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in academic centers. Adisadvantage of thismethod is that the qual-
ity of the data are dependent on the level of detail recorded in the
registry. As seen in studies based on administrative data, at times
the conclusions may be quite limited, as seen in studies of thyroid-
ectomy from the National Inpatient Sample.30
Other Methods of Developing Performance Measures
We should not preclude developing quality measures for proce-
dures for which there are no existing clinical practice guidelines or
registries. Although these qualitymeasuresmay not be as robust as
performance measures (and thus not suitable for public report-
ing), solo or group practices, academic departments, and hospitals
may still benefit from tracking qualitymeasures internally. Further-
more, by starting the process of developing and tracking quality
measures, we begin the long process of performance measure de-
velopment by presenting evidence to organizations such as the
AMA-PCPI to conduct more rigorous testing.31
There is compelling evidence for provider volume as a quality
measure. A study32 of the National Inpatient Sample showed that,
for certain procedures (eg, pancreatectomy), the postoperative
mortality rate varied from 3.8% in high-volume centers to 16.3% in
low-volume centers after adjusting for patient age, sex, race, pro-
cedure year, urgency of admission, Charlson score, and socioeco-
nomic status. However, the use of provider volume as a quality
measure is controversial. Although differences in mortality across
low- vs high-volume hospitals are observed on the aggregate level,
provider volume is not a good predictor of individual hospital mor-
tality rates. In addition, not all procedures are associatedwith a dif-
ference in provider experience.6 Thus, we must be careful not to
overuse this measure by assuming it to be true of all surgical proce-
dures and also not unfairly penalize high-performing hospitals re-
gardless of their volume. However, for selected procedures, includ-
ing pancreatectomy and esophagectomy,33provider volume canbe
an effective performance measure. 34
Thedevelopmentofpatient-centeredoutcomemeasuresshould
be a priority for otolaryngologists. Although performance measures
focused onmorbidity andmortality are well suited for high-risk pro-
cedures, low-risk procedures require patient-centered outcome
measures, especiallywhen the goal of the intervention is to improve
quality of life. 6 An example of such a procedure is cochlear
implantation 21; the risk ofmortality is low, but the effect onquality of
life fromapoor outcome canbe tremendous, preventing a child from
attending mainstream schools or an adult from continuing to work.
An advantage of alternative forms of performancemeasure de-
velopment other thanusingguidelines or registries is that almost any
topic canbe targetedwithin reason. The combinationof a systematic
reviewandanexpert panel canprovide a similar framework toguide-
linedevelopmentandresultinthecreationofhigh-qualityperformance
measures.35 A disadvantage of this method is that there are added
stepsinadvancingfromaqualitymeasuretoapubliclyreportableper-
formancemeasurebecauseendorsement by theAmericanAcademy
ofOtolaryngology–HeadandNeck Surgerymust beobtainedprior to
submitting to national quality organizations, such as the AMA-PCPI.
Conclusions
Performance measures are an important tool that can aid otolaryn-
gologists in achieving effective, efficient, equitable, timely, safe, and
patient-centeredcareasoutlinedbytheInstituteofMedicine.Theuse
ofperformancemeasurement,bothforqualityimprovementandcost
containment, is here to stay. As experts inour specialty, wemust take
the lead in creating well-developed quality and performance
measures.
ARTICLE INFORMATION
Submitted for Publication: June 5, 2015; final
revision received August 8, 2015; accepted
September 23, 2015.
Published Online:November 25, 2015.
doi
Author Contributions: Drs Vila and Lieu had full
access to all the data in the study and take
responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Vila, Schneider, Lieu.
Acquisition, analysis, or interpretation of data: Vila,
Piccirillo.
Drafting of the manuscript: Vila.
Critical revision of the manuscript for important
intellectual content: All authors.
Obtained funding: Vila, Piccirillo.
Administrative, technical, or material support: Vila.
Study supervision: Schneider, Lieu.
Conflict of Interest Disclosures:None reported.
Funding/Support:This work was supported by
training grant 5T32DC00022 from the National
Institute on Deafness and Other Communication
Disorders of the National Institutes of Health.
Role of the Funder/Sponsor: The funding
organization had no role in the design and conduct
of the study; collection, management, analysis, and
interpretation of the data; preparation, review, or
approval of the manuscript; and decision to submit
the manuscript for publication.
Additional Contributions:J. Gail Neely, MD,
provided thoughtful discussion in the early stages
of the manuscript, and Lauren T. Roland, MD
(Department of Otolaryngology–Head and Neck
Surgery at the Washington University School of
Medicine in St Louis), offered helpful comments in
reviewing the manuscript. There was no financial
compensation.
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Quality Measures in Otolaryngology–Head and Neck Surgery Review Clinical Review & Education
(Reprinted) JAMA Otolaryngology–Head & Neck Surgery January 2016 Volume 142, Number 1
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