It’s safe to say that Americans realize our health care system is in trouble. In polls, people cite paying for health care costs as one of their three most serious economic problems and consistently rank it as a top national priority behind the general economy, gas prices, and Iraq. Earlier this month a Harris Interactive Survey found that a full one-third of Americans want to rebuild their health care system from scratch, a greater proportion than any European country. Finally, it seems that the American people have disabused themselves of the notion that the U.S. has the best health care in the world.
Or have they? While people may agree that too many Americans are uninsured and that health care costs too much, they still tend to think that the quality of care people receive—regardless how many people actually get it –is top-notch. This is a misconception that goes more or less unaddressed in the mainstream health care debate. That’s a sad omission: if we don’t talk about quality as a separate variable—and understand the reality of our system’s poor performance—we’re going to miss out on a big piece of the health care puzzle.
In May, the New England Journal of Medicine
(NEJM) printed a graphical representation of two Gallup polls from
November 2006 and 2007. The poll results show a deep “split between
public dissatisfaction with the overall system’s performance and
patients’ satisfaction with personal health care. (See below).
NEJM notes that "whereas more than 70 percent of Americans are
quite negative about the country’s coverage and costs…a mere 15 percent
complain about the quality of care they receive.” Indeed, while the
numbers clearly show that people are happier with their own health
care than with the system as a whole, there is no dimension with which
their happier than the quality of care they personally receive.
No doubt one of the reasons that quality doesn’t make it into the
health care discussions as readily as coverage or cost is because of
this very satisfaction: if people are happy, then there’s no problem—so
why pick a fight where there need not be conflict? Health care reform
is already hard enough.
But quality is a problem. Just because Americans are happy with
their care, doesn’t mean that they are getting the best care—or even
recommended levels of care, as determined through medical consensus.
In 2003, Elizabeth McGlynn, the associate director of RAND’s health care program, led the first national, comprehensive study on the quality of care for adults. (Read that sentence again: we didn’t have a major nation-wide study on quality until just five years ago.
The Institute of Medicine did focus on medical errors in its 1999
report, “To Err is Human"; but the RAND study looked at whether doctors
were following “best practice.”) Quality has clearly been an overlooked
issue in health care assessments.
Maggie has touched on McGlynn’s study in a previous post,
but it’s worth discussing again here. Using telephone interviews and
two-year medical records, McGlynn’s team assessed whether or not 13,275
participants in 12 metropolitan regions received the level of care that
doctors recommend for their specific ailments (25 conditions in all,
including congestive heart failure, hypertension, breast cancer,
diabetes, asthma, coronary artery disease, STDs, headaches, and alcohol
dependence). What they found was that, on average, patients receive
just 55 percent of recommended care for their conditions. (“Recommended
care” was determined by (1) poring over national guidelines and medical
literature to come up with key indicators and (2) subjecting these
indicators to four nine-person, multi-specialty panels, who nixed or
okayed the metrics).
This proportion was remarkably consistent across different kinds of
care. The authors found “little difference among the proportion of
recommended preventive care provided (54.9 percent), the proportion of
recommended acute care provided (53.5 percent), and the proportion of
recommended care provided for chronic conditions (56.1 percent).”
In testimony
before the Senate Finance Committee last month, McGlynn nicely summed
up the implications of these numbers: “we spend nearly $2 trillion
annually on health care and we get it right about half the time.”
Follow-up research from McGlynn and collaborators has shown that this success rate is cuts across demographics. In 2006,
McGlynn’s team broke up their 2003 study population along various
social divisions to see how different groups fared when it came to
receiving care. The researchers found that, with some slight variation,
everyone was getting around 55 percent of what the needed: women
received 56.6 percent of recommended care, and men 52.3 percent; people
under 31 received 57.5 percent of recommended care, and those over 65,
52.1 percent; blacks (57.6 percent) and Hispanics (57.5 percent) had
slightly higher scores than whites (54.1 percent); and those with
annual household incomes over $50,000 had higher scores than those with
incomes of less than $15,000 (56.6 percent vs. 53.1 percent).
When it comes to quality care, no one comes out a winner–but the one group that
is significantly worse off than the average is children. In 2007,
McGlynn and colleagues repeated the methodology of their 2003 study,
but this time they looked at 2,851 children. They found that, on
average, children were receiving just 47 percent of recommended care
overall and only 41 percent of the preventive services that they
needed. Children with chronic illnesses fared a bit better, receiving
about 53 percent of needed service.
These are incredibly underwhelming numbers. Few of us would be
satisfied if our doctor told us that he we were only going to get 55
percent of the appropriate care—yet that’s exactly what’s happening,
and people aren’t batting an eyelash. (Important note: saying that
people receive 55 percent of recommended care is not the same
as saying that everyone should get twice the number of surgeries,
treatments, or prescriptions as they currently do. The point is about appropriateness of care, not the volume of care).
How can we reconcile inappropriate care and high satisfaction? Patients
tend to view health care in terms of how responsive it is to their
perceived needs—and these needs don’t always have a whole lot to do
with clinical guidelines. A 2005 Wall Street Journal/Harris Interactive
poll reported that
patients’ first priority it to have a doctor with strong interpersonal
skills. Eighty-five percent of Americans said that it was “extremely
important” for their doctor to act respectfully toward them; 84 percent
said the same for listening carefully and being “easy to talk to.”
Technical know-how was less important: 80 percent said good medical
judgment was extremely important and 78 percent said the same of being
up-to-date with medical research.
Granted, the difference between 80 and 85 percent may not seem
huge—it’s clear that people still value medical expertise as well as
interpersonal skills. It would be wrong to claim that people are
willing to accept bad medicine so long as it’s presented with a smile.
But take the WSJ poll and the Gallup data and you can see why people
are more satisfied with quality than McGlynn’s research would suggest:
once they find a friendly doctor with whom they feel comfortable, a big
chunk of their priorities are fulfilled. If patients like their
doctor, they will probably assume that he is giving them high quality
care—but that doesn’t mean that patients are actually getting the right
care at the right time. (This, of course, is a major reason why
consumer-driven medicine is flawed: it assumes that people will
naturally make health care decisions based on some objective analysis
of what makes them healthier; but, when it comes to their health,
people are incredibly subjective and emotional).
Indeed, patient are generally ill-informed when it comes to medical science. Remember the findings last year that suggested that the yearly physical is an unnecessary waste of time and resources? A March survey
from the U.K. found that what patients most want their doctors to do
for them is a “thorough physical examination.” Patient preferences
rarely jibe with cutting-edge medical knowledge.
Given all this, we have to be very careful not rely on the polls and
decide that quality isn’t an issue. As McGlynn put it in her testimony,
“all too often people assume that if we take care of the problems
with cost and access, the quality problem will solve itself,” But even
“if we find solutions to the problems of uninsurance and underinsurance
and we control rising health care costs we will not have solved the
quality problem. It is a separate problem. It requires separate solutions.”
And just what are these solutions? McGlynn is quick to point out that
better health care IT could go a long way in reducing “the burden of
data collection.” With a central repository of medical records,
procedures, and outcomes, we’ll slowly develop a huge data set with
which we can regularly assess quality and trends in care.
Decision-support technology can help to standardize treatments, so more
people are getting the full checklist of recommended care. An
investment in comparative-effectiveness research can help diffuse
broader awareness of what works and what doesn’t, refining care
delivery—and helping to combat over-treatment, which actually puts our
health at risk.
We also need to reform our physician payment schedules: The current
fee-for-service system is a major obstacle to quality care as it
encourages high-volume rather than measured, appropriate treatments.
It’s critical that reformers understand one simple fact: quality is not
a given. Nor is it just a question of patient satisfaction, but also of
the appropriateness of care. Thinking otherwise is just perpetuating
the myth that America doesn’t have a quality problem. And, as McGlynn
noted before the Senate in June, “if you do not believe you have a
problem, [then] you have no motivation to invest in finding and
implementing solutions.”
Niko, I think it is rather telling that consumers are satisfied with the care the personally receive from physicians but find system performance lacking, yet RAND attempted to discover if PHYSICIANS were following best practices.
This is a remarkable disconnect. If the system is broken, it is an administrative/leadership issue, not a problem with the front line workers’ performance. System issues are not synonymous with physician issues.
Engaging physicians will help fix the health care system. Blaming them will develop a force of general resistance and suspicion. There is a problem, but I am becoming more convinced that the approach to improving it has simply worsened it because of a subtext that implies the ills of the health care system should be laid at the feet of physicians, rather than leadership, where it belongs.
Complex issue indeed.Is the practice medicine a science or an interpersonal relationship artform?
The answer, if there is one, may drive the quality debate?
(“Give me a doctor short and stout-
Who with rosey cheeks and a twinkle in his eyes-
Tell me it is my time to die”)
Dr. Rick Lippin
Southampton,Pa
“Complex issue indeed.Is the practice medicine a science or an interpersonal relationship artform?
The answer, if there is one, may drive the quality debate?”
It’s both, of course. It’s what makes medicine so fascinating. What you might call “perceived” quality by the patient is a valid part of the mix, but there also has to be something objective. I had a contractor once who I liked a great deal, but who did terrible work on my house. The latter ultimately trumped the former.
Satisfaction polls are usually meaningless.
For example most parents rate the school that their kid goes to as better than average even when the objective data says otherwise.
Similarly most people think their congressman is doing a good job while they are currently giving congress itself a 9% favorability rating.
It’s the Lake Wobegone effect – everyone is above average.
Asking people about satisfaction without them having any objective criteria produces meaningless data. How would you know that you didn’t get some needed care unless you had some independent information? Where would you get it?
Ask stupid questions, get stupid answers.
Disagree with robertdfeinman below.
In medicine of course having a satisfying experience with your doctor or your hospital counts for something.
How do you objectively measure the quality of a friendship or a marriage?
Or for that matter a sense of happiness or contentment?
Is your objective data on “quality” going to deny a person’s feelings or experience? That sounds awfully paternalistic to me?
Rick Lippin
I’ll chime in here. Having observed a patient experience for 108 days at the bedside regularly, I can tell you overwhelmingly the quality issues do not belong at the feet of the front line providers. For the most part we were satisfied with the performance of the majority of doctors and nurses. There’s one exception for the doctor and one exception for the nurse. In both of those cases, the patient care quality was still poor, but it was the result of the same system failures that caused the same quality issues as the “good” doctors and nurses. My point is, we personally liked almost all of the direct caregivers, the one’s we didn’t like I feared letting that be known as it could result in retribution against the patient…the problems were bad enough to threaten his life without having personality issues thrown in the mix. Our healthcare system is…money-driven (wink wink) and that’s why quality is poor, that’s the problem.
Finally, a person’s perception is their reality. Consumers don’t have enough hard data to know whether or not they got “good” care, they know when it was bad, but aside from gut instinct they might not know it was mediocre or poor. Somebody who had an unneccessary surgery but had no complications might think they got good care. I could go on all day I’ll stop now.
PS from me
Heard from a group of Docs at the hospital bedside-
“Good morning Sir/M’am-We decided, based on our quality data analysis, that you are not feeling well this morning”
Nuf said
Dr.Rick Lippin
PS from Rick Lippin
Heard from a group of doctors at a patient’s hospital bedside-
“Sir/M’am- We all decided,based on our quality data analysis, that you are not feeling well this morning”
Nuf said,
Dr. Rick Lippin
If most folks only get about half the recommended care and they end up feeling satisfied enough to dish out an acceptable rating, maybe there is something wrong with the standards of recommendation.
I have had health care experiences where I felt it was as much about an appointment fee as anything very substantive to my health.
The notion that the average person only receives appropriate care about half the time raises a couple of questions for me. First, how does this metric, however it’s measured, compare with the performance of healthcare systems in other develop countries – Western Europe, Canada, Japan, etc? Second, attempts to measure defects remind me of the automotive industry. Car model A may have, say, 50 defects and car model B may have only 25. Does that mean model B is of higher quality? Suppose all of A’s defects are minor fit and finish issues but B’s include such problems as: (1) the car stalls frequently or doesn’t start, (2) there are serious engine and/or transmission defects, (3) the brakes don’t perform as they should. I’ll take model A every time even though it has twice as many defects.
Since I’ve had five surgical procedures over the last 15 years, I’m most concerned about outcomes when I have a significant medical issue. Was my surgical outcome as good as could be expected? Did I manage to avoid getting an infection during my hospital stay? Were the nurses competent, reasonably pleasant and were they able to avoid medication mistakes? If I should have been discharged with a recommendation to take aspirin but wasn’t but it did no harm, I saw my doctor a week later and he recommended it then, I don’t consider that much of a medical mistake. The bottom line, at least to me, is that it’s medical outcomes (with risk adjustment factored in) that matter. The focus on process may be easier to measure, but I think it’s less valuable and less informative in trying to assess the quality and performance of a healthcare system, a hospital, a physician group practice or an individual doctor.
Let’s not confuse quality of care with quality of the experience.
You can have a very pleasant experience with an incompetent person. If people generally are happy with the quality of their experience then we are lucky to have so many empathetic health care workers.
However, objective data indicates that quality of care is poorer than elsewhere. People can’t judge this, they have no basis for comparison.
The poll measured something, just not something very important.
Robert: “Let’s not confuse quality of care with quality of the experience.”
We had both and it’s hard to say which was the cart and which was the horse. Did the bad experience result in poor care or did the poor care make for a bad experience experience? I’d say the poor care caused a really bad experience.
Barry: “it’s medical outcomes…that matter.”
Barry, I like you but I’m cyber-taking-you-by-the-lapels. We had a good outcome, couldn’t have been better.
You said: “The focus on process…I think it’s less valuable and less informative in trying to assess the quality and performance…”
Barry, we had a great outcome in spite of medical care, not because of it. You are supposed to be dx with aspirin and don’t get it, no harm done, you don’t consider that an error or cause for concern. That’s playing roulette. You wouldn’t feel the same way if you found out you were supposed to be dx with an rx for steroids and didn’t get it so your _______ swelled and ruptured, causing additional hospitalization, possibly additional surgery and another opportunity for a life threatening infection. I learn a lot from you, Barry, but I have to wholeheartedly disagree with you here, processes are crucial, note the many heparin stories in the media. The thousands who had no heparin issues, well, that’s a good outcome, so we’re not concerned. The hundreds who did have life-threatening issues (let’s not forget not every single incident is going to get national media attention), well, they wound up living (in spite of increased costs due to the error) so that’s a good outcome so no need to measure or improve the process. Several dozen deaths as a result of the same failure, bad outcome, now it finally merits improving the process? Well, at this stage we’ve got dead babies and lawsuits flying.
Barry, please email me with your address I will send you my book it will change your opinion.
http://www.marketwatch.com/news/story/us-health-system-earns-d/story.aspx?guid=%7BC8565FAD-46D7-46AD-9FF4-7CE58DF41B47%7D&dist=msr_2
Lisa,
Your points are well taken. I enjoy your posts too even when they’re critical of me.
I didn’t mean to suggest that process in not important. Rather, if we don’t measure the right things or misinterpret what we find, it could lead to significant and costly policy mistakes in trying to improve the healthcare system. For example, the U.S. healthcare system consistently ranks poorly compared to other developed countries on life expectancy. Yet, Phillip Longman, in his book, “Best Care Anywhere,” states that half of the improvement in life expectancy in the U.S. since 1950 has nothing to do with healthcare or the healthcare system. Instead, he says it’s attributable to (1) a sharp reduction in the number of people who smoke, (2) much safer cars (air bags, anti-lock brakes, etc.), and (3) the shift in our economy away from physically demanding and dangerous jobs in manufacturing, mining and agriculture and toward knowledge based services.
We could have two hospitals that achieve equal risk adjusted outcomes from various surgical procedures. One uses electronic records and one doesn’t. The one that does has fewer adverse drug interactions and requires less duplicate testing because records can be located when needed. The more cost-effective hospital provided superior care, in my view, even though its record on ultimate surgical outcomes was similar. Similarly, you could have two primary care doctors who do equivalent jobs of keeping comparable patient panels healthy. One practices much more defensive medicine than the other and therefore drives much more utilization of the healthcare system. So, for the same ultimate results, one doctor practiced much more cost-effectively than the other.
At the end of the day, I want to measure the right things to maximize the chance of developing the right policies that lead to the best healthcare possible for the least cost to taxpayers and society so that we can free up resources for the many other worthwhile priorities that we all need and want. It’s about as simple as that.
Barry, now you’re contradicting your initial post or I’m misunderstanding you:
“We could have two hospitals that achieve equal risk adjusted outcomes from various surgical procedures.” According to your first post, and you’re interest in outcomes being more important and valuable than processes, why, then would it matter whose using EMR’s or having medication errors or problems with inefficiencies? If they had the same outcome, the process isn’t as important or valuable so why, then, study or analyze it?
I don’t agree with that at all, but that’s what I read in your initial post.
Lisa,
I think outcomes are more important than process, but that doesn’t mean that process is unimportant or irrelevant. In my two hospitals with equal risk adjusted surgical outcomes that you referred to, the one that reduces or eliminates adverse drug interactions and duplicate testing because it uses electronic records means that it is more efficient and cost-effective. Maggie often talks about squeezing waste out of the system. This is an example. In short, the healthcare system needs to maximize outcomes and control costs. We can only spend a given dollar one time, and there are lots of other important priorities, both public and private, that we need to finance. I want good outcomes, but I want efficiency and cost-effectiveness too. For me, it’s as much about efficient resource allocation as it is about high quality and good outcomes.
Mostly to Lisa and Barry about process, let me make a general observation: medicine, as opposed to a small number of other disciplines, doesn’t have a good history of monitoring process compliance, when it becomes utterly essential for someone to break process, and reviewing the processes in relation to outcomes.
Most often mentioned is a prototype is aviation safety. Checklists are an obvious examples of process, but what is less obvious is that checklists have branches into emergency procedure checklists; one of the few things pilots memorize is are emergency procedures, sometimes with seemingly nursery-rhyme mnemonics (e.g., how to recover from a stall).
What is variously called crew resource management (CRM) or cockpit resource management is another area to look at process, and getting everyone involved. Two accident reports come to mind: United 232 in Sioux City, where absolutely perfect CRM kept an apparently unflyable aircraft, with an unsurvivable problem, in the air long enough to make a controlled crash with many survivors. Air Florida 90, from Washington National to the 14th Street Bridge, is an example of a total CRM failure: the copilot saw the critical problem but neither asserted himself to the captain nor aborted the takeoff.
Another area is what the military calls after-action review. The closest parallel in medicine is the mortality and morbidity conference, because it’s more focused on errors that how things worked, including what worked very well and needs to be remembered.
Just as the FAA has a mandatory no-fault reporting system of near-collisions, one of the problems is that we need to insulate appropriate process/outcome review from a buffet for malpractice attorneys turning cases into class actions. I defined a “root cause analysis” module that could go through some specific workflow databases and find the common elements in hospital-acquired infection, but my marketing folk promptly rejected it, saying no risk manager would want its reports discoverable. They did make the interesting observation that while HIPAA protects patient-specific material, there is no such protection on the kind of aggregates that help process improvement — and are seen as hunting licenses for lawyers.
HC, everything is already cloaked in secrecy in the medical establishment, and they do this to evade and avoid consequences, instead of improving processes. I don’t see how offering immunity if they promise to make things better is going to accomplish that goal. People have to be responsible for their actions and face consequences whether intentional or not.
Mandatory reporting of a near miss in aviation didn’t result in harm to another person, in other words, there’s no actionable event that needs to be mitigated through the courts.
We already hear repeatedly (when patients are harmed) that so and so “didn’t mean to” cause harm. Well, if this same harm (Heparin) came to patient after patient after patient due to the same failures, well, heck yea that establishes negligence and is actionable in this country, whether they like it or not. See Dennis Quaid. THAT’S why they don’t want their reports, or anything, discoverable. Because there’s something to hide. If reports and history showed pattern of improving processes (like reporting and studying near-misses) then they’d likely not find themselves as culpable when they hit the court room.
On the other hand, I know how lawyers can sink their teeth into the most innocuous piece of data and fabricate a case based on nothing at all…or redefine for themselves what that data really means. A good lawyer could convince a jury 2+2 equals 3, and have stacks of proof of same. So that element is never going to go away. I still don’t see that as an excuse to maintain the status quo…make it harder for folks to prevail in a courtroom and keep doing what they’re doing. Malpractice suits are not the reason we have poor quality healthcare.
In fact, maybe if data on infections, errors, etc, were made very public, quality would improve just as dramatically. I’d like to see the Feds raid JCAHO and start posting all their files on the internet.
Lisa,
I don’t find the medical establishment to be monolithic. If anything, the problem with a number of large hospitals where “I’ve consulted is that the departments act like feuding warlords. One example: we were putting in a modified anti-shoplifting system to protect babies, in the nursery, from being kidnapped — there had been several cases. Simple enough? Sensors at the doors of the nursery and possibly outside doors, and alarms in the nursing station and security office?
Neonatal nursing insisted that they had to have control of the sensors in the outside doors and of the alarms. Physical plant wanted control because it was their doors. Security wanted control because it was security. Biomedical engineering concluded the bracelet was a sensor on a patient and wanted control. It took, IIRC, 8 months of wrangling to make a decision that should have taken 30 minutes.
“Mandatory reporting of a near miss in aviation didn’t result in harm to another person, in other words, there’s no actionable event that needs to be mitigated through the courts.” Absolutely not the case. Commercial pilots are constantly in fear of failing a proficiency test or a physical, and going from six figures to zero income. Most aviation accidents have multiple causative factors, but there’s a perception that the airlines, manufacturers, FAA, etc., would like to call it pilot error and avoid institutional responsibility. No-fault was absolutely necessary to get accurate reporting, because it was the edge situations where, for example, an interaction between air traffic control centers, or a pilot and terminal control, or an instrument that gave confusing results, were the things that needed to be fixed.
I never said malpractice suits are the reason for bad medicine, or, in fact, that there’s any one factor. You make a point of what happens “when they hit the court room.” A large problem, in my experience, is what happens in avoiding the court room. It’s not common, but there have been a fair number of situations where the insurer insisted that the physician settle out of court, telling him that they wouldn’t defend him — which he considered an opporunity to clear his name. The hospital, to avoid blame, pulled privileges from the clinician, who wasn’t the total cause of a complex situation.
One of the nice things about being a doctor in that situation, I suppose, is that you have the access and knowledge to take in the hotel room where the suicide note is found.
“If reports and history showed pattern of improving processes (like reporting and studying near-misses) then they’d likely not find themselves as culpable” It seems you assume there is going to be some objective situation where these patterns can be established. Administrators and insurers want to avoid risk. Courtrooms are not places to find truth.
“In fact, maybe if data on infections, errors, etc, were made very public, quality would improve just as dramatically. I’d like to see the Feds raid JCAHO and start posting all their files on the internet.”
Posting files in what form? Who defines the statistical analysis? I have no objections, and have worked on data mining health records, where it can be extremely difficult to do statistical cause analysis on free-form text.
Indeed, I’d start with a technically simpler problem: start out by posting the protocols for every clinical trial, some of which are posted anyway. They contain the statistical hypothesis tests to be applied to test results, in what is a randomized CONTROLLED trial, massively easier to evaluate objectively than finding the root cause of an obscure hospital-acquired infection. I don’t care if the trial was funded by government or industry — as I read the Declaration of Helsinki, the data is unethical to suppress. Let me know the URL for all industry-sponsored trial results, along with the predefined evaluation criteria.
There was a show, “Medical Investigations”, a few years ago, I was forbidden to watch, as I’d start screaming at the alleged epidemiologists and the idiocy displayed. If you haven’t read it, get a copy of Laurie Garrett’s _The Coming Plague_, a fantastic read and scientifically accurate, and think of the screenplays that could come out of each chapter. I remember one report of a cluster of hospital-acquired Legionella pneumonia cases, and how unlikely the source had been: steam humidifiers brought to the bedside, where a combination of circumstances in cleaning the hot steam vents were getting them full of bacteria — a place you’d expect sterility. Nobody understood the temperature tolerance of Legionella species.
Since publication of the IOM’s groundbreaking reports outlining the prevalence of preventable medical errors and the actions that can be taken to significantly reduce them, U.S. healthcare industry leaders have made significant investments in clinical process, technology and organizational infrastructure to improve quality and patient safety. And significant additional investment is anticipated to be required in the foreseeable future. However, in our increasingly challenging reimbursement and economic environment, it is becoming increasingly important to be able to demonstrate adequate ROI to sustain the pace of investment required to truly impact care.
Have you noticed how much everyone wants to find “some way” to measure Quality of Care? And the benefits of Evidence Based Care? And the financial impact of improved Quality? And, have you noticed that the best that people are able to do is bring anecdotal evidence…a few examples…some case studies…some hypotheses about the relationship between clinical process and clinical outcomes? Almost every presenter at the most recent Zynx Health Conference in San Diego brought illustrations of benefits – clinical, operational and financial – yet the resemblance they bore to each other was coincidental, at best.
We believe the reason for this is that the science of Hospital Quality Management is relatively immature. Hospital Financial Management, by contrast, is very mature, as evidenced by things like standard financial statements, consistent charts of accounts, universally accepted metrics and measurements, easy benchmarking, etc. Comparable capabilities are not possible in the current world of Hospital Quality Management – not for lack of demand or desire, but for lack of commonly agreed-upon definitions, metrics, and reporting mechanisms.
My firm is currently working to assemble a collaborative of five to ten multi hospital healthcare systems to address this issue and develop a commonly accepted approach to quality measurement.
Hi all, thanks for the comments.
Zagreus–good to hear from you. I think we’re more or less in agreement: as you no doubt know from reading Health Beat, neither Maggie or I want to give administrators/leaders/policymakers an out when it comes to our health care problems. If you look at the solutions I propose, none of them are really punitive toward doctors, and strategies like comparative-effectiveness research & payment schedule reforms are very much “system issues.” In other words, I don’t think anyone’s out to vilify doctors; it’s just to note that (a) getting more access to care and (b) making care cheaper are not the entirety of (c) making care better.
To all those who point out that patient experience IS important: Yep. I agree again here. As Chris Johnson says, it’s both outcomes and personal satisfaction that matter. But the danger–which I think we’ve fallen into–is to not look BEYOND satisfaction. That doesn’t mean we have to jettison it completely, of course. As Rick suggests, the doctor-patient relationship is ultimately one between two human beings. As such, I wouldn’t go as far as Robert in dismissing the utility of satisfaction; but I also don’t believe that urging us to look at quality is the same as saying patient satisfaction is entirely irrelevant. The truth is that medicine is BOTH an art and a science. We want patients to be happier AND healthier, which means giving the right care at the right time.
Scott Hodson–thanks for your comment. You’re right on this, too: quality metrics are harder to wrangle with than say, cost. This is, I think, part of why quality gets the shrift. In today’s data-driven world, you focus on what you can measure–particularly on what you can measure the most readily. That’s coverage and cost. As the comments here have shown, quality is a more difficult animal. But McGlynn’s efforts also show that it’s not impossible to create a methodology for coverage–one that can be considered alongside of/synthesized with other quality metrics, including (to a certain extent) patient satisfaction.
Ginger–You’re right, saying that people should get “more” care is not thew way to go. But as I say in the post, quality is about appropriateness. So by McGlynn’s standards, if medical consensus is that you need two specific tests, and you undergo twelve–and none of the ones you actually need–that is poor quality medicine. More is being done to you, but that doesn’t mean that it’s appropriate. It’s not a question of volume.
Niko,
You triggered a line of thought when you mention if 2 tests are necessary, why get 12? My immediate question is “how does one define a discrete test?”
Let me take an example, and from an area that tends to get great quality and satisfaction: veterinary medicine. My housemate had me talk to the vet, who, in my opinion, is the veterinary equivalent of the story of the title for the person last in the class: doctor.
In this case, my friend was told that Zeus, the dog, was “anemic”. He asked me to call and get the labs and give him some insight. There was no problem in getting the information, except that I was only read the hemoglobin, hematocrit, and red cell count (and things not relevant).
I asked “what were the indices”? These are “tests” that are actually computed from the three specific variables above, but I’ve never seen an automatic blood cell tester that doesn’t automatically compute them. He asked “what are they?”, and I did a little tutorial on the phone, and, after hanging up, grabbed a textbook to find the forgotten formula, and then worked them out by hand. Sadly, those and other numbers proved Zeus was in end-stage renal failure.
But here’s the point — at least in clinical chemistry and hematology, the automated analyzers do groups of tests, and it is really cheaper and simpler just to put the blood samples in, without going through the labor of finding the ones that only had one or two tests requested. If you wanted to do just a red blood cell count, the analyzer doesn’t know how to do only one. You’d have to do it manually, which is laborious.
What has been reasonable, especially for large labs, is to create “panels”, typically of 7 to 24 tests that are related. With some medication changes I’m on, I need to go in and get a 7-test panel, but we are only interested in 1 or 2. It’s still economical.
What is not economical is to do, for example, multiple imaging studies that won’t affect diagnosis or treatment. This does get tricky, because in some conditions, you may have three imaging modalities that could pick up an abnormality, but you don’t know if 1 or 3 will catch it. There’s a lot of discussion of that sort with respect to breast cancer screening.
I have thoroughly annoyed some physicians that, when asked why they ordered some test, for a patient I represented, answered, “to document the extent of the lesion.”
Did you plan to operate, such that you need to know its boundaries?
“No”.
“Are you going to do successive imaging through treatment, so that you can track if the treatment is working?”
“No.”
“Then why are you doing the test?”
“…to document the extent of the lesion.”
Recognizing that if this kept up, someone would document the bruises on the physician, I gave up. There’s an Army saying that applies to some tests: “we don’t need a reason. It’s our policy.”
Happily, when I recently had a consultant suggest some long and annoying testing, I talked to my primary care physician and said “The consultants agree that I have a high probability of having conditions 1, 2 or both. There is a drug that treats both. The test would only suggest a probability I have condition 1.
“Why don’t we just try the treatment, and, if things improve, assume I had 1 and 2?”
He agreed, and the treatment is making me feel much better. The consultant is upset.
I’ve rambled on as usual, but there are really several questions about the performing of multiple tests:
1. Will a given test result affect diagnosis or treatment?
2. If not, is it a result that is a natural by-product of doing a more relevant test? Can the specific test be gotten as a stand-alone?
3. Is there evidence that doing “overlapping” tests will pick up something actively being considered, but that you don’t know in advance if one or all will detect the condition?
I am a medical microbiologist, and I don’t know how to evaluate a physician. I’ve had some serious health issues – so how am I to know how many cardiac stress tests or thallium scans I should have and how frequently? indeed, now that I am having some blood sugar issues, do I go with the ADA or the college of endochronologists guidelines?