title: Who is watching the watchmen: Is quality reporting ever harmful?
abstract: BACKGROUND
  Quality reporting is increasingly used as a tool to encourage health systems, hospitals, and their practitioners to deliver the greatest health benefit. However, quality reporting systems may have unintended negative consequences, such as inadvertently encouraging "cherry-picking" by inadequately adjusting for patients who are challenging to take care of, or underpowering to reliably detect meaningful differences in care. There have been no reports seeking to identify a minimum level of accuracy that ought to be viewed as a prerequisite for quality reporting.
  
  
  METHODS
  Using a decision analytic model, we seek to delineate minimal standards for quality measures to meet, using the simplest assumptions to illustrate what those standards may be.
  
  
  RESULTS
  We find that even under assumptions regarding optimal performance of the quality reporting system (sensitivity and specificity of 1), we can identify a minimal level of accuracy required for the quality reporting system to "do no harm": the increase in health-related quality of life from a higher rather than lower quality practitioner must be greater than the number of practitioners per patient divided by the proportion of patients willing to switch from a lower to a higher quality provider.
  
  
  CONCLUSIONS
  Quality measurement systems that have not been demonstrated to improve health outcomes should be held to a specific standard of measurement accuracy.
authors.affiliation: Division of Comparative Effectiveness and Decision Science, Department of Population Health, School of Medicine, New York University, New York, NY, USA.
authors.forename: R Scott
authors.initials: RS
authors.lastname: Braithwaite
authors.affiliation: Division of Bioethics, Department of Population Health, School of Medicine, New York University, New York, NY, USA.
authors.forename: Arthur
authors.initials: A
authors.lastname: Caplan
keywords: Quality reporting; decision analysis; pay for performance; physician reporting; quality