title: Challenges in assessing the process-outcome link in practice.
abstract: The expanded use of clinical process-of-care measures to assess the quality of health care in the context of public reporting and pay-for-performance applications has led to a desire to demonstrate the value of such efforts in terms of improved patient outcomes. The inability to observe associations between improved delivery of clinical processes and improved clinical outcomes in practice has raised concerns about the value of holding providers accountable for delivery of clinical processes of care. Analyses that attempt to investigate this relationship are fraught with many challenges, including selection of an appropriate outcome, the proximity of the outcome to the receipt of the clinical process, limited power to detect an effect, small expected effect sizes in practice, potential bias due to unmeasured confounding factors, and difficulties due to changes in measure specification over time. To avoid potentially misleading conclusions about an observed or lack of observed association between a clinical process of care and an outcome in the context of observational studies, individuals conducting and interpreting such studies should carefully consider, evaluate, and acknowledge these types of challenges.
authors.affiliation: RAND Corporation, 1776 Main Street, PO Box 2138, Santa Monica, CA, 90407-2138, USA, parast@rand.org.
authors.forename: Layla
authors.initials: L
authors.lastname: Parast
authors.forename: Brian
authors.initials: B
authors.lastname: Doyle
authors.forename: Cheryl L
authors.initials: CL
authors.lastname: Damberg
authors.forename: Kanaka
authors.initials: K
authors.lastname: Shetty
authors.forename: David A
authors.initials: DA
authors.lastname: Ganz
authors.forename: Neil S
authors.initials: NS
authors.lastname: Wenger
authors.forename: Paul G
authors.initials: PG
authors.lastname: Shekelle
mesh_terms: D006801:Humans; D064887:Observational Studies as Topic / Q000379:methods / Q000592:standards; D017064:Process Assessment, Health Care / Q000379:methods / Q000592:standards*; D011787:Quality of Health Care / Q000592:standards*; D016032:Randomized Controlled Trials as Topic / Q000379:methods / Q000592:standards; D012052:Reimbursement, Incentive / Q000592:standards*