Why ‘Quality’ Care Is Dangerous
Editor’s note: This is just one side of the story from one set of constituents.
By Jerome Groopman and Pamela Hartzband
1,481 words
8 April 2009
The Wall Street Journal
A13
English
(Copyright (c) 2009, Dow Jones & Company, Inc.)
The Obama administration is working with Congress to mandate that all Medicare payments be tied to “quality metrics.” But an analysis of this drive for better health care reveals a fundamental flaw in how quality is defined and metrics applied. In too many cases, the quality measures have been hastily adopted, only to be proven wrong and even potentially dangerous to patients.
Health-policy planners define quality as clinical practice that conforms to consensus guidelines written by experts. The guidelines present specific metrics for physicians to meet, thus “quality metrics.” Since 2003, the federal government has piloted Medicare projects at more than 260 hospitals to reward physicians and institutions that meet quality metrics. The program is called “pay-for-performance.” Many private insurers are following suit with similar incentive programs.
In Massachusetts, there are not only carrots but also sticks; physicians who fail to comply with quality guidelines from certain state-based insurers are publicly discredited and their patients required to pay up to three times as much out of pocket to see them. Unfortunately, many states are considering the Massachusetts model for their local insurance.
How did we get here? Initially, the quality improvement initiatives focused on patient safety and public-health measures. The hospital was seen as a large factory where systems needed to be standardized to prevent avoidable errors. A shocking degree of sloppiness existed with respect to hand washing, for example, and this largely has been remedied with implementation of standardized protocols. Similarly, the risk of infection when inserting an intravenous catheter has fallen sharply since doctors and nurses now abide by guidelines. Buoyed by these successes, governmental and private insurance regulators now have overreached. They’ve turned clinical guidelines for complex diseases into iron-clad rules, to deleterious effect.
One key quality measure in the ICU became the level of blood sugar in critically ill patients. Expert panels reviewed data on whether ICU patients should have insulin therapy adjusted to tightly control their blood sugar, keeping it within the normal range, or whether a more flexible approach, allowing some elevation of sugar, was permissible. Expert consensus endorsed tight control, and this approach was embedded in guidelines from the American Diabetes Association. The Joint Commission on Accreditation of Healthcare Organizations, which generates report cards on hospitals, and governmental and private insurers that pay for care, adopted as a suggested quality metric this tight control of blood sugar.
A colleague who works in an ICU in a medical center in our state told us how his care of the critically ill is closely monitored. If his patients have blood sugars that rise above the metric, he must attend what he calls “re-education sessions” where he is pointedly lectured on the need to adhere to the rule. If he does not strictly comply, his hospital will be downgraded on its quality rating and risks financial loss. His status on the faculty is also at risk should he be seen as delivering low-quality care.
But this coercive approach was turned on its head last month when the New England Journal of Medicine published a randomized study, by the Australian and New Zealand Intensive Care Society Clinical Trials Group and the Canadian Critical Care Trials Group, of more than 6,000 critically ill patients in the ICU. Half of the patients received insulin to tightly maintain their sugar in the normal range, and the other half were on a more flexible protocol, allowing higher sugar levels. More patients died in the tightly regulated group than those cared for with the flexible protocol.
Similarly, maintaining normal blood sugar in ambulatory diabetics with vascular problems has been a key quality metric in assessing physician performance. Yet largely due to two extensive studies published in the June 2008 issue of the New England Journal of Medicine, this is now in serious doubt. Indeed, in one study of more than 10,000 ambulatory diabetics with cardiovascular diseases conducted by a group of Canadian and American researchers (the “ACCORD” study) so many diabetics died in the group where sugar was tightly regulated that the researchers discontinued the trial 17 months before its scheduled end.
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FYI – I’m sure you’ve all seen the “anti-measurement” piece in the WSJ…to let you know that we are not risking this becoming : I wanted to provide you all with a letter Debra and I have submitted; and below it are letters for Peggy O’Kane and from Bernie Rosof (chair of the AMA-PCPI – which reinforces the value of our “constructive engagement” with them) which are part of concerted effort to assure this does not “catch fire.” We have sent copies of these (even “unpublished” to key hill staff who have noted their appreciation). Peter
To the Editors of the Wall Street Journal:
Drs. Groopman and Hartzman are right in their April 8 opinion piece that arbitrary and rigid measures of medical care are both unfair to doctors and unsafe for patients. But the consumers, companies and doctors who favor measuring and rewarding good practices don’t endorse unreasonable or unrealistic standards.
Far from it: The criteria for measuring doctors’ and hospitals’ performance, we believe, must be realistic, attainable and based on evidence. And they must evolve as new facts come to light about the best way to treat patients. No one would suggest measures be set in stone.
What we have suggested is that we can no longer ignore the crisis in the quality and safety of the health-care system.
The plain fact is that our system is in deep trouble: It is dangerous (100,000 unnecessary deaths a year); ridiculously expensive (if health-care costs continue to rise at their present rate, the cost of Medicare and Medicaid alone will jump from one-twentieth to one-fifth of the economy by 2050 – the size of the entire federal government today); and unfair (African-Americans, for instance, are far more likely to lose a leg to diabetes and otherwise receive poorer treatment than whites.)
Many of the important improvements in medical care we enjoy now are the result of measuring the quality of the care people receive and using the information as a tool so doctors and patients too can improve care.
One element the authors do get right: We need to measure how well treatments work, not just which processes doctors use. We need to know if the care patients get is safe and effective. Physicians and hospitals need this information to improve. And patients have a right to know which hospitals and doctors are better at ensuring patients get the right care at the right time.
We cannot afford the human and financial costs of a system without feedback or accountability.
Sincerely,
Debra L. Ness
President, National Partnership for Women & Families
Co-Chair, Consumer-Purchaser Disclosure Project
Peter V. Lee
Executive Director, National Health Policy, Pacific Business Group on Health
Co-Chair, Consumer-Purchaser Disclosure Project
Letter to the editor of the WSJ – April 8 2009
Drs. Groopman and Hertzberg raise important examples of why we need to be deliberate about our efforts to improve the quality of health care (“Why ‘Quality’ Care Is Dangerous,” April 8). New science frequently reveals gaps in medical evidence, and quality experts are sensitive to the concerns that arise.
Those of us who develop quality measures are responsible for adjusting them when new facts emerge. Opportunities abound to accelerate our pace of learning. For instance, electronic medical records will enable us to go beyond clinical trials, collect and analyze a wealth of patient data in real time, and refine clinical guidelines accordingly.
What’s the alternative to evidence-based medicine? It is waiting 15 to 20 years for medical advances to reach patients (Institute of Medicine, 2001). It is a system that delivers lifesaving treatment only half the time (McGlynn et. al., 2003). And it’s up to 88,000 deaths every year that could be avoided were evidence-based care to be routinely delivered (NCQA, 2008). It is the human mind overwhelmed by the complexity of medical knowledge and its applicability to complicated patients.
Translating current research into the best treatment for patients is a complex proposition. It will require major shifts in the way medicine is practiced.
The World Health Organization has ranked the U.S. health care system 37th in the world in terms of quality. To change that sad status quo, we must use the best tools that we have–clinical guidelines and quality measures–to move forward, and all the while leverage new discoveries to improve them.
Margaret E. O’Kane
President
National Committee for Quality Assurance
Bernard M. Rosof, MD, MACP; Chair, Board of Directors Huntington Hospital; North Shore Long Island Jewish Health System; Member, National Quality Forum Board of Directors
The April 8 op-ed by Jerome Groopman and Pamela Hartzband, “Why Quality Care is Dangerous,” is right to urge great care in developing healthcare quality measures, but ignores the reality that some of the dramatic improvements in healthcare are the results of quality/performance measures. Simply put, we can only improve what we can measure.
Measures allow us to see where we are now and make the changes that avoid medical errors, save lives, and create a race to the top that ensures world-class care no matter where you live. We know from more than 30 years of data in the Dartmouth Atlas that there is widespread variation in the quality of care in many common chronic conditions. We know that for certain chronic conditions there are things you should absolutely do. We have a very strong evidence base of what should be done in many areas like diabetes and cardiac conditions. However, a RAND study shows that less than 50 percent of people receive the care that the evidence base supports.
It is true that caution is advised in developing quality measures that are too narrow and rigid, particularly in the face of new findings. Quality metrics should not be static, but should be as dynamic as the changing evidence base in health care. This is quite possible to achieve.
We cannot and should not be satisfied that half of us are getting the right care at the right time. Quality metrics can light the way for more equitable, high quality care for every patient, every time they see their doctor or other healthcare providers. Now is not the time to roll back this progress.