Small practices cannot let false assumptions drive quality measurement - we can 'do' quality and do it well

Although the federal government and other health care stakeholders have expressed interest in moving the nation's health care system toward a value-based system that relies on measuring the quality of health care delivered against the dollars spent to provide that care, new research suggests that this may not work well for primary care practices.

via www.aafp.org

If we accept the notion that the only way to measure quality is with biometrics (e.g. HbA1c) then we're stuck with a statistical problem: no PCP has enough data to be statistically meaningful.

If we accept that assumption then we go down the path of presuming to force solo and small practices to either wither & die or become part of big Virtually Integrated Health Systems.  I posted yesterday to give folks a heads-up on why such VIHSs may not be the right way to go given their very strong interest in continuing the status quo ("Don't slaughter my cash cow!").

If we accept that assumption then we can easily accept all the studies that link practice size to 'quality.' 

Those studies are a neat trick: 

"Hey, let's define 'quality' as something that only works in large organizations."

"Gee look Bob, it appears that only large organizations are able to measure and report on quality."

"Small practices must not care about quality.  They are bad people.  Let's force them to become large organizations or go out of business."

Health care measurement is stuck in a geo-centric paradigm. 

"The celestial bodies revolve around the earth.  Their movements are very strange, but once we accept that the earth is the center of the universe we can compound theories that explain these strange movements."

I for one am tired of torturing nature like that.  We know from the work of Dana Safran @ Tufts, John Wasson @ Dartmouth and others that we can use patient reported outcome measures to identify how well a practice and even an individual PCP performs.  With PROMs we have very large denominators and are not stuck trying to explain the bizarre motions of the celestial bodies.

I know the orthodoxy of quality measurement will send robed inquisitors, so if you don't hear from me for more than a week please send a rescue party.

Comments

[l dudley]

I happened on this blog through SERMO and find this entry pretty awesome!
I am going to watch you and find out more about this blog
you should check out SERMO
- 113,000 doctors are listening

[Kathleen Patton]

Great post.
The construct of The Hospital as Center of the Universe is deeply flawed. This wouldn't pass the scrutiny of my son's 10th grade philosophy course, for crying out loud.
Ask Galileo.