Evaluation of the effect of performance monitoring and feedback on care process, utilization, and outcome

OBJECTIVE - We evaluated a program of performance measurement and monitoring by assessing care process, utilization of services, and outcomes. RESEARCH DESIGN AND METHODS - Information on 63,264 diabetic individuals who were continuously enrolled as members of Kaiser Permanente Southern California from 1 January 1994 to 31 December 1997 was used to evaluate the program. Time trends in testing for glycemic test and control and screening for dyslipidemia, use of lipid-lowering drugs, and microalbuminuria were evaluated as measures of care process. Time trends in hospitalization, outpatient appointments, prescriptions, and laboratory tests were evaluated as measures of utilization. Outcomes were hospitalization for myocardial infarction, ischemic stroke, and lower-limb amputation. RESULTS - Between 1994 and 1997, improvements were evident in the process measures. The mean number of hospitalizations and the mean and median number of outpatients visits did not change. The mean number of laboratory tests increased from 13.2 in 1994 to 23.6 in 1997. The mean number of prescriptions for any medication increased from 19.7 to 24.3. Hospitalization rates for myocardial infarction did not change, but rates increased for ischemic stroke and lower-limb amputation. CONCLUSIONS - Our findings suggest that measurement and monitoring of clinical performance can bring about modest improvements in measures of the processes of care in the absence of financial incentives, centrally driven interventions, and specialty care for all patients. In our setting, process improvements were associated with higher utilization of laboratory services and more prescriptions without an immediate return in terms of lower hospital utilization.