Pitfalls of using performance measures to evaluate the quality of hip fracture care.

The objective of this study was to determine feasibility of using RAND quality indicators to evaluate hip fracture care. Retrospective chart review was used to determine the adherence to quality indicators and the location of documentation of compliance. A chart abstraction tool was created for systematic extraction of data from multiple chart components. A total of 111 patients underwent operative treatment of a hip fracture and met inclusion criteria in either 1998 or 2003. The main outcome measure was the rate of compliance with quality measures. Overall, compliance was 88% for the 7 performance measures. Physician notes were the most accurate chart component but, if examined alone, would have only resulted in a reported rate of 81% adherence to indicators. Review of the nursing notes, ancillary service notes, results, and orders was required to fully document quality of care. Ceiling effects were noted for 4 of the 7 quality indicators as noncompliance was rare for these measures. The results of this study highlight the need for a thorough method of abstracting multiple chart components to accurately report quality of care. This is an important consideration for any pay-for-performance program. Specifically, the failure to review all chart components may lead to incorrect conclusions about the quality of care delivered by individual providers. In addition, the selection of quality measures subject to ceiling effects may limit the usefulness of quality reporting initiatives.