Regular readers know my opinion on P4P. I have often expressed my concerns about calling something quality when in fact it only represents one of many dimensions of a complex concept called quality.
Dr. Groopman and colleague have an outstanding editorial which makes the case once again – Why ‘Quality’ Care Is Dangerous
These and other recent examples show why rigid and punitive rules to broadly standardize care for all patients often break down. Human beings are not uniform in their biology. A disease with many effects on multiple organs, like diabetes, acts differently in different people. Medicine is an imperfect science, and its study is also imperfect. Information evolves and changes. Rather than rigidity, flexibility is appropriate in applying evidence from clinical trials. To that end, a good doctor exercises sound clinical judgment by consulting expert guidelines and assessing ongoing research, but then decides what is quality care for the individual patient. And what is best sometimes deviates from the norms.
Yet too often quality metrics coerce doctors into rigid and ill-advised procedures. Orwell could have written about how the word "quality" became zealously defined by regulators, and then redefined with each change in consensus guidelines. And Kafka could detail the recent experience of a pediatrician featured in Vital Signs, the member publication of the Massachusetts Medical Society.
We have a vast bureaucracy which develops "quality measures." This bureaucracy believes in a religion of performance measurement. They believe that adherence to performance measures leads to better patient outcomes. But Dr. Groopman offers several examples of the flawed reasoning that this religion provides.
I personally am agnostic about performance measures. I agree with Dr. Groopman that the entire movement is causing us to focus on the wrong issues in medicine. Given that we only have limited time to think and reason, this misplaced religious belief in performance measures must detract from the remaining issues in patient care. We must continue to object to this incorrect health care strategy.
For another nail in the coffin reader Dr. RW’s brilliant post – Leapfrog’s performance scores are meaningless
{ 4 comments… read them below or add one }
Do you have an alternative to suggest? I assume you’re not in favor of just going back to assuming that all health care is perfect, all the time.
Groopman’s commentary isn’t exactly a stellar piece of scholarship. Long on weasel-words, short on facts. Please see Dr. Sucher’s excellent comments on this article here: http://www.kevinmd.com/blog/2009/04/are-quality-measures-doing-more-harm.html#comments
Even when the guidelines have retrospectively been shown to be flawed, where’s the evidence of patient harm? Did the harm outweigh the benefits? You should know better than to make an argument without these numbers.
Sounds like a straw-man argument to me. If you’ll actually take the time to talk with the folks at, say, the NQF or NCQA you might be pleasantly surprised.
The alternative is to not do stuff just for the sake of doing stuff. If we used the same strict criteria for changes to the health care system that we use for changes in health care, there would be fewer changes, fewer disruptions, and less cost. To get a new medication approved, there must be randomized prospective studies that demonstrate beyond statistical doubt that the medication is safe and effective. To get a regulation that affects the entire health care system put in place, all that is required is a critical mass of folks in the right place to decide that it’s a good idea. They are generally well-meaning, but where is the proof that outlawing certain abbreviations, doing a time out before surgery, forbidding range orders, requiring verbal orders to be signed, dated, and timed within 24 hours, ad nauseam, actually has a real benefit? All of these, and the dozens of other diktats of the powers that be over the last decades, are individually trivial, but collectively are sand in the gears of healthcare. All are intended to prevent one perceived problem or another, but where are the Class I studies that prove benefit? There are no doubt retrospective studies for some of them, and hundreds of anecdotes, but no studies that show a benefit net of costs.
Dr. Sucher’s comments (that you reference) are mighty sloppy. He dismisses two specific examples that Kevin MD cites as harmful guidelines as just 2 examples, implying that we should believe him instead of our own lying eyes. My own experience is that hospitals spend more time and effort making sure that orders are signed and dated correctly than they spend ensuring that they are carried out correctly, and more effort in making sure that “time-outs” are documented correctly than in ensuring that the right stuff is actually in the operating room to do the procedure.
Most clinicians that you ask will tell you that they could do 30-50% more work at no decrease in quality if they were freed from the rent-seeking, empire building, and self-aggrandizing bureaucrats that justify their existence by generating rules, regulations, and guidelines every year. Enough is enough. Let the docs run the hospitals, or at least set up one hospital somewhere where they do. Run the experiment to see where the outcomes are better and where the cost is less. I know where I would place my bet.
Of course, doctors should be accountable for the quality of the care they provide. Of course, there is evidence based medicine. Of course, doctors should practice evidence based medicine. The trouble with evidence based medicine is that it is fluid, as Dr. Groopman pointed out in the original article on which this blog is based. Evidence thus requires the continuous attention of the reading physician. The conscientious physician can be much more on top of the literature than a guideline can be because he is a thinking being and not set on paper at a specific period of time.
Guidelines are overly simplified parameters of health care. They are an oversimplified interpretation of the evidence. The reality is that many guidelines are not really based upon real evidence. Rather, they are based upon the opinions of designated physicians.
They are also under the influence of all sorts of forces not all of which have the best interests of the patient at hand. There are insurance companies that do not want to pay for services. There are pharmaceutical and device companies that want to promote their products. There are physicians who want to promote their specialties and their procedures. There is all sorts of collusion since there are millions of dollars at stake. Guidelines would be much better and be more respected within the medical community, if all these pernicious influences were removed.
So, there is no reason to think that guidelines are better than the physicians or hospitals that they want to improve. They may be better than the mediocre or subpar physician. But that physician is not likely to read guidelines.
There are all sorts of ways of improving medical care and avoiding mistakes. Guidelines may be more wishful thinking or more window dressing for a system we are unwilling to reform. Systemic reforms are likely to improve our health care. Since fifteen percent or so of our population has no insurance, extension of insurance to this population would necessarily improve over all the quality of our health care.
1. Better selection of medical students. The reality is that the heavy indebtedness of our medical students is scaring away medical school applicants. There are 42000 applicants for about 18000 slots. If there were more than three candidates per slot, the average graduating doctor would be significantly more talented and better qualified and more representative of the general populations to be served.
2. If medical education were free, medical doctors would not have to learn and do procedures to pay back their loans. Procedures do serve to generate income. If they are unnecessary, they lower the over all quality of our health care delivery.
3. If doctors could have more time per patient without the interference of procedures or devices, that would generate better rapport, attention to detail and avoid many misdiagnoses, miscommunications, etc. That is as true of the colonoscopy as it is true of the primary care visit. Perhaps, payment reform will help bring this about. The patient provides evidence of his immediate need, his past medical history, his family history, his lifestyle, his preferences and his approach to life. Gathering this evidence is important. This evidence takes effort, time and reflection. We are not providing that time to internists and other doctors so how can we be serious about quality in health care. How can you apply the evidence of the literature if you have not carefully gathered the evidence from the patient. But that is what we are doing in this country.
4. Access to properly organized and appropriate medical information and supportive services (rather than form filling harassment or rigid guidelines) at the point of care could also go a long way. Simple prompts and reminders whether through reminders or check lists can reduce errors and improve patient safety. Appropriate supportive continuing medical education to support life long learning without conflict of interest could also be of help. Reading about EMRs, I do not get the impression that decision support is a prime concern. If there are 100 vendors for EMRs will there be 100 styles of medical practice? Will 100 companies have to create 100 styles of evidence based medicine.
5. Having a medical workforce and health insurance rules commensurate to our needs. The absence of primary care physicians results in patients going to doctors too late with problems that are more difficult to solve. Having patients going to emergency rooms or specialists results in almost by definition a poor and expensive clinical encounter with the exception of those cases that need immediate or specialist attention. Similarly, denying patients access to care because insurance companies work on the principle of pre-existent conditions also creates neglect of certain medical problems and is inconsistent with quality and continuity of care. Similarly, the fact patients are forced by their employers to change insurance quite regularly and patients have to search for new primary care physicians with loss of continuity is also inconsistent with quality care.
6. Universal health insurance. As a Canadian trained physician, I am always perplexed that America worries so much about the quality of the care of the insured but not of the absence of the care for the uninsured. It does not seem to bother people that we have uninsured children. Copayment fees are absent in Canada by law and patient can check on anything early on without worry of cost. In this country, the converse seems to be true. By having different standards of care for various segments of the population: Medicare, Medicaid, private insurance, community centers, and VA hospitals, we have fragmented our health care delivery and thus by definition eroded the standards of health care. It seems that every week another insurance sent me another volume of guidelines by which to practice. How could one read that and then remember which company said what.
We have, in effect, institutionalized Medicaid mills for the poor and are thus all paying the price with substandard care and for others a complexity of rules and guidelines that only breed cynicism. Similarly training in the inner city breeds cynicism among doctors since we give substandard care to many segments of our population. But then in isolated cases call for quality care.
7. As long as we have profit making insurance companies and quality insurance companies seeking to set the standard the care, cynicism will rein within our health care system. The solutions to our health care dilemmas and quality will remain elusive. There will simply be no widely respected standard of care.
In summary, the inputs into health care that bring about quality are many. We have to be thoughtful and honest about what inputs we put into health care to bring about quality medicine. I do not see commitment to quality medicine in this country.
I did forget one thing in my rant.
If we were really interested in quality would we be permitting pharmaceutical companies to fund CME.
Bohdan A. Oryshkevich, MD, MPH