title: It's NOT FAIR! Or is it? The promise and the tyranny of evidence-based performance assessment.
abstract: Evidence-based medicine (EBM), by its ability to decrease irrational variations in health care, was expected to improve healthcare quality and outcomes. The utility of EBM principles evolved from individual clinical decision-making to wider foundational clinical practice guideline applications, cost containment measures, and clinical quality performance measures. At this evolutionary juncture one can ask the following questions. Given the time-limited exigencies of daily clinical practice, is it tenable for clinicians to follow guidelines? Whose or what interests are served by applying performance assessments? Does such application improve medical care quality? What happens when the best interests of vested parties conflict? Mindful of the constellation of socially and clinically relevant variables influencing health outcomes, is it fair to apply evidence-based performance assessment tools to judge the merits of clinical decision-making? Finally, is it fair and just to incentivize clinicians in ways that might sway clinical judgment? To address these questions, we consider various clinical applications of performance assessment strategies, examining what performance measures purport to measure, how they are measured and whether such applications demonstrably improve quality. With attention to the merits and frailties associated with such applications, we devise and defend criteria that distinguish between justice-sustaining and justice-threatening performance-based clinical protocols.
authors: Center for Ethics and Humanities in the Life Sciences, Michigan State University, East Fee Hall, 965 Fee Road, Room C222, East Lansing, MI 48824, USA. Libby.Bogdan-Lovis@ht.msu.edu
authors: Elizabeth
authors: E
authors: Bogdan-Lovis
authors: Leonard
authors: L
authors: Fleck
authors: Henry C
authors: HC
authors: Barry
mesh_terms: D001675:Bioethics; D019317:Evidence-Based Medicine; D017048:Health Care Costs; D006801:Humans; D017063:Outcome Assessment, Health Care; D010043:Outcome and Process Assessment, Health Care; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000941:ethics / Q000592:standards / Q000639:trends; D017064:Process Assessment, Health Care; D058996:Quality Improvement; D011787:Quality of Health Care / Q000191:economics / Q000941:ethics; D012052:Reimbursement, Incentive / Q000941:ethics; D012935:Social Justice; D013647:Task Performance and Analysis; D014481:United States