Medicine
Several months ago, I reviewed the many challenges associated with measuring quality in primary care practices:
Quality measurement in primary care needs to move beyond what is easy to measure. For example, current metrics target underuse of health services (e.g. not ordering enough recommended screening tests) rather than overuse (e.g. ordering tests too often or for no good reason). They have a myopic focus on individual chronic conditions rather than assessing overall quality of care for a patient with multiple diseases, where some disease-oriented goals might be inappropriate. They provide retrospective information rather than real-time feedback. And they fail to measure at all many of the personal qualities that most patients would agree are essential to a good primary care physician.
Along similar lines, the February 10th issue of Medical Economics contains an insightful article by family physician and quality guru L. Gordon Moore, MD, titled "Dreaming of the ideal practice." Dr. Moore points out that improved information technology and adherence to disease management guidelines, while the cornerstone of "medical home" accreditation, isn't necessarily associated with better care from a patient's perspective. "Primary care is inherently different from the rest of the healthcare delivery system," Dr. Moore asserts. "It is the first point of access, has relationships over time, provides comprehensive services, and coordinates care through the rest of the health system." Therefore, he says, these are the very things that can and should be measured to define "quality":
first point of contact;
person-focused (as opposed to disease focused) care over time;
comprehensiveness of care; and
care coordination for people who need care beyond the capacity of the primary care setting.
While I wholeheartedly agree that these elements are essential for good primary care, they aren't incompatible with traditionally measured qualities, either. In other words, you can see a doctor who knows the most appropriate drugs to use to manage diabetes and congestive heart failure, and also happens to be great at focusing on the whole person and coordinating care with other health professionals. Rather, what Dr. Moore seems to be arguing is that the latter should come before the former in value, which would have been obvious to a previous generation of family physicians, but is a mildly revolutionary concept in an increasingly "pay for performance" health care world. I think he's on to something.
- Quality And Chronic Disease Management
JAMA (Feb 18, 2009) has an interesting commentary by Patrick Conway and Carolyn Clancy of the Agency for Healthcare Research and Policy (AHRQ) on “Transformation of Health Care at the Front Line”,[1] which tries to address issues of quality assessment...
- Right-sizing The Care Of Patients With Serious Illness: It's About Time
Concerned about the overuse of ineffective or harmful practices in older patients with serious illnesses, the High Value Task Force of the American College of Physicians (ACP) recently published a synthesis of best practices on patient-centered communication...
- Extra Diagnostic Tests Don't Reassure: Another Reason To Choose Wisely
Steering patients away from unnecessary and potentially harmful tests and treatments is an essential component of high-quality primary care. The March 1st issue of American Family Physician includes two articles that reflect this philosophy as embodied...
- Do Practice Culture And Clinician Stress Affect Patient Safety In Primary Care?
Initiatives to reduce medical errors in inpatient settings have found that sustained improvements in safety cannot be achieved by simply exhorting health professionals to “try harder” or making evidence-based care protocols widely available (1, 2)....
- Care Management For Chronic Health Conditions
When my three-year old son began having recurrent coughing fits and shortness of breath after exercise, my wife and I knew the probable diagnosis. We made an appointment with our family doctor who confirmed that our son, indeed, had asthma. After prescribing...
Medicine
Dreaming of the ideal (family) practice
Several months ago, I reviewed the many challenges associated with measuring quality in primary care practices:
Quality measurement in primary care needs to move beyond what is easy to measure. For example, current metrics target underuse of health services (e.g. not ordering enough recommended screening tests) rather than overuse (e.g. ordering tests too often or for no good reason). They have a myopic focus on individual chronic conditions rather than assessing overall quality of care for a patient with multiple diseases, where some disease-oriented goals might be inappropriate. They provide retrospective information rather than real-time feedback. And they fail to measure at all many of the personal qualities that most patients would agree are essential to a good primary care physician.
Along similar lines, the February 10th issue of Medical Economics contains an insightful article by family physician and quality guru L. Gordon Moore, MD, titled "Dreaming of the ideal practice." Dr. Moore points out that improved information technology and adherence to disease management guidelines, while the cornerstone of "medical home" accreditation, isn't necessarily associated with better care from a patient's perspective. "Primary care is inherently different from the rest of the healthcare delivery system," Dr. Moore asserts. "It is the first point of access, has relationships over time, provides comprehensive services, and coordinates care through the rest of the health system." Therefore, he says, these are the very things that can and should be measured to define "quality":
first point of contact;
person-focused (as opposed to disease focused) care over time;
comprehensiveness of care; and
care coordination for people who need care beyond the capacity of the primary care setting.
While I wholeheartedly agree that these elements are essential for good primary care, they aren't incompatible with traditionally measured qualities, either. In other words, you can see a doctor who knows the most appropriate drugs to use to manage diabetes and congestive heart failure, and also happens to be great at focusing on the whole person and coordinating care with other health professionals. Rather, what Dr. Moore seems to be arguing is that the latter should come before the former in value, which would have been obvious to a previous generation of family physicians, but is a mildly revolutionary concept in an increasingly "pay for performance" health care world. I think he's on to something.
- Quality And Chronic Disease Management
JAMA (Feb 18, 2009) has an interesting commentary by Patrick Conway and Carolyn Clancy of the Agency for Healthcare Research and Policy (AHRQ) on “Transformation of Health Care at the Front Line”,[1] which tries to address issues of quality assessment...
- Right-sizing The Care Of Patients With Serious Illness: It's About Time
Concerned about the overuse of ineffective or harmful practices in older patients with serious illnesses, the High Value Task Force of the American College of Physicians (ACP) recently published a synthesis of best practices on patient-centered communication...
- Extra Diagnostic Tests Don't Reassure: Another Reason To Choose Wisely
Steering patients away from unnecessary and potentially harmful tests and treatments is an essential component of high-quality primary care. The March 1st issue of American Family Physician includes two articles that reflect this philosophy as embodied...
- Do Practice Culture And Clinician Stress Affect Patient Safety In Primary Care?
Initiatives to reduce medical errors in inpatient settings have found that sustained improvements in safety cannot be achieved by simply exhorting health professionals to “try harder” or making evidence-based care protocols widely available (1, 2)....
- Care Management For Chronic Health Conditions
When my three-year old son began having recurrent coughing fits and shortness of breath after exercise, my wife and I knew the probable diagnosis. We made an appointment with our family doctor who confirmed that our son, indeed, had asthma. After prescribing...