Reporting on quality


Category : Medical Rants

A recent study discusses the problem of quality. I suspect it only tells part of the story – Good medical care? It’s a toss-up

Americans are all in the same leaky boat when it comes to receiving the standard of care for basic health conditions, according to a study in the March 16 issue of the New England Journal of Medicine. People of all colors, ages and incomes get only about 55% of the care that’s recommended.

“It doesn’t matter where you live, if you’re rich or poor, insured or uninsured, you get the right care only about half the time,” says study author Dr. Steven M. Asch, a health researcher with Rand Corp.

And we must remember that these performance measures only apply once we know your diagnosis. I am unaware of measures of diagnostic acumen – and that clearly is important.

The patients in the study reported seeing one to 17 doctors (the average was 2.6) over the two years. That alone, says Dr. Donald Berwick, president of the Institute for Healthcare Improvement, is one reason why quality suffers.

“Healthcare is highly fragmented. Let’s say a person with asthma or high blood pressure or diabetes sees several doctors,” says Berwick, whose organization is working to reduce the numbers of preventable deaths among hospitalized patients. “They don’t share common records, they don’t share information, and the ball gets dropped.”

I am often critical of Don Berwick (who I know). However, he has the right idea here. We need conductors for the health care symphony. Unfortunately, few students are selecting these careers in 2006!

Why do we have a lack of conductors (my euphemism for generalists)? I will list several reasons: compensation, life style, status (within the medical community), complexity. Generalists have the most difficult jobs! Please understand that sentence. I really believe that being a family physician, general internist or general pediatrician has so much complexity in 2006 that it represents the most difficult track in medicine.

Our problem is that patients see us with any possible complaint. They have many problems, and we must juggle those problems.

As Berwick says, patients generally benefit when one physician understands their problems and manages all those problems. Yet our reimbursement system provides incentives against that rational system. Subspecialists can care for a single problem and receive the same (or greater) reimbursement for a visit.

If we want better quality, we must understand and learn how much time good quality takes. It will take more time for each visit, but I believe that time (and appropriate reimbursement) will be the key factor in improving health care. No other profession works under, or is asked to work under, such severe time pressures.

Getting back to the article, the following paragraph should also make you think:

Among the differences found across the demographic spectrum were that more women (57%) than men (43%) were screened for disease, but more men (59%) than women (56%) were treated for disease. Older people had better quality of care for chronic diseases than did younger people, but younger people were more likely to receive preventive care. Overall, blacks and Hispanics scored about 3.5 percentage points higher than whites did on quality of care.

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Comments (4)

“Healthcare is highly fragmented. Let’s say a person with asthma or high blood pressure or diabetes sees several doctors,” says Berwick, whose organization is working to reduce the numbers of preventable deaths among hospitalized patients. “They don’t share common records, they don’t share information, and the ball gets dropped.”

Dr. Centor, this post illustrates some of the things I’ve been saying for a long time – from hospitalists right on through specialists.

Going back to the original generalist model and cutting out specialists unless there’s a very urgent need would help balance things.

As a patient with a chronic illness, I was shunted off to 7 different specialists in about a year and a half. I was finally able to discern what the underlying medical problem was, but I’m fairly certain that none of my physicians tied it all together, because none of them saw the entire picture. That’s a pretty scary realization, from a patient’s perspective.

A friend who is a physician sent me a link to a chart earlier this week – – and told me that in a few years, primary care will be managed by mid level providers. If my PCP can’t tie things together, then I’m supposed to trust a PA to do so?

Health care is crumbling. It’s hard to pinpoint one particular cause – there are too many. But it’s not too late to restore some balance, and really, it needs to be done soon.

“But it’s not too late to restore some balance”

so the question is then how does one convince or force physicians to choose primary care…and then how do you incent them to stay in primary care. ?

I finally in the last month went to see an internal med dr as my GP has given me such issues and I have listened to db rave about the importance of them for awhile now.

He was young and an osteopath and works in clinic with about ten other IM drs. He talked with me for almost thirty minutes, explained that he really didn’t know what was wrong with me, agreed that it is really, really odd, then asked me ” As a scientist you’ve done a lot of research on this, what do you think is going on?” I almost fell off the table.

He listened to me talk and didn’t treat me like an idiot or a hypochondriac. He looked at the labs but then listened to my clinical symptoms as well which in several cases contridict the lab results. Then we discussed a possible underlying genetic disorder in my family, normally asymptomatic in women, but exposed in a case of extreme hypothyroidism.

Mostly he just listened and respected what knowledge I could provide. wow! is this what drs are supposed to be like? Bravo!

two opposing views of quality are seen above

the journal artice leading this post measures quality care as the percentage of health screening tests that were ordered or doumented.

The above poster sees quality care realted to good listening skills, empathy, and humility.

ahard to provide both types of quality in rushed office visits

bottom line: Quality care as defined by anyone is more likeley to be practiced if the practioner is given enough time

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