Is US healthcare ready for quality? | Haider Javed Warraich

The brokenness of medicine not only affects millions of patients every day, but is now also threatening the entire US economy

Medicine is unique in being the one profession that never teaches even its recruits how they, or the services they deliver, are paid – and importantly, by whom. When I started my internship in internal medicine not too long ago, I knew as much about the financial structures and payment models of my chosen profession as any lay person did (read: nothing).

Most questions would usually be answered with medicine's newest favorite catch-all, "the system is broken". It is used when patients walk up to physicians to discuss whether they can help them understand if the procedures or tests they are about to undergo are covered under their insurance. It is used to explain why a test has to be repeated even though the patient underwent a similar test in a different institution. More often than anyone would like, it is used in the aftermath of a medical error or a "near miss".

The brokenness of medicine, however, has reached the extent that not only does it affect the millions of patients who interact with this unwieldy machine on a daily basis, but is now threatening the entire United States economy. In case you may have forgotten, medicine accounts for a fifth of the United States GDP, far higher than other developed countries yielding similar to worse outcomes, with "medical waste" accounting for about $750bn annually. Policy makers certainly have not been blind to this fact and legislation such as the Affordable Care Act (ACA) hope to cut medicine, and its wastefulness, to size.

But introducing a culture of quality has not been easy and doctors provided some of the greatest resistance. "Physicians view quality improvement with suspicion," said Dr Joseph Jacobson, chief quality officer at the Dana Farber Cancer Institute in Boston, Massachusetts. "Interventions often don't work well, are not as intuitively valuable and often add more work ... but the door was always open and patient safety was the wedge."

These changes at the top are now trickling down to the bottom. While in most evaluation sessions, I am handed the feedback sandwich (a cold slice of negativity sitting between two warm toasts of positive acknowledgement). In one recent session, I was provided a record of all the patients I had discharged from the hospital and what their eventual outcome was. As a group, the residents in my program are provided data about the quality of care we deliver such as how much time elapses between adverse outcomes, what time are patients discharged and how much time we take to admit patients who present to the emergency room.

All of the residents now rotate through a mandatory quality improvement rotation in which we look at individual cases and analyze what errors led to a mishap occurring and what individual and system factors can be rectified to avoid such an error in the future. At times sitting in our Morbidity and Mortality Conference, a forum previously used to place blame for bad patient outcomes, I forget that I am not in business school with all the talk about system failures and fish-bone diagrams. Quality improvement, now, is a required component of residency training throughout the United States.

There is also a human aspect of quality improvement training. Professor Harlan Krumholz, a cardiologist and director of the Center of Outcomes Research and Evaluation at Yale says:

We need for the socialization that drains physicians of their humanity to be turned around and use medical training to enhance the sensitivity and emotional intelligence of physicians, to help them see through the eyes of patients and feel an obligation to create healing, supportive care environments that deliver care in ways most likely to help patients achieve the outcomes they desire.

While the incorporation of quality improvement at the grassroots may take years to demonstrate its upshot, there are fears that this revolution may be dead on arrival. This movement was born as a reaction to pressure from legislators, policy makers and the public about sky-rocketing costs and the high prevalence of medical errors. One motivation for physicians and healthcare professionals to become involved in this revolution was that given that healthcare reform was inevitable, if "we" didn't do it, someone from Washington would. And to this day, the reactive nature of this revolution continues to weigh it down.

Consider the issue of hospital re-admissions, the main thrust of most quality improvement initiatives. Under the ACA, hospitals that have high rates of patients being re-admitted to the hospital within 30 days after their discharge are penalized. Residents prefer the term bounceback. It is postulated that bouncebacks are an indicator of poor transitional care provided by the hospital staff. Surprisingly, though, re-admissions are penalized more than any other parameter, thus making them the keystone of the new revolution. Yet a key question has not yet been answered: are re-admissions an accurate reflection of quality of care, and can quality interventions in fact reduce re-admissions?

While it would make sense that re-admissions reflect poor quality of care that resulted in the patient needing to come back to the hospital, the data, which is only now starting to emerge is somewhat ambiguous. Many re-admissions are, in fact, not preventable and little variation is found in preventable re-admissions between hospitals delivering varying quality of care. In fact, interventions to improve patient care such as increasing access to primary care and increasing patient survival in diseases such as heart failure actually result in increased re-admissions as sicker patients live longer and are more likely to be readmitted. According to Dr Karen Joynt, a national expert in health policy, the current metrics for value are not adequate.

I think that if you asked patients what parameters matter to them, you would hear that mortality and the experience (of care) are highest on the list.

Therefore, training an entire generation of residents and practicing physicians to think primarily about reducing re-admissions may be misguided. In fact, a recent study in Health Affairs suggests that more recent graduates, those most likely to be integrated in the quality revolution, actually accrue higher healthcare costs.

The data does not hold up for some other targets of quality improvement interventions. The role of primary care, thought widely to be the silver bullet to reduce costs and improve care, remains somewhat unclear. A recent study by Dr Joynt published in the Journal of the American Medical Association showed that areas with a higher density of primary care physicians actually had higher preventable costs for sicker patients. Annual physical exams, reimbursed at a much higher rate than other clinic visits, and long thought to be beneficial, have no proven benefit. All of this suggests that what seems logical is never always the right thing until data proves it to be so. Much of what is practiced in medicine is either because it has been done for long enough that it isn't questioned anymore or that it makes sense. While the Centers for Medicare and Medicaid Services are now providing substantial funding for demonstration projects to define best practices, these projects are being undertaken only after legislation has already been passed and not being used to inform them.

Medicine's quality revolution has already shaken up how physicians think and train and resulted in a proliferation of academics building their careers around outcomes research and quality improvement but it cannot afford to be reactive. Dr Krumholz who has been a part of this revolution since its inception told me:

In the past, people interested in improving care were neglected to the sidelines – now it is the main show. © 2013 Guardian News and Media Limited or its affiliated companies. All rights reserved. | Use of this content is subject to our Terms & Conditions | More Feeds

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