title: Excellent Patient Care Processes in Poor Hospitals? Why Hospital-Level and Patient-Level Care Quality-Outcome Relationships Can Differ.
abstract: Studies finding weak or nonexistent relationships between hospital performance on providing recommended care and hospital-level clinical outcomes raise questions about the value and validity of process of care performance measures. Such findings may cause clinicians to question the effectiveness of the care process presumably captured by the performance measure. However, one cannot infer from hospital-level results whether patients who received the specified care had comparable, worse or superior outcomes relative to patients not receiving that care. To make such an inference has been labeled the "ecological fallacy," an error that is well known among epidemiologists and sociologists, but less so among health care researchers and policy makers. We discuss such inappropriate inferences in the health care performance measurement field and illustrate how and why process measure-outcome relationships can differ at the patient and hospital levels. We also offer recommendations for appropriate multilevel analyses to evaluate process measure-outcome relationships at the patient and hospital levels and for a more effective role for performance measure bodies and research funding organizations in encouraging such multilevel analyses.
authors.affiliation: Center for Innovation to Implementation, VA Palo Alto Health Care System (152-MDP), Menlo Park, CA, USA. john.finney@va.gov.|Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA. john.finney@va.gov.
authors.forename: John W
authors.initials: JW
authors.lastname: Finney
authors.affiliation: Center for Innovation to Implementation, VA Palo Alto Health Care System (152-MDP), Menlo Park, CA, USA.|Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Keith
authors.initials: K
authors.lastname: Humphreys
authors.affiliation: Mental Health Services, Veterans Health Administration, Washington, DC, USA.|Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA.
authors.forename: Daniel R
authors.initials: DR
authors.lastname: Kivlahan
authors.affiliation: Center for Innovation to Implementation, VA Palo Alto Health Care System (152-MDP), Menlo Park, CA, USA.
authors.forename: Alex H S
authors.initials: AH
authors.lastname: Harris
mesh_terms: D006761:Hospitals / Q000592:standards*; D006801:Humans; D010043:Outcome and Process Assessment, Health Care / Q000379:methods / Q000592:standards*; D005791:Patient Care / Q000379:methods / Q000592:standards*; D019984:Quality Indicators, Health Care / Q000592:standards*; D011787:Quality of Health Care / Q000592:standards*
keywords: outcomes; performance measurement; quality assessment