A New Comprehensive Measure of High-Value Aspects of Primary Care

We thank Dr. Armstrong for her interest in and support of our work on the Person-Centered Primary Care measure.

The use of the word "parsimonious" in our article refers to parsimonious theory and the principle of parsimony, sometimes referred to as Occam's razor. Within research and science, the principle of parsimony is based on limiting assumptions and limiting unnecessary elements when identifying a scientific solution - the simplest answer is often the best. This principle has been identified and promoted within US healthcare and measures work, as exemplified by the concluding statement with the Institute of Medicine's report (now the National Academy of Medicine), Vital Signs: Core Metrics for Health and Health Care Progress (1):

A parsimonious and standardized set of core measures aimed substantially at outcomes could improve the ability of both decision makers and the public to direct their attention and understanding to the most important issues in health and health care.

(1) Institute of Medicine. Vital signs: Core metrics for health and health care progress. Washington DC: The National Academies Press;2015.

Competing interests: None declared

The article by Etz et al. is a well done study which adds to what we know about what constitutes comprehensive and effective primary care. I was confused however by the repeated use of the word 'parsimonious' in the methods, results and conclusions sections of the abstract. 'Parsimonious' as I understand it is has a negative connotation - and according to the Online Merriam Webster dictionary is an adjective meaning "unwilling to spend money or use resources; stingy or frugal." Synonyms include terms like "meanness, miserliness, close-fistedness, penny-pinching, and frugality - leave no doubt as to what the word means. Given this, I came away confused as to what the author's intended meaning was. The results of good research are diminished when not communicated in a clear and succinct fashion.

Competing interests: None declared

Etz et al. are to be congratulated for their tour de force entitled: A New Comprehensive Measure of High-Value Aspects of Primary Care. (1) I was asked to comment and emphasize that this new multi-item measure was associated with a very brief "What Matters Index" (or WMI in their text): a measure that is strongly associated with patients' quality of life, explicitly guides care, and predicts future costly emergency and hospital utilization. (2)

I would be remiss, however, if I did not point out that the authors assertion that this New Comprehensive Measure "provides a practical approach that allows the breadth of general practice to be assessed without the untenable burden of representing each construct with multiple measures" seems an overstatement. It may be true that this "crowd-sourced", 11 item compilation by clinicians, patients, payers, and experts is better and shorter than many others, but it its administration and scoring would be many times more expensive and burdensome than a single item. And, though each of its 11 items make both statistical and "crowd-sourced" sense, the very high inter-correlations suggest that patients satisfied or dissatisfied with their overall experience will probably be unable to differentiate very well among different constructs of care.

In other words, if this new comprehensive measure for primary care is used to rank practices, future investigators must demonstrate that, for the benefit of clinicians, each item reliably and usefully discriminates between attributes and deficiencies of services. They must also rigorously compare its cost-effectiveness with a proved single item, patient-reported measure for ranking practices. (3) Absent real-world proof of value, another multi-item measure will neither modify the measurement paradigm nor question its very assumptions. (4)

1. Etz RS, Zyzanski SJ, Gonzalez MM, Reves SR, O'Neal JP and Stange KC. A New Comprehensive Measure of High-Value Aspects of Primary Care Ann Fam Med May/June 2019 17:221-230; doi:10.1370/afm.2393. http://www.annfammed.org/content/17/3/221.full

2. Wasson JH, Ho L, Soloway L, Moore LG (2018) Validation of the What Matters Index: A brief, patient-reported index that guides care for chronic conditions and can substitute for computer-generated risk models. PLoS ONE 13(2): e0192475. https://doi.org/10.1371/journal.pone.0192475

3. Lynn Ho, MD; Adam Swartz, MD; John H. Wasson, MD. The Right Tool for the Right Job:The Value of Alternative Patient Experience Measures. 2013. J Ambulatory Care Manage Vol. 36, No. 3, pp. 241-244. https://www.researchgate.net/publication/262043479_The_right_tool_for_the_right_job_The_value_of_alternative_patient_experience_measures

4. Kurt C. Stange. Modifying the Measurement Paradigm or Questioning its Very Assumptions Ann Fam Med July/August 2015 13:384-385; doi:10.1370/afm.1827. http://www.annfammed.org/content/13/4/384.full

Competing interests: None declared