Measuring Quality: Good, Better, Best
Sit around a dinner table and ask, "What makes a good doctor?" You might think that this would ruin the party, but it doesn't. Try...
Sit around a dinner table and ask, "What makes a good doctor?" You might think that this would ruin the party, but it doesn't. Try it.
The first half of the dinner group might respond that "the doctor talks to me" or "knows my family" or is "easy to make an appointment with." By the time five people have answered in a similar way, it is then worthwhile to ask, gently, "Doesn't it matter if the doctor makes you better?" Answer: "Oh, we assumed that!" Wrong.
Quality does differ among practitioners, and quality does matter, in areas very important to all of us like the treatment of cancer, kidney disease or high blood pressure and what happens when we have a heart attack. According to the Institute of Medicine, quality health care is embodied in six essential elements, and requires that it be patient-centered, timely, effective, efficient, equitable and safe. As patients assess what quality means to them, they will need to rank each of the six elements in order of importance when choosing a physician or a hospital for a specific procedure. Ideally, every element is equally important, but some patients may, for example, sacrifice timeliness and wait an extra month in order to see a super-specialist.
The Patient's Guide to Quality
Right now, it takes work to find data about quality. If you want quality information about individual physicians, the data are scarce, but are becoming more available every day. Most health plans provide patient satisfaction data at least for all the doctors as a group, and, increasingly, by individual physicians. If a patient is relatively healthy, it is likely that how the doctor relates to them (patient-centeredness and timeliness) is going to be high on the list of importance, and these are well measured by patient satisfaction data.
The Internet provides a convenient gateway for patients and providers alike when looking for quality measures. For example, Healthgrades.com provides "quality reports" on 600,000 physicians, with information on medical training, board certification and any disciplinary actions taken in the past five years by state or federal authorities. The "effectiveness" quality element discussed above is likely related to board certification. In today's world, board certification is an indication that a physician had to pass a broad examination assessing what he or she knows, both generally and in a specific medical area. An up-to-date board certification is a general indication that a physician has kept up with current practice standards.
Education and training are also important aspects in assessing quality, although information just about where a physician is educated may not be very helpful when making a decision about who may or may not be the best doctor. The same is true regarding disciplinary actions. If an individual practitioner has lost his or her license to practice medicine, this may suggest a failing in "effectiveness" or "safety," and a patient would want to know that. However, given today's high rates of malpractice suits, being sued is not necessarily an indicator of a low quality -- but it is worth asking the physician about the judgment and whether the lawsuit was in the area relating to your disease.
Grades, Rankings and Report Cards
Data measuring the quality of the care delivered by individual physicians is becoming more commonly available. The best publicized individual physician outcome data are in the New York State Department of Health's cardiovascular surgery database. Every surgeon in the state who does coronary bypass surgery is included, and their "numbers" regarding patient survival or complication rates are reported. But this database illustrates the two major problems with individual physician outcome data. First of all, for physicians with a small number of patients, the data will be less reliable. This is just the law of small numbers. Data based on three cases is less reliable than data obtained from 100 cases. The mere fact that a surgeon does less than the average number of cases does not necessarily mean that his or her work is of poorer quality, but it may be a sign that he or she is not experienced or does not get referrals. In general, physicians who perform a greater volume of procedures have better results.
The second problem with individual physician outcome data is that it often does not take into account the severity of illness for each patient. To be meaningful, data on outcomes (such as death after heart surgery) must be compared only among patients with a similar severity of the medical problem. It is important to find out if the data on individual surgeons are "risk adjusted," or compared for similar severity. Another problem with this type of data is that they are presented statistically, and, unless the patient is a statistician, trying to figure out whether one surgeon's statistics are better than another's is difficult at best. The best way for patients to approach this type of information is to compare outcomes for a given procedure among a range of physicians with average to excellent ratings. It is best to choose a physician whose ratings are closer to the top, particularly as the case gets more complicated.
Data for hospitals are much more available. The Joint Commission on Accreditation of Healthcare Organizations (often referred to as "the Joint Commission") is the oldest and largest non-governmental agency that accredits hospitals and ranks their safety and quality. The federal government's Centers for Medicare and Medicaid Services provides information about hospital quality performance and outcomes and allows patients to compare hospital ratings. At present, both of these groups rank heart attack care and heart failure care in a large number of hospitals, and the Joint Commission also ranks the quality of care during pregnancy. Other national, nongovernmental groups that provide quality information include the National Quality Forum and the Institute for Healthcare Improvement. It is important to remember that hospitals that are outstanding in the treatment of one disease may not be in all diseases, and one should look for the specific condition when looking at rankings.
The concepts that apply to doctors and hospitals also apply to health plans. The National Committee for Quality Assurance is a private, not-for-profit organization whose mission is to improve the quality of health care by providing understandable information to help inform consumer and employer choice. The NCQA accredits and rates health in the areas of preventive care (staying healthy), acute care (getting better when ill) and disease management (coordinated care for the chronically ill. In general, the health plans with the higher number of people enrolled generally have better results.
Other public and private initiatives are gaining traction in promoting quality health care, and they are increasingly paired with physician and hospital payment methods to promote effective and efficient patient care. The medical home model provides an additional payment to primary care providers who coordinate the primary and specialty care of their patients, including medication management. The use of "checklists" in hospitals has been shown to reduce the rate of hospital-acquired infections and surgical complications. Pay-for-performance programs reward physicians for practicing evidence-based medicine, and "bundled payments" for episodes of acute care (such as for a heart attack) reduce fragmentation and communication gaps when patients are treated by multiple physicians. These and other initiatives help fine-tune our understanding of how to define high quality care, which, in turn, will translate into more effective and more valued care for both patients and physicians.