PEER-REVIEW OF THE QUALITY OF CARE - RELIABILITY AND SOURCES OF VARIABILITY FOR OUTCOME AND PROCESS ASSESSMENTS

Context.-Peer assessments have traditionally been used to judge the qu ality of care, but a major drawback has been poor interrater reliabili ty. Objectives.-To compare the interrater reliability for outcome and process assessments in a population of frail older adults and to ident ify systematic sources of variability that contribute to poor reliabil ity. Setting.-Eight sites participating in a managed care program that integrates acute and long-term care for frail older adults. Patients. A total of 313 frail older adults. Design.-Retrospective review of th e medical record with 180 charts randomly assigned to 2 geriatricians, 2 geriatric nurse practitioners, or 1 geriatrician and 1 geriatric nu rse practitioner and 133 charts randomly assigned to either a geriatri cian or a geriatric nurse practitioner. Main Outcome Measures.-Interra ter reliabilities for structured implicit judgments about process and outcomes for overall care and care for each of 8 tracer conditions (eg , arthritis). Results.-Outcome measures had higher interrater reliabil ity than process measures. Five outcome measures achieved fair to good reliability (more than 0.40), while none of the process measures achi eved reliabilities more than 0.40. Three factors contributed to poorer reliabilities for process measures: (1) an inability of reviewers to differentiate among cases with respect to the quality of management, ( 2) systematic bias from individual reviewers, and (3) systematic bias related to the professional training of the reviewer (ie, physician or nurse practitioner). Conclusions.-Peer assessments can play an import ant role in characterizing the quality of care for complex patients wi th multiple interrelated chronic conditions, but reliability can be po or. Strategies to achieve adequate reliability for these assessments s hould be applied. These strategies include emphasizing outcomes measur ement, providing more structured assessments to identify true differen ces in patient management, adjusting systematic bias resulting from th e individual reviewer and their professional background, and averaging scores from multiple reviewers. Future research on the reliability of peer assessments should focus on improving the ability of process mea sures to differentiate among cases with respect to the quality of mana gement and on identifying additional sources of systematic bias for bo th process and outcome measures, Explicit recognition of factors influ encing reliability will strengthen efforts to develop sound measures f or quality assurance.