In 2007, the 110th Congress of the American College of Obstetricians and Gynecologists (ACOG) listed the maintenance of high-quality patient care as a top legislative priority [14
]. All members were encouraged to urge Congress to implement P4P as a voluntary reimbursement system based on performance measures developed by ACOG. In 2006, ACOG began including “proposed performance measures” in ACOG practice bulletins. Some of these performance measures include: documentation of indication for episiotomy, percentage of women taking combination contraceptives with history of venous thrombo-embolic event, and percentage of women undergoing vaginal or abdominal hysterectomy who receive antibiotic prophylaxis.
When developing P4P measures, it is important to distinguish between quality measures and clinical practice guidelines [15
]. Practice guidelines are intended to be recommendations to be applied prudently to an individual patient or certain population based on clinical experience while acknowledging the flexibility in the practice of medicine. Quality measures are rigid tools. Practice guidelines are sometimes based on expert opinion compiled with the best available clinical knowledge recognizing that results of randomized controlled trials (RCTs) do not exist for many aspects of clinical practice. Providers should be cautious of accepting flexible practice guidelines as rigid quality measurements tied to reimbursement schemes. Unfortunately, very few aspects within the field of urogynecology can be based on evidence from RCTs. In the absence of solid data, practice within the specialty needs to be flexible and patient directed.
The biggest challenge urogynecology faces as a subspecialty in the implementation of P4P is the development of feasible and high-impact performance measures that can be adhered to rigidly. Unlike flexible practice guidelines that can be tailored to unique patients, P4P measures are not adjustable. Some performance measures discussed, such as antibiotic prophylaxis prior to incision, documentation of thromboembolic prophylaxis, and documentation of the surgical pause, can be universally agreed upon. However, other P4P measures specific to the field of urogynecology are more problematic to implement, as the definition of quality, a successful outcome, and what measures to use in our subspecialty still need to be determined.