Outcomes Movement

History

The value of outcomes measurement was recognized in the early 1900s, when Ernest A. Codman (1869–1940), a New England surgeon, said that treatment results and benefits should be documented. Codman created “end-result cards,” which contained basic patient demographic data, the diagnosis, the treatment, the short-term outcomes, and, when possible, the outcomes after 1 year. He contended that this type of information was necessary to make sound judgments about treatment efficacy. The movement became energized in the 1960s with the work of Avedis Donabedian (1919–2000), a physician and public health academician with a strong interest in healthcare quality. Donabedian's quality model began with structure (the medical facilities and personnel), continued with process (the treatment), and led to the outcomes (the effects of the care on patients). Donabedian stated that outcomes are crucial to judging the value of medical care and noted that mortality data alone are not sufficient. Quality-of-life indicators and patient satisfaction, though less easily measured, are also relevant and should be studied as well, in his view. At this point, the outcomes movement focused primarily on the patient rather than the healthcare delivery system as a whole.

The rapid rise in healthcare costs in the 1970s and 1980s has put the outcomes movement into an additional context. The focus now includes the financial issues and the concomitant effects on the medical system, insurance reimbursement, and federal programs. Technological innovations, the cost of new drugs and therapies, and the aging of the nation's population have thrust the issue of medical-care costs into the forefront. Insurance companies and other third-party payers as well as clinicians and hospital administrators have sought to distinguish between available therapies and those that work and matter. Researchers began to take note of the fact that different geographical areas exhibited wide variation in the use of resources and in the rates of certain medical procedures. After much investigation, however, the researchers did not find any meaningful differences in population characteristics and patient outcomes. This suggested, for example, that some surgical procedures were unnecessary, and limiting them to situations in which they would provide benefit could help contain rising costs. Other research claimed to demonstrate the lack of efficacy of some traditionally used interventions. By the 1990s, assessment and data-driven healthcare became the new mantra, and the outcomes movement came of age.

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