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What are the methodological issues related to measuring health care performance?

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Health system performance is currently high on national and international policy agendas. The past decades have seen a large development in the scope and use of performance measurement, which serves as an essential component of health system improvement. Information is crucial for the delivery of effective, equitable and efficient health care services, as well as for managerial purposes, such as ensuring accountability and transparency. Due to the complex nature of health systems, there are multiple information needs and uses which performance measurement must address. Health systems are extremely complex entities with multiple objectives. Most industrialized countries collect a variety of performance measures, both on the macro and micro levels, to adequately capture the different aspects and objectives that are important. Indicators range from population health measures and health status to nonmedical determinants of health, health system performance and patient accounts of experiences and satisfaction with their health system encounters. While this information is essential to health policy, there are several methodological challenges in developing and interpreting indicators, in particular composite indicators, that need to be recognized. Composite indicators of performance are an aggregation of a number of underlying performance indicators. Methodological challenges arise at each step in the process of calculating composite indicators. These include decisions about which indicators to choose and the quality of the data available, how to assign weights when aggregating the indicators, how to deal with collinearity among the indicators, and how to account for external factors impacting performance. Data limitations should be considered and explicitly presented before indicators are used, especially when they form a part of a composite measure. Proper risk-adjustment should also be used to control for variable patient characteristics and prevent problems of mis-attribution. In order to provide the most useful performance measures to help direct and plan health policy, these methodological issues must be taken into account, and and ideally composite indicators should be presented alongside indications of uncertainty.

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