In the beginning Code of Hammurabi- 18 th Century B.C.E. Sicily- 12 th Century French Revolution- 1789 Codman Method - Circa 1910 JCAHO-1950s 1950s-Present Donabedian-1960s 1960s-Present TQM-1980s 1980s-Present Pay-for for-performance (P4P)-Present Present and future
Patient Care Quality: The degree to which patient care services increase the probability of desired patient outcomes and reduce the probability of undesired outcomes, given the current state of knowledge.
Institute of Medicine Criteria- Healthcare should be: Safe Effective Patient-centered Timely Equitable Efficient
A Proposed Definition for Quality in Healthcare Quality is the provision of efficient and effective care to appropriately selected patients at the right time and in an expert manner, consistent with the current state of medical knowledge and patient preferences. J. Shalowitz, MD, MBA
Why are we paying attention to standards?
Institute of Medicine Reports
This is progress? Recipients received 54.9% of recommended care. We found little difference among the proportion of recommended preventive care provided (54.9%), the proportion of recommended acute care provided (53.5%), and the proportion of recommended care provided for chronic conditions (56.1%). Source: McGlynn et al: NEJM 348:2635-2645, 2645, 2003
Cholesterol high in those at risk for heart ills Wed Feb 8, 2006 8:20 PM GMT NEW YORK (Reuters Health) - People who are at highest risk for cardiovascular disease generally have the lowest level of control of high cholesterol levels, investigators report. "Given the significance of cardiovascular disease as a public health problem in the US and the proven benefits of lipid-lowering therapy for primary prevention," the researchers comment, "efforts to improve the treatment and control of (high cholesterol) and to eliminate disparities... should be considered among our highest national healthcare quality improvement priorities." Dr. David C. Goff, from Wake Forest University School of Medicine in Winston-Salem, North Carolina, and colleagues evaluated 6704 subjects aged 45 to 84 years who were free of clinical cardiovascular disease at the start of the study between 2000 and 2002. Overall, 29 percent of the participants had poor lipid profiles. Of these, only 54 percent were taking lipid-lowering drugs, and of those receiving treatment, only 41 percent achieved their target levels, the researchers report in the American Heart Association's journal Circulation. Poor lipid levels were seen in 12 percent of subjects at low risk for cardiovascular disease, 34 percent of those at intermediate risk, and 49 percent of participants at high risk. More than 80 percent of those in the low-risk group were being treated, compared with only about half of the higher risk groups. Goff and his associates report that this pattern was similar among ethnic groups, except for Chinese Americans, who were less likely to be affected. However, African Americans and Hispanic Americans were less likely to be treated and controlled than non-hispanic whites. This, the team suggests, is likely due to socioeconomic characteristics and healthcare access.
Can we assure quality? Standards change Different standards for different locations and same location by different groups Practice is, by its nature, imperfect Factors other than professional inputs are out of the healthcare system s s control, e.g., patient compliance and environmental issues But we can assure the process is under control
Some terms used in quality assessment: 1. Morbidity and Mortality 2. Incidence and Prevalence 3. Sensitivity and Specificity 4. Validity 5. Reliability 6. Timing of reviews: Prospectively, concurrently and/or retrospectively? 7. What or who do we target for review? E.g., Disease in the population, physician treatment of that disease, sentinel events? 8. Efficacy versus effectiveness 9. Local variations
Efficacy vs. Effectiveness Efficacy Patient Population Homogeneous; patients with coexisting illness Heterog all test Effectiveness Homogeneous; patients with coexisting illness Heterogeneous; eneous; Includes often excluded patients who usually have Procedures Standardized Often variable Testing Conditions practice Ideal Conditions of every day Practitioner Experts All users Adopted from: Institute of Medicine 1989.
Methods of Evaluation: Structure Process
Where do we get standards?
Take your pick: National Guideline Clearinghouse (www.guideline.gov( www.guideline.gov) Zentralstelle der Deutchen Artzeschraft zur Qualitatssicherung in der Medizin, GbR (http://aezq.de( http://aezq.de) Agency for Healthcare Research and Quality-AHRQ (www.ahrq.gov( www.ahrq.gov) The Cochrane Collaboration (www.cochrane.org( www.cochrane.org) National Institute for Clinical Excellence-NICE (www.nice.org.uk( www.nice.org.uk) Scottish Intercollegiate Guidelines Network-SIGN (www.sign.ac.uk( www.sign.ac.uk) Canadian Task Force on Preventive Health Care/ Groupe D Etude D Canadien Sur Les Soins De Sante Preventifs (www.ctfphc.org( www.ctfphc.org) National Committee for Quality Assurance-NCQA (www.ncqa.org( www.ncqa.org) New Zealand Guidelines Group (www.nzgg.org( www.nzgg.org) Specialty Societies (for some U.S. Canadian and U.K. sites, see: www.medic8.com/clinicalguidelines.htm ) Locally developed, e.g., by physician groups, hospitals/health systems, health plans or government
Which Standards Do We Use?
WHERE MEDICATION ERRORS OCCUR Administration 13% Dispensing 1% Monitoring 25% Ordering 61% Source: Nebeker et al., Archives of Internal Medicine, May 23, 2005
When Do We Stop Doing Paps? ACOG: No age limit on pelvic/pap smears USPTF: The USPTF recommends against routinely screening women older than age 65 for cervical cancer if they have had adequate recent screening with normal Pap smears and are not at otherwise high risk for cervical cancer There is fair evidence that screening women older than 65 is associated with an increased risk for potential harms, including false-positive results and invasive procedures.
How Often Do We Re-Evaluate Standards?
Examples: Estrogen Use in Post Menopausal Women Anti-Dysrhythmic Drugs in Asymptomatic Patients Bone Marrow Transplantation Treatment for Metastatic Breast Cancer Bleeding, purging and blistering
Can the Standards Be Accurately Audited?
Example: Questions about data quality forced California to conduct a special study of data accuracy, which found striking variations across hospitals in the validity and reliability of coding certain risk factors overcoding overcoding (coding conditions not supported by medical record documentation) rates ranged from 10% at a putatively high- mortality hospital to 74% at a facility considered low mortality. Source: Iezzoni, LI: JAMA:278:1600-1607, 1607, 1997
Do Publishing Standards Change Behavior or Affect Outcomes?
Consumers and purchasers rarely search out the information and do not understand or trust it; it has a small, although increasing, impact on their decision making. Physicians are skeptical about such data and only a small proportion makes use of it. Hospitals appear to be most responsive to the data. In a limited number of studies, the publication of performance data has been associated with an improvement in health outcomes. Source: Marshall, MN et al: The Public Release of Performance Data. JAMA 283:1866-1874, 1874, 2000
Is the Behavioral Change Sustainable?
In the case of physicians, remove the stimulus and the response goes away.
Some examples: Leapfrog Group: CPOE, High Volume, Intensivists (www.leapfroggroup.org) AHRQ (formerly AHCPR) (www.ahrq.gov) NCQA: Accreditation of MCOs and HEDIS (www.ncqa.org) FACCT (absorbed into the Markle Foundation): Prevention, Staying Healthy, Treating Acute Illness (Getting Better), Living with Chronic Illness, End of Life Issues (www.markle.org)
Methods of Evaluation: Structure Process Outcome
Some problems evaluating outcome measures: 1. Account for factors other than medical care 2. Know the natural course of the condition before evaluating outcomes of the intervention 3. Adjust for severity of illness Examples: Acute Physiology and Chronic Health Evaluation (APACHE) and Medis Groups: Individual vs. Institutional Evaluations
Some problems evaluating outcome measures: 1. Account for factors other than medical care 2. Know the natural course of the condition before evaluating outcomes of the intervention 3. Adjust for severity of illness 4. Control for vigilance effect 5. Decide what outcome is measured
Types of Outcome Measures Functional Status Psychological Status Complications (Morbidity) Death (Mortality) Patient/Family Judgments Appropriate/Efficient Use of Services Source: James Roberts, M.D.
Sample SF36 Questions
New Drugs May Help Against Gout, Colitis Associated Press December 7, 2005 5:31 p.m. The gout study involved about 760 patients and compared febuxostat with allopurinol, both of which remove excess urate from the blood. Urate deposits crystals in the feet and other joints, causing bouts of painful inflammation. Over a year, febuxostat was three times more effective at lowering urate to a healthy level. But the febuxostat patients only had slightly fewer gout attacks by the end.
Some problems evaluating outcome measures: 1. Account for factors other than medical care 2. Know the natural course of the condition before evaluating outcomes of the intervention 3. Adjust for severity of illness 4. Control for vigilance effect 5. Decide what outcome is measured 6. Decide when to measure outcomes- What are the problems with too short or too long intervals? 7. Decide who chooses the outcome/who is the customer 8. Choose who or what is being evaluated, e.g., physician (if so which?), institution, payer, system, country 9. Choose the threshold for an outcome to register 10. Assess whether it is worth the cost
Who or What is being evaluated? Example: Pennsylvania Health Care Cost Containment Council (PHC4) Outcomes by Hospital or Physician: http://www.phc4submit.org/cabg/default.aspx?year=2002 Results: -The state s busiest surgeon performed 352 open-heart and CABG procedures in 2003 while three physicians did just one apiece. The average was about 130 procedures per surgeon. -Patients treated by surgeons who performed higher numbers of procedures-in the 200 to 250 range- were twice as likely to survive surgery as those whose physicians performed fewer than 100 procedures that year. Patients with higher-volume Surgeons also tended to have shorter lengths of stay in the hospital. -The statewide average length of stay was 5.9 days, but averages at individual hospital s varied widely from three-point five days to eight days. -The data showed no apparent relationship between higher costs and improved outcomes. Source for summary: Modern Healthcare April 4, 2005
Examples: 1. In 1994, Iowa stopped using MedisGroup data to risk adjust hospital outcomes citing costs as the reason. 2. In 1995, Colorado followed for the same reason. 3. In 1990, California decided not to implement a Pennsylvania-like like program for risk adjustment when the cost was projected to be $61.2 Million.
Volume-Quality Relationships
Volume-Quality Relationships What are the possible reasons for volume- quality relationships? What are the public policy implications? Do volume-quality relationships apply to all conditions?
Volume-Quality Relationships What are the possible reasons for volume- quality relationships? What are the public policy implications? Do volume-quality relationships apply to all conditions? What is more important: physician, hospital and/or both?
What are the ethical implications for reporting quality results?
Change from Quality Assurance to Quality Improvement
Transition from: Quality Assurance Quality Improvement Externally Driven Internally Driven Follows Organizational Structure Follows Patient Care Focused on Individuals Focused on Process Delegated to a Few Embraced by All Works toward Endpoints Has No Endpoints Assures Quality (Perfection) Improves Quality Divides Analysis of Integrates Analysis Effectiveness/Efficiency Source: James Roberts, M.D.
And finally How do we combine cost, quality and access considerations to assess value in healthcare? Competing sample definitions: Given a certain cost, how can I maximize quality? Given a desired quality, how can I minimize cost? What comparable questions would you ask that incorporate access?