The danger of non-exhaustive quality measures: requiring hip fracture repair surgery within 48 hours – a case study

Quality measures are widely used globally in order to measure clinical performance and organizational efficiency of the healthcare systems. However, in a race to achieve certain numerically defined goal, the more important purpose of any organizational step being aimed at improving clinical outcomes could be overshadowed. The introduction of the requirement to perform most hip fracture surgeries in the first 48 h of hospitalization by the Israeli Ministry of Health (IMOH) provides an interesting example of the complexity of this phenomenon. In 2004, the IMOH decided that hospitals would receive the full DRG payment for hip fractures operations only in cases in which the operation is performed within 48 h of hospitalization. In 2013, the IMOH proceeded to designate the proportion of less than 48 h surgeries as an official quality parameter for comparing hospital performance. Despite the widely acknowledged and proven clinical benefit of earlier surgery for hip fracture patients, the desired proportion of such surgeries in a given population is not easily defined for a given population, as a significant number of patients may be unsuited for immediate surgery due to medical instability, having a serious co-morbidity or receiving anticoagulant treatment. Rushing these patients to surgery can be therefore expected to have a negative effect on their outcomes, and the subsequent increase in hip fracture mortality recorded in Israel after 2013 may be a result of that. This example suggests that designating an organizational quality measure without adjusting it for the patient’s medical condition may make it too inaccurate to guide healthcare policy.