALYs gained less its opportunity cost. The first two studies demonstrated how quality indicators could be ranked by their relationships to QALYs and costs. However, uncertainty in the values of candidate indicators could affect how quality indicators are prioritized. Linear meta-models offer a method that is partially successful in prioritizing indicators in the presence of uncertain indicator levels. Focus groups, with participants representative of stakeholders who would select or use quality indicators, were conducted to explore their perceived usefulness of prioritizing quality indicators under a health economic framework. The usefulness and applicability of the framework appeared to revolve around three main themes of incorporation of evidence, ease of understanding or interpretation of health economic outputs, and the scope of the framework. Ease of interpretation appeared to be the main barrier to the utility of the health economic framework in prioritizing quality indicators. Collectively, these studies show how a health economic framework can be operationalized to prioritize quality indicators in a way that is potentially useful, but resource requirements and barriers in interpretation of the health economic framework may limit its adoption.Ph.D