Using Outcomes to

Improve Health Care

Decision Making

Primer

Management Decision and Research Center

Health Services Research and Development Service

Office of Research and Development

Department of Veterans Affairs

In collaboration with

Association for Health Services Research
Using Outcomes to Improve Health Care Decision Making / by Donald L. Zimmerman ... et al.

Boston, MA: Management Decision and Research Center; Washington, DC: VA Health 

Services Research and Development Service, in collaboration with Association for 

Health Services Research, 1997.

p. cm.

Includes bibliographical references. Primer.

DNLM: 1. Outcomes Assessment (Health Care) -- United States. 2. United States. Dept. 

of Veterans Affairs. Management Decision and Research Center. 3. United States. 

Dept. of Veterans Affairs. Health Services Research and Development Service. 

4. Association Health Services Research

W84.AA1 U85 1997

The Health Services Research and Development Service (HSR&D) is a program within the Veterans Health Administration’s Office of Research and

Development. HSR&D provides expertise in health services research, a

field that examines the effects of organization, financing and management

on a wide range of problems in health care delivery — quality of care,

access, cost and patient outcomes. Its programs span the continuum of

health care research and delivery, from basic research to the dissemination

of research results, and ultimately to the application of these findings to

clinical, managerial and policy decisions.
Using Outcomes to 

Improve Health Care 

Decision Making

Donald L. Zimmerman, Ph.D.

Jennifer Daley, M.D.

Purpose of primer series: to disseminate information

that will support VA managers in their efforts to improve the quality

and cost-effectiveness of health care for veterans. The primer series

is part of a larger set of dissemination initiatives developed by the

Veterans Health Administration’s (VHA) Office of Research and

Development through its Management Decision and Research Center and in collaboration with the Association for Health Services

Research.

Purpose of Using Outcomes to Improve Health

Care Decision Making: to introduce the purposes, scope

and general approaches to outcomes and outcomes measurement.

The primer provides a basic framework for understanding outcomes

and how outcomes measurement can be used by decision makers in

VA. The primer is not an exhaustive text in outcomes and it is not a

how-to manual; however, a list of more in-depth reference material is

provided in Appendix C. Appendices A and B provide a select list of

organizations within and outside VA that perform and disseminate

outcomes research.

Suggested audience: health care professionals involved in

health care system decision making. This includes managers

involved in policy, administration, clinical care and strategic planning. Other users include Veterans Service Organizations, health

care educators and students.

Suggested uses: outcome measurement training programs

in Headquarters, Veterans Integrated Service Networks and medical

centers, resource for program planning and evaluation, curriculum for medical schools, nursing schools, schools of business administration and public health, continuing medical education courses,

and other medical and health professional training programs.

March 1997

Boston, Massachusetts
Table of Contents

i

Contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

What are outcomes? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

How are outcomes measured?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Why is VA interested in outcomes measurement? . . . . . . . . . . . . 2

How are outcomes used?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

How is VA using outcomes measurement to achieve its 

vision for the future?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

What do VA managers need to know about using outcomes

measurement and research findings to improve services? . . . . 5

What are some examples of outcomes research conducted 

at VA? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Concluding remarks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

References and endnotes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Appendix A: What organizations perform outcomes 

research? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Appendix B: What organizations disseminate outcomes

research?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Appendix C: Where do I go for more information?. . . . . . . . . . 21
Contributors

Donald L. Zimmerman, Ph.D., is Executive Director of the Pennsylvania Health Care Cost Containment Council-- an independent state

agency responsible for addressing escalating health costs, ensuring the

quality of health care and increasing access for all citizens regardless

of ability to pay. Previously, Dr. Zimmerman was President of the Center for Health Research and Communications, Inc. His primary interests are in health information policy, quality improvement processes,

managed care program design and research methodology.

Jennifer Daley, M.D., is Acting Director, Health Services Research

and Development Program, Brockton/West Roxbury VA Medical Center, and a Senior Research Associate in the Department of Veterans

Affairs Health Services Research and Development Career Development Program. She is also Assistant Professor of Medicine at Harvard

Medical School, where she is a staff physician in the Division of General Medicine and Primary Care, Beth Israel Hospital, and is a consultant to the Picker Institute. Dr. Daley's main research interests are in

quality of care measurement, outcomes and effectiveness research and

risk adjustment methodologies. In addition to her numerous other

research publications, she is the author of the Guidebook on Uses of

Mortality Data: Applications in Hospital Quality Assurance Activities

(1990) and is co-editor of Through the Patient's Eyes (1993).

Kenneth W. Kizer, M.D., M.P.H., as Under Secretary for Health in

the Department of Veterans Affairs, is responsible for managing the

Veterans Health Administration (VHA), the nation's largest integrated

health care system. Among Dr. Kizer's previous positions are Chairman of the Department of Community and International Health, University of California, Davis; Director, California Department for

Health Services; Chairman of the Board, The California Wellness

Foundation; and Director, Health Systems International, Inc. Dr. Kizer's special areas of interest include health promotion and primary

care.

John R. Feussner, M.D., is VA's Chief Research and Development

Officer. Dr. Feussner oversees all of the VHA’s internal and extramural research programs. Prior to his current appointment, Dr. Feussner

served for 13 years as the Director of the Health Services Research

and Development Service (HSR&D) field program, the Center for

Health Services Research in Primary Care, and five years as Associate

Chief of Staff for Ambulatory Care at the Durham VA Medical Center.

Dr. Feussner has held several senior academic appointments at Duke

University and the University of North Carolina, including Professor

in Duke's Division of General Internal Medicine and Associate Professor in the Department of Community and Family Medicine, and Associate Professor of Health Policy and Administration at the University

of North Carolina School of Public Health. Over the last seven years,

Dr. Feussner has been a Senior Research Associate in the Cecil G.

Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.

iii
iv

Acknowledgments. Special thanks go to Ralph Swindle, Ph.D.,

Richard L. Roudebush VA Medical Center (Indianapolis); Lois Camberg, Ph.D., West Roxbury VA Medical Center; and Mary Darby, 

Consultant, for their contributions in developing the primer. Appreciation also is extended to colleagues throughout the Department of

Veterans Affairs (VA) for their thoughtful comments in reviewing an

earlier draft of the primer: Maureen Baltay, VA Headquarters; Galen

Barbour, M.D., Washington VA Medical Center; Paulette Cournoyer,

R.N., D.N.Sc., West Roxbury VA Medical Center; Ron Gebhart, M.D.,

VA Headquarters; Peter P. Henry, Fort Meade VA Medical Center;

Gerald Holman, M.D., Amarillo VA Medical Center; Janet Jones,

R.N., M.H.A., Fort Harrison VA Medical Center; Robert Lynch, M.D.,

Jackson VA Medical Center; Cynthia McCormack, R.N., Denver VA

Medical Center; Kenneth Mizrach, East Orange VA Medical Center;

Terry A. Morrow, VA Headquarters; Jacqueline Parthermore, M.D.,

San Diego VA Medical Center; Kathy Richards, R.N., Ph.D., Little

Rock VA Medical Center; Jerry Spenney, M.D., Birmingham VA Medical Center; Rebecca Williams, R.N., Denver VA Medical Center; and

Mary Vassar, R.N., M.S., VA Headquarters.
Preface

v

Anew VA is taking shape to meet the needs of America's veterans--

a VA that is committed to change and ready to face increased

demands for accountability and excellence in health care.

Perhaps the most visible of VA's changes are its reorganization

into integrated service networks, its implementation of universal primary care, a heightened focus on customer service and its conversion

from a hospital-based, specialty-focused system to one centered on

outpatient-based primary care. Many other changes are being implemented, and still others are in the works. Quite simply, every

process and every practice is being re-examined to see if it is still

appropriate in today's rapidly changing health care environment --

and whether it will continue to be appropriate in tomorrow's world.

Underlying VA's sweeping transformation are several strategic

objectives and guiding principles. Among these are the goals of

demonstrating excellence in health care value and excellence in

teaching and research. Essential to achieving these goals is knowing

what works most efficiently and effectively. And that means that VA

must measure its performance at all levels, evaluate variations from

benchmarks and rapidly institute process redesign where needed.

Likewise, we must monitor what our patients feel about the accessibility and quality of the care they receive. These activities fall under

the general rubric of outcomes management.

The Veterans Health Administration (VHA) is committed to applying existing outcome measures to our work, where appropriate, and

to supporting new developments in outcomes research. In fact, VA is

now uniquely positioned to advance knowledge in this area.

This primer is one of several VHA efforts to assist health care

managers, clinicians and policy makers -- both within and outside VA

-- to better understand outcomes research and its use to improve

both health care decision making and services.

Kenneth W. Kizer, M.D., M.P.H.

Under Secretary for Health

Veterans Health Administration

. . .VA must measure its

performance at all 

levels. . .
Introduction

vii

For decades, clinical epidemiologists have sought to establish the

"real world" effectiveness of diagnostic tests and treatments. These

researchers have been concerned not only with the "intervening"

variables that characterize disease status, but with the "patient outcome" variables that characterize patients' health status.

Health services researchers have broadened that research paradigm to include issues related to the patient, the provider of health

care and the health care delivery system -- focusing their research

questions at the interface of one or more of these dimensions. The

term "outcome," accordingly, carries a broader meaning within the

construct of this broader research paradigm. To the health services

researcher, outcomes are the results of interactions within the health

care system that include patient, employee or provider satisfaction;

quality of care; system efficiency; cost-effectiveness; and cost of care.

Measuring and understanding the implications of outcomes have

assumed increasing importance in recent years, as providers, purchasers, policy makers and consumers have stepped up their efforts

to improve the body of evidence on which medical decision making is

based and to maximize the value of health care expenditures.

The Department of Veterans Affairs has made an appropriately

strong commitment to use the tools of outcomes research to improve

the system's accountability for patients' health status, satisfaction

with care, ease of access, quality of care and efficiency of operations.

This primer has been prepared to help clinicians, managers and policy makers acquire a clearer understanding of the dimensions of outcomes research by answering some basic questions about outcome

measurement and its potential role in improving health care value.

The primer is written in a question-and-answer format for reading

ease and accessibility. Because of the prominent role that VA

research has played in the broader outcomes research field, several

VA research products are highlighted. Resources for further information, including appendices of organizations involved in the conduct and dissemination of outcomes research and an appendix listing

more in-depth readings, also are provided.

John R. Feussner, M.D.

Chief Research and Development Officer

Veterans Health Administration

The Department of 

Veterans Affairs has

made an appropriately

strong commitment to

use the tools of outcomes

research to improve the

system’s accountability. . .
Simply put, outcomes are the results of specific health care services and interventions. They may be measured at several levels: the

community, the system and the individual. When information about

outcomes is properly collected and analyzed, outcomes may be useful

tools for assessing the effectiveness, quality and value of health care

services. They also may be used to compare the benefits and costs of

different treatment approaches.

Outcomes encompass many aspects of health care, including clinical quality, cost, effectiveness, access, patient satisfaction and

resource use. Post-discharge mortality was the first outcome to be

systematically assessed on a large scale, but outcomes run a gamut

of measures that include functional status, rates of complications

and/or readmission, length of stay, length of recovery, cost-effectiveness and patient satisfaction with care. Outcomes are as varied as

the questions concerning health care services, so the specific outcomes in which you are interested will depend on the issues you are

trying to address.

Avariety of data sources may be used to measure health care outcomes, but the three most frequently used sources are:

n administrative records,

n medical records, and

n patient and provider surveys.

These data sources have their own unique strengths and weaknesses. Administrative records, for example, are particularly useful in

tracking service utilization and costs, but lack clinical detail. Medical records are better sources of clinical information, but may be

incomplete or illegible. In addition, the abstraction of relevant data

from medical records is a time-consuming and expensive task.

Patient and provider surveys may be used to assess functional status, satisfaction with care or perceptions of how care was provided.

But they too are costly because of the time required to administer

them and the expertise needed to analyze them properly. The SF-36

and the TyPe instruments are examples of some of the better-known

survey tools in use, but there are hundreds more.1

VA is using patient survey data in a number of ways. The National Customer Feedback Center, for example, surveys patients annually on their perceptions of care coordination and continuity, access to

needed services, waiting times and whether the care they received

met their expectations. This information is then used to monitor

compliance with VHA's customer service standards. In addition,

VA's Ambulatory Care Data Capture Project will improve VA's ability

to track data about ambulatory care patient encounters and to assess

outcomes of care.

Regardless of which data sources are used, outcomes must be

tracked and assessed rigorously over time to identify the organizational characteristics and processes that affect quality and to use

that information to improve services. Reliable data collection is necessary to develop strong evidence for health care decision making.

What are outcomes?

1

How are outcomes measured?

. . . outcomes are the

results of specific health

care services and 

i n t e r v e n t i o n s .
"Excellence in health care value [and] excellence in service as

defined by its customers" are at the core of VA's ongoing transformation into a comprehensive, integrated health care system, Under Secretary for Health Kenneth W. Kizer notes in Prescription for Change,2

VA's strategic plan for reorganizing health care delivery. Value in

this case means health care services that are not only high-quality,

but appropriate and cost-effective. Outcomes measurement provides

objective information to customers and promotes data-driven decision making by VA managers.

The private sector also is interested in outcomes measurement,

where its use has expanded rapidly. Providers, purchasers, payers

and patients all have different interests in outcomes measurement.

Purchasers and payers, for example, want to maximize the value 

of their health care dollars. Providers want to improve the quality 

of their care and be able to demonstrate it. Patients want information that will help them select good providers and participate 

more knowledgeably in decisions concerning their health care

n e e d s .

Outcomes once were the domain of the researchers who pioneered

them, but with the demand for greater value and accountability in

health care, interest in using outcomes measurement to guide health

care delivery has spread throughout the industry. "You can't manage

what you can't measure" is the oft-quoted phrase with regard to the

importance of outcomes measurement. Outcomes analyses may be

used by clinicians, health care system managers and policy makers

to better manage costs, quality, patient health status, patient satisfaction and overall system performance. Possible uses of outcomes

include:

n Identify areas for quality improvement and use data for quality

improvement processes. VA is using quality improvement methods

to help clinicians improve their treatment outcomes and cost-effectiveness.

n Establish performance benchmarks, which identify the best performance in the industry for a particular process or outcome. VA is

working to develop and monitor performance benchmarks for network and facility managers.

n Track and compare provider performance over time. VA will

assess and compare quality at the national, network and facility levels.

n Develop evidence-based clinical practice guidelines. VA's Office of

Performance Management Services is facilitating the production of

guidelines for many common conditions and interventions. Examples of this work are detailed guidelines for use with patients having

acute ischemic heart disease and for treatment of major depression.

VHA’s Office of Research and Development contributes to the evidence base for guidelines such as these and through it’s Health Services Research and Development Service is funding new research to

evaluate implementation of practice guidelines.

2

Why is VA interested in outcomes measurement?

How are outcomes used?

Outcomes measurement

provides objective 

information to customers

and promotes datadriven decision making

by VA managers.

“You can’t manage what

you can’t measure. . .”
n Establish clinical "Centers of Excellence" by allowing providers to

identify those treatments and conditions where they excel. VA also

hopes to develop new service lines at the national, network and facility levels.

n Inform patients and purchasers in their selection of providers. VA

believes that outcomes measurement will help it demonstrate the

quality and value of its services.

n Assess new and existing technologies. VA's Technology Assessment Program is coordinating information on technology assessment

and related activities within VA and assessing the use of selected

clinical technologies for VA.

n Educate patients. VA is studying whether patient participation in

health care decision making improves treatment outcomes and

patient satisfaction.

n Improve provider-customer relations. VA wants to identify how

well veterans' needs and expectations are being met.

n Assess system change. Outcomes measurement will help VA monitor and evaluate the effects of change underway within VA.

One important VA objective emphasized in Prescription for

Change is to promote a culture of continuous quality improvement

that will maximize the value of the health care services VA provides.

VA is using outcomes data and measurement tools to achieve that

objective. Following the guidance in Prescription for Change, VA has

launched a number of activities, including:

n Use #1: Developing performance indicators -- which are

defined, measurable variables used to monitor important

aspects of patient care -- to assess the effectiveness and efficiency of all VA programs. Those measures reflect five domains

of value:

n cost/price,

n technical quality,

n customer satisfaction,

n patient function, and

n access to care

Measurement categories and performance indicators have been

developed for use in performance agreements between Headquarters

and the Veterans Integrated Service Network (VISN) directors.

These performance agreements evaluate processes and progress in

networks and facilities. Additionally, work is progressing in the

development of performance measures in ambulatory care, mental

health and the special emphasis programs. Performance measures

collected uniformly across all VA medical centers and VISNs ultimately may permit the comparison of medical centers within a VISN,

in different VISNs and of similar medical centers across the country.3

3

How is VA using outcomes measurement to achieve its

vision for the future?
n Use #2: Establishing provider, service line, facility, network and systemwide benchmarks and performance measures for the five domains of value. Where possible, measures

that permit performance comparisons between VA and non-VA

providers will be developed.

n Use #3: Developing, revising and disseminating national

practice guidelines that reflect outcomes data. VA's Office of

Policy, Planning and Performance and the Office of Patient Care Services are working together to design a process for developing, revising and disseminating national practice guidelines. Practice

guidelines are systematically developed statements designed to

improve and standardize care. They generally are based on a combination of the best available scientific evidence and expert opinion.

Practice guidelines for rehabilitation medicine, ischemic heart disease and major depression were produced and others are underway.

n Use #4: Refining and developing new risk-adjustment

methodologies to facilitate comparison of VA, private sector

and other service populations. Risk adjustment, which controls

for differences in patient populations such as age and comorbid conditions, is a major issue in outcomes measurement. New risk-adjustment tools have been developed to assess readmissions, length of

stay, pressure sore development in long-term care, surgical morbidity

and mortality, psychiatric and substance abuse readmissions and cardiac surgery.

n Use #5: Establishing performance monitoring systems and

mechanisms for dissemination of best practices systemwide.

Benchmarking and performance monitoring systems that routinely

track performance and provide timely feedback to providers are

underway. In addition, the Office of Policy, Planning and Performance is taking steps to establish a Center for Dissemination of

Innovations to assist the field in keeping abreast of best practices,

which serve as blueprints for achieving exemplary outcomes. Clinical programs and facilities that meet new performance excellence criteria may soon apply for selection as a Center of Excellence to

celebrate and disseminate best practices.

n Use #6: Exploring the use of "report card" measures for use

in VA, especially for chronic diseases. Report cards are becoming increasingly popular throughout the industry as tools that allow

policy makers, purchasers and patients to compare and understand

provider performance by supplying data for specific measures of

health care quality and utilization, patient satisfaction and other

areas of interest. VA is interested in developing and applying measures that assess processes of care, similar to those in the Health

Plan Employer Data and Information Set (HEDIS). VA is discussing

this idea with the National Committee on Quality Assurance, which

oversees the development and updating of HEDIS.4

4

Report cards are 

becoming increasingly

popular throughout the

industry as tools that

allow policy makers,

purchasers and patients

to compare and 

understand provider

performance. . .
Outcomes measurement will provide VA managers with a better

understanding of how care is delivered within their organizations.

Outcomes measurement supplies objective data to assist in decision

making and helps managers achieve greater accountability. But the

practical integration of outcomes information and analysis into dayto-day program operations, clinical behavior, systems of care and policy is no simple task. Managers who want to make good use of

outcomes findings should bear in mind the following guidelines:

n Guideline #1: Make sure that research results are relevant

to your organization before trying to put them to work for

you. Many factors play a role in determining the applicability of a

given study to a specific setting, although they are often overlooked.

These factors include variables such as patient characteristics, the

standards of care or methods that were used in the study and the proposed use or purpose of the study intervention. You should also pay

close attention to differences in provider types, sites of care and delivery system characteristics. Managers may want to consider consulting with a researcher or other expert who is knowledgeable about the

strengths and limitations of specific outcomes findings for advice on

the applicability of those findings before trying to adopt them. (See

contact information in Appendix A for VA Office of Research and

Development and Health Services Research and Development Service.)

n Guideline #2: Be careful in interpreting research results.

Evidence-based decision making is the ideal. But sometimes, despite

all efforts, there are no clear-cut answers. For example, the effects of

a specific treatment may be difficult to separate from other confounding variables. Or, the effectiveness of a new medical device

may be highly dependent on factors such as provider training and

experience, financial incentives associated with using the device,

patient socioeconomic status, the setting in which care is provided

and the quality of follow-up care. Or, changes associated with higher

patient satisfaction may not conform with what has been shown to

be the most effective medical treatment. Research findings that are

ambiguous or inconclusive should be avoided as tools for changing

clinical behavior. VA managers might consider requesting literature

reviews or new research from VA's Technology Assessment Program.

(See contact information for this program and others in Appendix B.)

n Guideline #3: Work with clinicians. Clinicians want to practice good medicine, but they need to be convinced that suggested

changes will indeed improve patient outcomes. The best way to

enlist clinicians' backing is to involve them in the process from the

outset. By engaging their help in defining and solving problems,

they are more likely to applaud those solutions. Use good, reliable

data to support recommended changes. Dissemination of research

results to clinicians without educational or other activities is not

likely to make a difference in their behavior.

n Guideline #4: Equip yourself to evaluate the impact of the

change. System managers and policy makers must be able to evaluate the effects of outcomes-based interventions and changes. That

means being able to isolate and measure the effects of complex interdependencies within the organization that, taken together, "create" a

5

What do VA managers need to know about using outcomes

measurement and research findings to improve services?

Outcomes measurement

supplies objective data

to assist in decision

making. . .

Evidence-based decision

making is the ideal. But

sometimes, despite all

efforts, there are no

c l e a r-cut answers.
given set of outcomes. Measurements should differentiate behavior

of clinicians, managers, policy makers and consumers.

n Guideline #5: Be realistic about what can be accomplished. Systematic improvement is hard work, and it takes time. 

If you go in with the idea that you will make dramatic strides in a

short time, you likely will be disappointed with the results.

VAinvestigators are conducting outcomes studies on a wide

range of topics, all in an effort to improve the quality and cost-effectiveness of health care services for U.S. veterans. Here are just a few

examples of the scores of VA outcomes studies that are either already

completed or underway:

n Quality Assessment: The Veterans Ambulatory Care Assessment Project is identifying key variables to assist managers in

assessing the quality of care for patients with hypertension, diabetes

and chronic obstructive pulmonary disease.5

n Best Practices for Surgery: A study of the management and

organization of surgical services will provide managers with best

clinical and management practices for providing surgical care to support surgical quality improvement efforts.6

n Acute Myocardial Infarction: The Brockton/West Roxbury VA

Medical Center is conducting a study of the appropriateness and

necessity of cardiac catheterization, coronary angioplasty and coronary artery bypass graft surgery -- three alternative treatments following an acute myocardial infarction -- to identify possible

overutilization or underutilization.7

n Quality of Life: The Veterans’ Health Study is monitoring

ambulatory veterans with common illnesses such as diabetes and

chronic obstructive pulmonary disease. This study includes patients'

evaluations of their own overall physical and mental well-being, ability to conduct normal activities of daily living and general satisfaction with their health.8

n Schizophrenia Patient Outcomes Research Team (PORT):

The PORT for Schizophrenia will help VHA policy makers reconfigure programs to improve the quality of care for these severely dysfunctional and disabled patients.9

n Oral Health: The Dental Longitudinal Study examines the

effects of various treatments on oral health outcomes for aging veterans. Study results help VA managers to more efficiently design and

effectively target intervention strategies for these high-risk patients.1 0

n Treatment of Aneurysm: The Aneurysm Detection and Management trial examines the necessity of surgery for aneurysms that

are not large or symptomatic. If postponing such surgery is safe,

many unnecessary operations could be avoided -- resulting in significant cost savings and reduced patient suffering.11

n Liver Cirrhosis: An ongoing clinical trial is investigating treatment to prevent development of cirrhosis in patients with alcoholrelated liver disease. A simple, effective treatment is being sought to

reduce human suffering and health care costs.12

6

What are some examples of outcomes research conducted

at VA?
n Patient-physician Interaction: A study at the Portland VA

found that patient outcomes can be improved by enhancing interaction and information exchange between outpatients and physicians.

This study suggests an intervention that easily could be adopted in

VA primary care clinics to improve patient outcomes and patient satisfaction.13

n Prostate Cancer: There is no universally accepted "best" treatment for prostate cancer -- one of the most significant health risks

facing male veterans. A large-scale, national study is under way in

VHA, in collaboration with the National Cancer Institute, to evaluate the use of surgery to remove the prostate entirely versus medical

treatment as symptoms develop. Each treatment strategy is being

examined for its impact on patient health status and overall costs.14

n Cardiac Services: The Denver VAMC is conducting a study of

how the organization and processes of its cardiac services unit are

affecting outcomes in open heart surgery for atherosclerotic cardiovascular disease. Among the outcomes being measured are patient

health-related quality of care, chest pain and patient satisfaction

with care.15

n Care for Homeless Veterans: A study comparing a new program of domiciliary care with standard VA treatment for homeless

veterans with chronic alcohol and drug addiction is expected to provide VA policy makers with better strategies for serving this very

needy veteran population.16

7
Concluding remarks

Appendices

9

Outcomes measurement helps bring the focus of the entire health

care delivery system back to the patient. Rigorous and continuous

evaluation of the processes of care through outcomes measurement

and analysis ultimately will improve the quality of care.

The technical capabilities of this still-young field have expanded

dramatically during the past few years -- in accordance with demands

on health care managers to demonstrate greater accountability for

the value of the services they provide. It's not surprising that the use

of outcomes measures has become more central to the management

and practice of good clinical care.

VA will continue to use the tools offered by outcomes measurement to enhance its efforts to provide excellent health care services

to U.S. veterans. All levels of the organization will be engaged to

improve health care quality and value: patients and their families,

providers, the staff who contribute to the processes of care, the

administration and the communities served by VA facilities. VA’s

Office of Research and Development through its Health Services

Research and Development Service will continue to support the

development and application of outcomes measures to improve the

quality of health care for our nation’s veterans.

Outcomes measurement

helps bring the focus of

the entire health care

delivery system back to

the patient.

The following appendices provide more detailed information on VA

and non-VA organizations that perform and disseminate outcomes

research and offer additional readings on the topic.
References and endnotes

11

1. For more information on survey instruments, contact the Health

Outcomes Institute for the TyPe condition-specific instruments at

612/858-9188, fax: 612/858-9189, or the Medical Outcomes Trust, for

the SF-36 Health Survey and other generic and condition-specific

instruments, 20 Park Plaza, Suite 1014, Boston, MA, 02116, phone:

617/426-4046, fax: 617/426-4131, e-mail: motrust@worldnet.att.net.

2. Kizer, K.W. Prescription for Change: The Guiding Principles and

Strategic Objectives Underlying the Transformation of the Veterans

Healthcare System. Washington: U.S. Department of Veterans

Affairs, Veterans Health Administration, March 1996.

3. For more information on performance measures and other activities of VA’s National Performance Data Resource Center, contact

Eileen Ciesco, Ed.D., Acting Director, phone: 919/286-6978, ext. 229,

FTS: 700/671-6978, fax: 919/286-6864.

4. For more information about HEDIS, contact the National Committee on Quality Assurance at 202/955-3500, fax: 202/955-3599.

5. For more information on the study, Veterans Ambulatory Care

Assessment Project, contact Dan Berlowitz, M.D., Bedford VAMC,

phone and FTS: 617/687-3250, fax: 617/687-3106, e-mail:

berlowitz.dan@bedford.va.gov.

6. For more information on the study, Coordination and Patient Outcomes: A Study of Surgical Services, contact Martin P. Charns,

D.B.A., Management Decision and Research Center, Boston VAMC,

phone: 617/278-4433, FTS: 700/839-4433, fax: 617/278-4438, emall: charns.martin@forum.va.gov.

7. For more information about Brockton/West Roxbury VAMC’s

study of the appropriateness and necessity of three alternative treatments following acute myocardial infarction, contact Laura Petersen,

M.D., M.P.H., Principal Investigator, Brockton/West Roxbury Health

Services Research and Development Program, phone: 617/323-7700,

ext. 6278, FTS: 700/885-6278, fax: 617/363-5587, e-mail:

petersen.laura._l@ brockton.va.gov.

8. For more information on the study, Health-related Quality of Life

in Veterans: The Veterans Health Study, contact Lewis E. Kazis,

Sc.D., Edith Nourse Rogers Memorial Veterans Hospital, phone and

FTS: 617/687-3250, fax: 617/687-3106.

9. For more information on the study, A Comparative Study of VA

Mental Health Services for Schizophrenia, contact Robert Rosenheck, M.D., West Haven VAMC, phone: 203/937-3850, FTS: 700/428-

3850, fax: 203/937-3433.
12

10. For more information on the study, Dental Longitudinal Study,

contact Judith Jones, D.D.S., M.P.H., Bedford VAMC, phone:

617/687-2644, FTS: 700/840-2470, fax: 617/687-3511, e-mail:

jones.judith@bedford.va.gov.

11. For more information on the study, Aneurysm Detection and

Management Trial, contact Frank A. Lederle, M.D., Minneapolis

VAMC, phone: 612/725-2000, ext. 2679, FTS: 700/780-2158, fax:

612/725-2118, e-mail: leder002@maroon.tc.umn.edu.

12. For more information on the study, Colchicine in the Treatment

of Alcoholic Cirrhosis of the Liver, contact Timothy R. Morgan, M.D.,

Long Beach VAMC, phone: 310/494-5756, FTS: 700/966-5756, fax:

310/494-5674, e-mail: morgan.timothy_r@longbeach.va.gov.

13. For more information on the study, Patient-Physician Interaction and Patient Outcomes, contact David Hickam, M.D., Portland

VAMC, phone: 503/423-6775, FTS: 700/424-7288, fax: 700/424-

5367, e-mail: hickam@portland.va.gov.

14. For more information on the study, Prostate Cancer Intervention

Versus Observation Trial (PIVOT): A Randomized Trial Comparing

Radical Prostatectomy Versus Palliative Expectant Management for

the Treatment of Clinically Localized Prostate Cancer, contact Timothy J. Wilt, M.D., M.P.H., Minneapolis VAMC, phone: 612/725-2000,

ext. 2681, FTS: 700/780-2681.

15. For more information on the study, Processes, Structures and

Outcomes of Care in Cardiac Surgery, contact Karl E. Hammermeister, M.D., Denver VAMC, phone: 303/399-8020, ext. 3051, FTS:

700/322-3146.

16. For more information on the study, Case Managed Residential

Care for Addicts: An Outcomes Study, contact Kendon Conrad, Ph.D.,

Hines VAMC, phone: 708/216-2414, FTS: 700/381-5876, fax:

708/216-2316, e-mail: kendon.conrad@uic.edu.
Appendix A: What organizations perform

outcomes research? 

13

Both the private and the public sectors are heavily involved in outcomes research. Numerous universities, academic medical centers,

hospitals, group practices, foundations, managed care organizations,

trade associations, health care purchasers and purchasing coalitions

participate in efforts to measure and apply outcomes to health care

decision making, and to develop new and better measures.

Within the federal government, VA is a leader in conducting and

supporting outcomes studies, and VA scientists and clinicians are

key members of the national community of experts in outcomes

research. VA's outcomes research activities are conducted through

the Office of Research and Development.

Listed below are a number of organizations within and outside VA

that conduct outcomes research. 

Within VA

n Office of Research and Development

VA Headquarters

John R. Feussner, M.D., Chief Research and Development Officer

phone and FTS: 202/273-8284

fax: 202/273-6526

e-mail: feujoh@mail.va.gov

VA's Office of Research and Development focuses its efforts on the

health and care of our nation's veterans. The office oversees the full

range of medical research, multi-site cooperative studies, rehabilitation research and health services research in VA. Outcomes research

is a priority for VA’s Office of Research and Development, and several of these studies are highlighted on pages 6 and 7 of this primer.

q Health Services Research and Development Service

(HSR&D)

VA Headquarters

Shirley Meehan, M.B.A., Ph.D., Acting Director 

phone and FTS: 202/273-8287

fax: 202/273-9007

e-mail: meeshi@mail.va.gov

Within the Office of Research and Development, the Health Services Research and Development Service provides expertise in

health services research, a field that examines the effects of health

care organization, financing and management on a wide range of

delivery issues, including quality of care, access, cost and patient

outcomes. These programs span the continuum of health care

research and delivery, from research to the dissemination of

research results, and, ultimately, to the application of these findings to clinical, managerial and policy decisions.
14

s Health Services Research and Development Service

Management Decision and Research Center (MDRC)

Boston VAMC

Martin P. Charns, D.B.A., Director

phone: 617/278-4433

FTS: 700/839-4433

The MDRC’s mission is to enhance the delivery of the highest

quality health care by providing VA senior staff with consultation, technical assistance, management information and

research findings. MDRC’s four interdependent programs --

management consultation, information dissemination, technology assessment, management and organizational research --

provide VA researchers and managers with powerful tools for

planning and decision making, helping them find solutions to a

wide range of problems in health care delivery.

s Health Services Research and Development Field Programs

HSR&D Field Programs are Centers of Excellence in targeted

focus areas. These nine Field Programs foster the integration of

research and practice, linking the clinical aspects of patient care

with administrative needs through a core of VA staff at selected

medical centers. Each program develops its own research agenda and maintains affiliations with community institutions --

schools of public health, university health administration programs and research institutes -- to support its objectives.

m Center for Practice Management and Outcomes Research 

Ann Arbor VAMC

Rodney A. Hayward, M.D., Director

phone and FTS: 313/930-5100

Primary research areas: Optimal management of resourceintensive care including: quality monitoring and improvement, evaluation of outcomes of alternative treatments,

variations in practice and outcomes and resource allocation.

m Center for Health Quality, Outcomes and Economic 

Research

Edith Nourse Rogers Memorial Veterans Hospital, Bedford

Mark Prashker, M.D., M.P.H., Director

phone and FTS: 617/687-3250

Primary research areas: Health economics, productivity measurement, quality assessment in ambulatory and long-term

care, health outcomes measurement, case-mix measurement,

cost-effectiveness analysis and decision analysis.

m Center for Health Services Research in Primary Care 

Durham, VAMC

Ronnie Horner, Ph.D., Acting Director

phone: 919/286-6936

FTS: 700/671-6936

Primary research areas: Ambulatory care, women's

health, geriatrics, epidemiology of chronic disease.
m Midwest Center for Health Services and Policy Research 

Edward Hines, Jr. VA Hospital, Hines (with participating

VAMCs in Lakeside, North Chicago and West Side)

John Demakis, M.D., Director

phone: 708/216-2414

FTS: 700/381-2414

Primary research areas: Long-term care/geriatrics, sociodemographics, medical decision making, quality assurance, costeffectiveness, database development/management.

m Houston Center for Quality of Care and Utilization Studies

Houston VAMC

Nelda Wray, M.D., M.P.H., Director

phone: 713/794-7615

FTS: 700/528-7615

Primary research areas: Determinants of utilization of

health care, quality assessment using large databases and

outcome measures of quality of care.

m HSR&D Field Program for Mental Health 

Little Rock VAMC

G. Richard Smith, M.D., Director

phone: 501/688-1622

FTS: 700/740-1622

Primary research areas: Mental health services research,

cost-effectiveness of treatments, patient outcomes of care.

m Center for Health Care Evaluation

VA Health Care System, Palo Alto (with participating

Sierra Pacific VISN VAMCs in Fresno, Reno and San Francisco

[including Livermore] Northern California System of Clinics)

Rudolf H. Moos, Ph.D., Director

phone: 415/493-5000 ext. 65527

FTS: 700/463-5527

Primary research areas: Health care evaluation, health economics, diagnostic assessment and clinical decision making

and alcohol/substance abuse.

m VA Puget Sound Health Care System, Seattle Division 

Seattle VAMC (with participating VAMC in Portland, OR)

Stephan D. Fihn, M.D., M.P.H., Director

phone: 206/764-2430

FTS: 700/396-2430

Primary research areas: Care of the aging veteran, research

in ambulatory care, outcomes research and disease prevention/health promotion.

m Center for the Study of Healthcare Provider Behavior 

Sepulveda VAMC (with participating VAMCs in West Los

Angeles and San Diego)

Lisa V. Rubenstein, M.D., M.S.P.H., Director

phone: 818/895-9449

FTS: 700/966-9449

Primary research areas: Health care quality and outcomes,

quality improvement, clinical practice guideline implementation and primary care/managed care evaluation.

15
Outside VA

n Agency for Health Care Policy and Research (AHCPR) 

Center for Outcomes and Effectiveness Research 

Carolyn M. Clancy, M.D., Director

phone: 301/594-1485

website: www.ahcpr.gov

AHCPR offers on-line reports that address evidence-based practice

information, recommendations for clinical practice preventive interventions on more than 80 conditions, health technology assessments

and reviews, updates on the Medical Treatment Effectiveness Program (MEDTEP) and outcomes research. The Center for Outcomes

and Effectiveness Research conducts and supports studies of the outcomes and effectiveness of diagnostic, therapeutic and preventive

health care services and procedures.

Please note that this list is not intended to be exhaustive.

MDRC, AHSR and the authors are interested in knowing of

additional organizations that conduct outcomes research.

Please list additional programs on the “Fax us your comments!” page at the back of this primer and fax or mail it to

the MDRC.

16
17

Appendix B: What organizations 

disseminate outcomes research? 

The private and the public sectors also are committed to the dissemination of outcomes research. A majority of VA's outcomes dissemination activities are conducted through the Office of Policy,

Planning and Performance and the Office of Research and Development.

Listed below are organizations within and outside VA that disseminate products based on the results of outcomes research. 

Within VA

n Office of Policy, Planning and Performance

VA Headquarters

Gregg Pane, M.D., M.P.A., Chief Policy, Planning and Performance

Officer

phone and FTS: 202/273-8932

fax: 202/273-9030

e-mail: pangre@va.mail.gov

The Office of Policy Planning and Performance (OPPP) is responsible for integrating VHA's strategic planning and performance management activities with policy implications to ensure that quality

management considerations drive the planning activities and underlie

all operations. The office has primary responsibility for strategic

and delivery system planning initiatives, performance management,

policy review and analysis. Within the OPPP, the Performance Management Services are of particular interest.

q Performance Management Services (formerly the Office of 

Quality Management)

VA Headquarters

Nancy Wilson, M.D., Director

phone and FTS: 202/273-8936

fax: 202/273-9030

e-mail: wilnancy@va.mail.gov

The mission of the Office of Performance Management is to facilitate the delivery of VA health care value through ongoing performance improvement. Value is defined as the delivery of the best

patient outcomes for technical quality, satisfaction and functional

status at the lowest cost to the largest number of eligible veterans.

This office is responsible for system performance measures and

evaluation; benchmarking and best practices; data risk adjustments; leadership on issues related to the Joint Commission on

Accreditation of Healthcare Organizations (JCAHO) and the

National Committee for Quality Assurance (NCQA); facilitating

clinical guidelines; and the National Performance Data Resource

Center (NPDRC) and the National Customer Feedback Center

(NCFC). The NPDRC and the NCFC may be of particular interest

to managers working with outcomes data.
s National Performance Data Resource Center (formerly the 

Quality Management Institute) 

Durham VAMC

Eileen Ciesco, Ed.D., Acting Director

phone: 919/286-6978 

FTS 700/671-6978 ext. 229

fax: 919/286-6864

e-mail: ciesco.eileen@forum.va.gov

The mission of the NPDRC is to enable VISNs and facilities to

improve performance and advance the delivery of health care by

offering understandable, applicable, impartial and comparable

data and information systems that support VHA’s vision and

strategic principles.

s National Customer Feedback Center 

Brockton/West Roxbury VAMC 

Eileen Tarsky, R.N.C., Director

phone: 617/323-7700 ext. 5538

FTS: 700/885-5538

fax: 617/363-5539

The NCFC surveys inpatients and outpatients annually, collecting data on patients' perceptions of care continuity and coordination, access to needed services, waiting times and whether the

care they received met their expectations. These and other factors form the basis of VHA's customer service standards. The

NCFC provides each VA medical center with information about

how well each medical center is meeting these customer service

standards and how each medical center compares with its peers.

q National VA Surgical Quality Improvement Program

Brockton/West Roxbury VAMC and Hines VAMC

Jeannette Spenser, R.N., M.S., C.S., National Coordinator

phone: 617/323-7700 ext. 6738 or 6740

FTS: 700/885-6738

fax: 617/363-5567

e-mail: spenser.jeanette@brockton.va.gov

Continuous collection and analysis of valid information about surgical practice and outcomes within VHA are critical for monitoring

and improving the quality of care in all VA medical centers. The

National VA Surgical Quality Improvement Program (NSQIP) is

an example of a successful program of measurement and local use

of data for substantive clinical improvement. The NSQIP provides the best available outcomes data (risk-adjusted and normalized) for specific surgical interventions.

n Health Services Research and Development Service, MDRC, 

Technology Assessment (TA) Program

Boston VAMC

Karen Flynn, D.D.S., M.S., Manager

phone: 617/278-4469

FTS: 700/839-4469

fax: 617/278-4438

e-mail: flynn.karen@forum.va.gov

The Management Decision and Research Center has created a Technology Assessment Program to coordinate information from existing

technology assessment and related activities within VA and to assess

the clinical use of selected technologies for VA. The TA Program's

focus is to improve quality of care and efficiency of resource use

within VA by promoting evidence-based clinical practice and policy

decisions. The program's components include a technology assess18
ment information service, major assessments, technology assessment

education and methodology support within VA and a clearinghouse

for VA technology assessment activities.

q San Antonio Cochrane Center

San Antonio VAMC

Cynthia D. Mulrow, M.D., M.Sc., Co-director 

Elaine Chiquette, Pharm.D., Co-director

phone: 210/617-5190

fax: 210/617-5234

e-mail: cochrane@merece.uthscsa.edu

The Center is formally affiliated with the Cochrane Collaboration,

an international network of more than 2,000 individuals committed to preparing, maintaining and disseminating systematic

reviews of the effects of health care. Reviews are based on the

results of randomized controlled trails (RCTs) and, when RCTs

are not available, the most reliable evidence from other sources.

The reviews are disseminated through the Cochrane Database of

Systematic Reviews -- a regularly updated electronic journal, currently distributed on CD-ROM and disk (website:

hiru.mcmaster.ca/cochrane/). VA's San Antonio Cochrane Center

provides support to contributors to the Cochrane Collaboration

throughout the U.S. 

Outside VA

n Agency for Health Care Policy and Research (AHCPR)

Center for Health Information Dissemination

Christine G. Williams, M.Ed., Director

phone: 301/594-1360

website: www.ahcpr.gov

AHCPR offers on-line reports that address evidence-based practice

information, recommendations for clinical practice preventive interventions on more than 80 conditions, health technology assessments

and reviews, updates on the Medical Treatment Effectiveness Program (MEDTEP)and outcomes research. The Center for Health

Information Dissemination designs, develops, implements and manages programs for disseminating the results of agency activities,

including public affairs, information products, electronic dissemination, reference services, dissemination research and liaison activities. 

n Association for Health Services Research (AHSR) and

National Library of Medicine (NLM)

Health Services Research Projects (HSRProj) database

Marian Mankin, M.Ed., Associate Project Director (AHSR)

phone: 202/223-2477

fax: 202/835-8972

website: www.ahsr.org

HSRProj is a growing database of 4,000 records describing health

services research grants and contracts funded by the public and private sectors. The database provides information about current

research before the research results are published. Users can readily

access HSRProj through NLM's MEDLARS system and retrieve

information on a broad array of topics. The database provides primary investigator contact information to facilitate linkages among

researchers working within a topic area, allowing them to share

methodological and other lessons learned. A compendium of

abstracts of ongoing outcomes research projects is available from

AHSR upon request.

19
n National Library of Medicine

Health Services/Technology Assessment Text (HSTAT) Database 

National Information Center on Health Services Research and

Health Care Technology (NICHSR)

phone: 301/496-0176

fax: 301/402-3193

e-mail: nichsr@nlm.nih.gov

website: text.nlm.nih.gov

HSTAT is an electronic resource that provides access to the full text

of documents useful in health care decision making. HSTAT

includes clinical practice guidelines, quick reference guides for clinicians and consumer brochures sponsored by AHCPR.

Please note that this list is not intended to be exhaustive.

MDRC, AHSR and the authors are interested in knowing of

additional organizations that disseminate the results of outcomes research. Please list additional programs on the “Fax

us your comments!” page at the back of this primer and fax

or mail it to the MDRC.

20
For more in-depth reading on outcomes measurement and

research and its role in the delivery of care, the following publications may be helpful:

n Berwick, D.M. “A Primer on Leading the Improvement of Systems.” British Medical Journal, 312 (7031):619-22, March 9,1996.

n Brook, R.H., Chassin, M.R., Fink, A., et.al. “A Method for the

Assessment of Acute Medical Care for the Elderly: An Analysis of

the Literature.” Health Policy, 14 (3): 225-242, 1990.

n Brook, R.H., McGlynn, E.A., and Cleary, P.D. “Measuring Quality

of Care.” New England Journal of Medicine, 335 (13): 966-70, September 26,1996. 

n Buffum, M. and Dean, H., eds. Toward Enhanced Outcomes Measurement: An Outcomes Measurement Reference Book. Washington:

U.S. Department of Veteran Affairs, Nursing Service, Research Constituency Center, June 1996.

n Chassin, M.R. “Improving the Quality of Care.” New England

Journal of Medicine, 335 (14) : 1060-4, October 3,1996.

n Donabedian, A. The Methods and Findings of Quality Assessment

and Monitoring: An Illustrated Analysis. Ann Arbor: Health

Administration Press, 1985.

n Goodman, C., Snider, G., Flynn, K. Health Care Technology

Assessment in VA. Boston: U.S. Department of Veterans Affairs,

Health Services Research and Development Service, Management

Decision and Research Center (in conjunction with Association for

Health Services Research), May 1996.

n Halpern, J. “The Measurement of Quality of Care in the Veterans

Health Administration.” Medical Care, 34 (3 Supplement): MS55-

68, March 1996.

n U.S. Department of Health and Human Services, Public Health

Service, Health Care Financing Administration. Health Care

Financing Review: Consumer Information in a Changing Health

Care System. Washington: U.S. Government Printing Office, January 1997. HCFA Pub. No. 03385. 

n Lammers, J.C., Cretin, S., et.al. “Total Quality Management in

Hospitals: The Contributions of Commitment, Quality Councils,

Teams, Budgets, and Training to Perceived Improvement at Veterans Health Administration Hospitals. Medical Care, 34 (5): 463-78,

May 1996.

Appendix C: Where do I go for more

information? 

21
n The 1997 Medical Outcomes & Guideline Sourcebook. New York:

Faulkner & Gray, 1996.

n “The Nuts and Bolts of Outcomes Management.” Business and

Health, Special Report, 14 (4 Supplement B): 11-6, 1996.

n Pane, G.A. “The New VHA: Leading the Way in Performance

Measurement.” FORUM, June, 1996. [FORUM is the newsletter of

the Health Services Research and Development Service, U.S. Department of Veterans Affairs.]

n Perry, A. “How to Obtain Data Now to Measure Cost.” FORUM,

June, 1996. [FORUM is the newsletter of the Health Services

Research and Development Service, U.S. Department of Veterans

Affairs.]

n “Quality and Accountability in Practice: Measuring, Managing

and Making it All Work in a Reformed Health Care System.” Medical Care, 33 (1 Supplement): JS1-76.

n U.S. Congress. Office of Technology Assessment. Identifying

Health Technologies That Work: Searching for Evidence. Washington: U.S. Government Printing Office, September 1994. OTA-H608.

n U.S. Department of Health and Human Services. Public Health

Service. Agency for Health Care Policy and Research. Report to

Congress: The Feasibility of Linking Research-Related Data Bases to

Federal and Non-Federal Medical Administrative Data Bases. Washington: U.S. Government Printing Office, 1991. AHCPR Pub. No.

91-0003. 

22
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Using Outcomes to Improve Health Care Decision 

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