title: Quality of care by a hypertension expert: a cautionary tale for pay-for-performance approaches.
abstract: BACKGROUND
  Pay-for-performance programs may be widely implemented, but gaps remain in our understanding of the implementation of performance measurement approaches.
  
  
  OBJECTIVE
  To compare 3 approaches to hypertension quality measurement as applied to high-quality care delivered by a hypertension expert.
  
  
  METHODS
  Care of 23 patients treated by a single hypertension expert was assessed by 3 measurement approaches: (1) outcome, (2) a multicomponent process, and (3) "outcome-linked" process. Exemplary case studies were identified to illustrate additional challenges to applying the approaches.
  
  
  RESULTS
  Forty-four percent of patients (n = 10) had complete concordance between the outcome and outcome-linked process approaches, 22% of patients (n = 5) had complete concordance between the outcome and multicomponent process approaches, 52% of patients (n = 12) had complete concordance between outcome-linked process and multicomponent process approaches, and 22% of patients (n = 5) had uniform agreement among all 3 approaches. Case studies revealed numerous opportunities for misinterpretation or gaming by providers.
  
  
  CONCLUSIONS
  Currently available measurement approaches resulted in a varied assessment of provider performance under optimal hypertension care conditions suggesting that caution is required before their use for provider compensation.
authors.affiliation: Center for Quality Improvement Research, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio 44106, USA. brook.watts@med.va.gov
authors.forename: Brook
authors.initials: B
authors.lastname: Watts
authors.forename: Renee
authors.initials: R
authors.lastname: Lawrence
authors.forename: David
authors.initials: D
authors.lastname: Litaker
authors.forename: David C
authors.initials: DC
authors.lastname: Aron
authors.forename: Duncan
authors.initials: D
authors.lastname: Neuhauser
mesh_terms: D000368:Aged; D000554:Ambulatory Care Facilities; D005260:Female; D006801:Humans; D006973:Hypertension / Q000628:therapy*; D008297:Male; D008485:Medical Audit; D016347:Medical Records Systems, Computerized; D008875:Middle Aged; D009820:Ohio; D011785:Quality Assurance, Health Care / Q000191:economics / Q000379:methods*; D012052:Reimbursement, Incentive