Most Clinical Performance Measures Neglect Overuse Parameters

Erika Newton MD, MPH

Erika Newton MD, MPH Interview with:
Erika Newton MD, MPH
Department of Emergency Medicine
Stony Brook University Medical Center
Stony Brook, NY and
Brenda Sirovich MD, MS

Staff Physician Co-Director
Outcomes Group VA Medical Center
White River Junction, VT
Associate Professor of Medicine and of Community and Family Medicine
Geisel School of Medicine at Dartmouth, and
The Dartmouth Institute for Health Policy and Clinical Practice

Division of Trauma Surgery, Department of Surgery
Stony Brook University Medical Center
Stony Brook, New York

Medical Research: What is the background for this study?

Response: Clinical performance measures – quality indicators used to evaluate and motivate health care providers’ performance – play a central role right now in efforts to improve quality in U.S. health care. But their potential to influence care on a wide scale has some worried about unintended effects.

In particular, there’s been growing concern that if performance measures focus disproportionately on underuse of care – that is, measuring whether enough care is being provided – they risk leading to unexpected consequences.   Specifically, if incentives tend to reward clinicians for doing more without attention to whether they do too much – this could inadvertently contribute to the problem of excessive care, or overuse.

Medical Research: What are the main findings?

Response: We thought it was important to look at what that balance is – between measures of underuse and measures of overuse – in outpatient practice.   We looked at 16 major national collections of performance measures and essentially counted measures targeting underuse (‘Did the clinician do enough?’) versus overuse (‘Did the clinician do too much?’).

We found that over 90 percent of 521 outpatient measures targeted underuse, while a mere 7 percent of outpatient measures addressed overuse – in fact nearly half of the collections contained no overuse measures at all.

Medical Research: What should clinicians and patients take away from your report?

Response: We think there are two issues here. 

The first relates to the performance measures themselves.  Many are based on evidence, and many clinicians may view them as unassailable.  But with unbalanced efforts to increase utilization, it is almost certain that measures are not applied solely to individuals for whom they’re appropriate (everyone’s heard an example like the patient with terminal lung cancer who gets sent for a mammogram) and may be applied too often (a diabetic blood test, ‘hemoglobin A1c’ at every monthly visit would be too often).

We recommend that clinicians consider the possible downsides.  That’s hard to do every visit of every day – instead we believe clinicians should think about getting involved in designing policies within their practice or health system.  Most clinicians are well familiar with some hazards of performance measurement. Werner and Asch provide a nice summary of the issues (Ann Fam Med.2007;5(2):159-163).

The bigger issue relates to the effect of cultivating a “more is better” culture in medicine.  We believe patients and clinicians can play an important role in helping to address this – by trying to remain aware of the tendency.  We think that the best thing that could happen here is an honest dialogue in the office about, for example, diagnostic testing.  Many diagnostic tests may represent discretionary interventions – we would hope that patients could feel comfortable asking their provider, “Could you say more about that test; is there a reasonable alternative?” – and that providers would feel comfortable with those discussions, and with involving patients in discretionary decisions.

Medical Research: What are the implications of your report for policy makers?

Response: Our findings point to a need for policymakers to actively monitor for any aggregate effects of performance measurement. In addition, we believe there would be value in developing and implementing a prospective underuse/overuse taxonomy, to ensure greater balance within performance measure collections – or even within individual measures.

Medical Research: What recommendations do you have for future research as a result of this study?

Response: An important future direction would be to investigate the actual effects of clinical performance measurement (e.g. using measure sets which differ with respect to the balance of underuse : overuse targets) on provider behavior and healthcare utilization.


Newton EH, Zazzera EA, Van Moorsel G, Sirovich BE. Undermeasuring Overuse—An Examination of National Clinical Performance Measures. JAMA Intern Med. Published online August 10, 2015. doi:10.1001/jamainternmed.2015.4025.

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Erika Newton MD, MPH (2015). Most Clinical Performance Measures Neglect Overuse Parameters