There are global
measures and specific measures of health care quality. Just as we can take a
patient’s temp to rule in and out large swaths of work, we can ask global
questions like “the percent of patients who say their care is perfect” or “I get
exactly the care ….”
John Wasson is a health systems researcher at Dartmouth with decades of theoretical work on how questions are asked and what they mean, and he has decades of work applying the theory to real practices in settings across the US.
The global questions he
asks have been studied (not being a researcher by training I can only posit the
regression analysis etc that make up appropriate study). Remarkably awkward as
a sentence, this phrase is powerfully linked to positive responses on a host of
more specific indicators: access to care, continuity of care, no wasted time in
the office, having a good understanding of personal medical issues, having the
efficacy and confidence to manage those conditions. In turn these secondary
issues have been studied and linked to things with which we are more familiar:
Glycemic control in DM, systolic and diastolic blood pressure control in HTN, as
well as heavy hitter issues like rates of emergency room use and
hospitalization. Given the generally
woeful levels of quality in the US (NOT because we don’t care and are not
working hard but due to the fact that we’re hamstrung by a toxic environment in
health care), we need access to quality measures so we can make the case to
clean up this toxic environment. One approach is to ask
practices to report “percent of patients who have hypertension who have systolic
blood pressure controlled” (with then a paragraph or two defining the
appropriate denominator of “hypertension” and “established patient” and another
paragraph or two defining the numerator (exclusion factors where tight control
might be inappropriate, some patients who won’t engage) and a page or two
describing what “in control” means. (I submit for your
consideration the 20 page paper “Implementing the new HEDIS Hypertension
Performance Measure”) http://www.managedc This approach appears
eminently logical on its face until we realize that we’re treating a lot of
people in our practices who don’t have hypertension and we wonder if this one
measure can capture the true nature of our work or if it merely represents the
work we do to manage this one narrow biometric. This work appears
eminently logical until we start the laborious job of extracting SBP and DBP
from paper or electronic system that give them up grudgingly (especially as we
try to address the nuances of “in control” and “does this person deserve to be
excluded because of X?”). This work appears
eminently logical until we reflect on decades of research that identify
effective primary care as the foundation of high performing health systems and
not disease management. We in our offices and
with our patients must measure and manage systolic and diastolic blood pressure
and use the latest (hopefully untainted) medical evidence to guide our patients
to the best possible care. We COULD use a wide
swath of biometrics like this to reflect the bulk of our care, but recognize the
impossibility given the limitations of health information technology (the hype
gap), the fact that more and more of the primary care work force is walking the
financial plank in this toxic ocean of unfunded administrative trivia. We
could spend more and more of our time justifying
minutia. On the other hand,
maybe we could explore approaches that give us reliable information without all
the heavy lifting. If aggregate patient
experience in our practices achieve statistical meaning (it does) If patient experience
reflects fundamental attributes of primary care (it does) If patient experience
measures can be easily obtained (been there, done that) We could then use a
handful of global experience measures - like a handful of indicators on your
dashboard – as the feedback loop on the office systems we have created, as the
quality indicators others are demanding.
“I can get care when I
need it” means we have eliminated barriers for our patients in obtaining care –
first pillar of primary care
“I have a PCP who knows
me” continuity – second pillar of primary care
“My PCP provides for
the bulk of my needs” broad array of services – third pillar of primary
care
“My PCP coordinates my care” – fourth pillar of primary care.
There are numerous
studies behind each and every one of these metrics. Patients in aggregate can
accurately identify how well we perform these fundamental attributes of primary
care. When we perform well on these elements our patients achieve better
glycemic control, blood pressure control, miss fewer days from school and work,
and are hospitalized less often. This approach reflects
primary care – not discrete organ systems. This approach reflects our patients
and how we serve them – not simplistic “yes/no” responses to “do you have a searchable field for micrometric X?” L Gordon Moore MD
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