Another day in the life of a pediatric hospitalist, another bronchiolitis quality improvement project. Or so it seems. In this issue of Hospital Pediatrics, Berg et al1  present a quality improvement project, based on the American Academy of Pediatrics 2014 clinical practice guideline (CPG),2  aimed at decreasing overused interventions across the continuum of care (COC) in urgent care clinics, emergency departments (EDs), and inpatient units. Although similar initiatives have targeted >1 care setting,3,4  this appears to be the broadest effort to date. The other striking innovation of this project is what may be termed a “perfect care metric,” a composite measure of complete CPG adherence, as the primary outcome. To be “completely adherent” to the bronchiolitis CPG, providers must not have ordered any of the following 8 medical interventions: viral panels, respiratory syncytial virus antigen testing, complete blood counts, blood cultures, chest radiographs, antibiotics, albuterol, and systemic steroids.

The investigators took advantage of their setting, which comprises 2 freestanding tertiary hospitals, both with an attached ED, and 3 affiliated urgent care clinics that directly admit patients to the inpatient units. Over the course of the project, however, they went beyond these walls by providing education for the institution’s nurse-advice phone service and primary care clinics (although no data were collected at these clinics). Finally, they engaged families with handouts and supportive-care education once the diagnosis of bronchiolitis was made. Although family engagement is yet another innovation of this project that deserves its own discussion, including families as part of the COC not only makes sense but also should be a sine qua non in health care. Imagine a world where patients get harmonious advice from the nurse on the phone, the primary care provider in the clinic, the handout in the ED, and the hospitalist on the ward.

The focus on a composite quality measure is timely because health systems are using them more often. One notable example is the Hospital Star Rating System that was introduced by the Centers for Medicare and Medicaid Services to summarize quality data in a way that is easy for patients and consumers to understand and use.5  Composite measures integrate vast amounts of data into a single measure that captures overall quality, avoiding the information overload and confusion that multiple individual measures may create. Composite measures may be especially helpful for patients, payers, and health system leadership. Additionally, composite measures may also be useful in general hospitals with small pediatric units, in which limited numbers of patients with any particular disease make statistical stability of individual condition–specific measures an issue.6 

However, despite these benefits, composite measures can be misleading. One key problem is the inability to identify changes in the quality of care specific enough to target an improvement effort.7  A second issue with composite measures is a “spillover” effect.7  For example, providers may decrease their use of viral testing in bronchiolitis but increase antibiotic use for fear of missing a bacterial pneumonia. A single composite measure will conceal these interactions. Although the authors of this article used a composite measure for their primary outcome, they also presented the individual metric data by site to address these limitations. This disaggregated measure of information is essential for targeted improvement efforts.

Citing the above concerns in relation to the Centers for Medicare and Medicaid Services Hospital Star Rating System, the National Quality Forum convened a multidisciplinary summit8  and made recommendations that may be broadly applicable to hospital-based efforts and may provide a framework for composite measures moving forward. First, the methodology needs to be clear and needs to align with the intent and user needs. If some elements are weighted more than others, an explanation should be provided. Second, the composite measure needs to be transparent about what it does and does not convey. Third, data presentation needs to meet consumer priorities and user needs. Transparency of methodology and the ability to disaggregate the data are critical to ensure that composite measures function as intended.

So, are composite measures across the COC the next quality frontier? In this project, adherence was measured separately at each site rather than for each patient. Although this may be important to drive improvement efforts in each setting, it is less patient centered. For example, compare 2 patients with bronchiolitis who did not receive any of the 8 interventions studied except a blood culture and a chest radiograph. Imagine the first patient received a blood culture and chest radiograph in the ED, and the second patient received a blood culture in the ED and a chest radiograph in the inpatient unit. Both patients are exposed to the same potential harms, but the inpatient unit meets the perfect care metric for the first patient, but not the second, simply on the basis of the location of where the chest radiograph was obtained and not because it was avoided altogether across the COC. From a patient’s perspective, the true perfect care metric would include all interactions with the health system, from the first phone call to the hospital ward, and, although excluded from this study, also in the ICU and on subspecialty services. Now that would be perfect care across the COC.

Drs Garber and Parikh drafted, reviewed, and edited this commentary; and both authors approved the final manuscript as submitted.

FUNDING: No external funding.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.