Consensus Reached on Ambulatory Care Measures


Taking a crucial first step in an effort to make pay for performance work for office-based physicians, a coalition of physician groups, insurers, and the federal government has endorsed a set of 26 clinical performance measures for the ambulatory care setting.

The coalition—the Ambulatory care Quality Alliance (AQA)—was formed last year by the American Academy of Family Physicians, the American College of Physicians, America's Health Insurance Plans, and the Agency for Healthcare Research and Quality.

The starter set of 26 measures focuses on prevention, chronic care, and the overuse and misuse of certain treatments. The set could be implemented as early as next year

A unified set of measures will be valuable, said Paul Gluck, M.D., chair of the quality improvement and patient safety committee of the American College of Obstetricians and Gynecologists, but the key is choosing the right ones.

Quality targets should be based on whether they can be measured, whether they will improve care, and whether the physicians can influence the target, said Dr. Gluck of the University of Miami.

AQA's starter set of measures was assembled from existing measures developed by either the Physician Consortium for Performance Improvement or the National Committee for Quality Assurance. Most of the measures are now under review by the National Quality Forum.

AQA compiled the set in part to reduce the administrative burden on physicians, said John Tooker, M.D., CEO and executive vice president of the American College of Physicians. Most physicians deal with multiple health plans, and having a single set of uniform measures used across all plans would lessen the hassle factor for physicians, he said.

In addition to being less of an administrative burden, the measures are evidence based and were developed with physician input, he said.

The measures still need to be validated in the field. Dr. Tooker said he expects the measures will be adopted as they are ready to be implemented, possibly as early as next year.

AQA will also work this year on setting standards for data aggregation and reporting. And in the future, AQA plans to expand the measure set to include subspecialties outside of primary care.

The measures in the starter set were selected based on their clinical importance and scientific validity, feasibility, and their relevance to consumers, purchasers, and physician performance.

The starter set includes measures of preventive care related to breast cancer screening, colorectal cancer screening, cervical cancer screening, tobacco use and cessation, and vaccination for influenza and pneumonia. Other measures address prenatal care, diabetes, asthma, and depression.

This movement toward performance measures and pay for performance programs is already happening in many parts of the country, said Alan Nelson, M.D., a member of the Medicare Payment Advisory Commission (MedPAC) and a special advisor to the CEO of ACP.

“The pressure is coming from the purchasers of care who are insisting on buying value,” he said. “Medicare is taking the same approach.”

Mark McClellan, M.D., administrator for the Centers for Medicare and Medicaid Services, said his agency supports the AQA's efforts to implement valid, reliable measures. In a statement, Dr. McClellan called the initial set of measures a “milestone” in the area of ambulatory care.

But Dr. Nelson said he is concerned that most solo and small group practices are not equipped to gather and document the data needed to show compliance with the measures. As this effort moves forward, physicians will need to create patient registries and some efficient way of collecting the data needed for pay for performance.

MedPAC has acknowledged that difficulty and recommended that, under Medicare pay-for-performance initiatives, only information that can be collected through claims data should be used, he said.

Many of the performance measures that are being pushed by AQA are already in use within the Department of Veterans Affairs, said Rowen Zetterman, M.D., chief of staff at the VA Nebraska-Western Iowa Healthcare System in Omaha.

That bodes well for programs that use the measures going forward, since the VA has been able to significantly improve quality through its use of performance measures, Dr. Zetterman said.

The starter-set measures are online at

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