Correspondence
The Unintended Consequences of Measuring Quality on the Quality of Medical Care
N Engl J Med 2000; 342:519-520February 17, 2000
- Article
To the Editor:
Casalino (Oct. 7 issue)1 provides a voice for physicians who hold the intuitive conviction that tables of specialty-referral rates, formulary compliance, and hospitalization rates represent a subtle but nonetheless unacceptable diversion of the physician's focus from the life-and-blood patient to the gamesmanship of documentation. According to Heisenberg's uncertainty principle, as applied to the measurement of quality in health care, one cannot gather sufficient information about a physician's activities (the “object's position”) to determine the quality of care being provided without distorting the physician's professionalism (the “object's velocity”) — that is, without distorting the physician's attitudes, motivation, and overall ability to put the patient's interests above his or her own. I fear that “this result has nothing to do with inadequacies in the measuring instruments, the technique, or the observer.”2 It derives from the gravity of the physician–patient relationship, which is a very strong force. It's not nice to fool with Mother Nature.
2 ReferencesGary M. Stewart, M.D.
17400 Irvine Blvd., Suite N, Tustin, CA 927801
Casalino LP . The unintended consequences of measuring quality on the quality of medical care. N Engl J Med 1999;341:1147-1150
Full Text | Web of Science | Medline2
The new Encyclopaedia Britannica. 15th ed. Vol. 12. Chicago: Encyclopaedia Britannica, 1985:125.
To the Editor:
When I began practicing in 1971, quality control consisted of doctors meeting among themselves to discuss difficult, interesting, or mismanaged cases. Now we have a multimillion-dollar industry devoted to the exogenous imposition of excellence. When I was the medical director of a publicly funded outpatient clinic, we could not afford the price of a spirometer, but we could pay five times as much for a Joint Commission on Accreditation of Healthcare Organizations survey, after which we were “accredited” but still had no spirometer. Much of the money went toward overtime pay for health care personnel who made sure that every chart was in order. This was a waste of resources.
For my hospital's quality-assurance committee, I review charts that have been pulled according to standardized criteria and note, for instance, a patient with a digoxin level two 10ths of a point above the therapeutic level, and a patient with pneumonia who was discharged as clinically improved but without x-ray confirmation. Invisible to committee scrutiny are a 60-year-old patient with intractable vomiting who was discharged after a complete, negative gastrointestinal workup but readmitted two weeks later with neurologic symptoms, a large brain tumor, and increased intracranial pressure, as well as a 73-year-old patient found to have a dry infarct in the distribution of the middle cerebral artery on computed tomographic scanning two days after receiving a diagnosis of coexistent Bell's palsy and cervical radiculopathy from a neurologist in the emergency department and not being given tissue plasminogen activator.
Our obsession with quality assurance often becomes a commitment to mediocrity, or worse. The auditors' dictum, “If it's not in writing, it didn't happen,” has a corollary: if it is in writing, it did happen. I have watched colleagues shunt time from an actual encounter with a patient into its charting. Reality may be reconstructed as desired. Professionalism suffers.
Robert S. Bobrow, M.D.
270 E. Main St., Suite 1, Bay Shore, NY 11706To the Editor:
Casalino argues that measurement of quality may compromise the willingness of caring physicians to go the extra mile. However, the culprit here is not the measurement of quality but rather the financial pressures under which physicians increasingly operate and which compel them to make constant trade-offs between quality and cost. These financial pressures, if anything, make valid quality measurement even more essential. In fact, robust measures of quality include assessments of patients' experiences,1 allowing people to judge whether a doctor's practice of spending extra time with his or her patients is worth the scheduling delays or perhaps the added cost.
Reports of staggering rates of medical errors,2 excessive underuse and overuse of proven clinical processes,3 and insupportable variations in patterns of practice4 have caused a skeptical public to demand accountability. Well-constructed tools that account both for patients' experiences and for clinical quality will allay some of Casalino's concerns about the unintended consequences of overly narrow measurement. His suggestion that some measures be rotated is a reasonable way of ensuring that physicians do not spend undue effort “playing for the test.”5
According to Casalino, quality measurement will be a disadvantage to individual physicians because large systems “can afford to purchase expensive data systems and hire quality-improvement experts.” This discrepancy is neither unfair nor inappropriate. Although we may wax nostalgic about the shift from “mom and pop” groceries to warehouse superstores, such changes are driven by the perception that larger entities offer better products and more convenience at a lower cost. If the organization of physicians into large medical groups, hospitals, and networks allows us to improve quality and efficiency (a premise that has not been entirely proved), why should this approach not be recognized and rewarded?
In the future, computerized data bases containing easily accessed quality measures will create an educated population that will vote with its feet when selecting providers. Like Casalino, we believe that it is vital that such measures capture both the science and the art of medicine. If solo practitioners are able to match large organizations for quality (and cost), patients may well favor them, especially when the latter seem impersonal and bureaucratic. Likewise, if the large organizations provide care of demonstrably higher quality, patients and payers will most likely migrate to them. Physicians who fail to measure up to the metrics of quality and value will undoubtedly lose patients. This is sad, but it is also inevitable and right.
5 ReferencesRobert M. Wachter, M.D.
Kaveh G. Shojania, M.D.
University of California, San Francisco, San Francisco, CA 94143-01201
Cleary PD ,Edgman-Levitan S . Health care quality: incorporating consumer perspectives. JAMA 1997;278:1608-1612
CrossRef | Web of Science | Medline2
Lazarou J ,Pomeranz BH ,Corey PN . Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA 1998;279:1200-1205
CrossRef | Web of Science | Medline3
Schuster MA ,McGlynn EA ,Brook RH . How good is the quality of health care in the United States? Milbank Q 1998;76:509, 517-509, 563
CrossRef | Web of Science4
Chassin MR ,Galvin RW . The urgent need to improve health care quality: Institute of Medicine national roundtable on health care quality. JAMA 1998;280:1000-1005
CrossRef | Web of Science | Medline5
Eddy DM . Performance measurement: problems and solutions. Health Aff (Millwood) 1998;17:7-25
CrossRef | Web of Science | Medline
Author/Editor Response
Dr. Casalino replies:
To the Editor: Bobrow and Stewart eloquently express the “intuitive conviction” of many physicians that quality measurements lead to unintended consequences. Yet relying only on physicians' professionalism and on “doctors meeting among themselves to discuss . . . cases” has not been enough; I agree with Wachter and Shojania that organized, systematic efforts to improve quality are necessary. Efforts to improve quality require efforts to measure it. As measurements are designed and implemented, explicit attention should be devoted to the anticipation of unintended consequences and to their minimization when they appear undesirable, as I discussed in my article.
Bobrow and Stewart are aware of the problems brought on by quality measurement, problems that they — unlike quality-improvement experts who are not physicians — have experienced firsthand. Yet criticism is not enough: if physicians do not help to create and implement systems to improve quality, others will.
Wachter and Shojania describe the “culprit” as financial pressures that compel “constant trade-offs between quality and cost.” This trade-off is disliked by both physicians and patients but is inevitable, since medical resources are not infinite. Despite their assertion that financial pressures are the culprit, they conclude with a very optimistic vision of what economists would call a perfect market: educated consumers, they suggest, will use quality measures (and presumably costs as well) to vote with their feet when selecting physicians, and efficient, high-quality physician organizations will succeed while others will fail. I agree that this would be desirable, insofar as it is possible. But since neither the measures nor the market is likely to be perfect, researchers, purchasers of health care, and policy makers should actively seek to anticipate and to minimize undesirable and unintended consequences of quality measurement and of market competition as well.
Lawrence P. Casalino, M.D., Ph.D.
Stanford Coastside Medical Clinic, Half Moon Bay, CA 94019- Citing Articles (2)
Citing Articles
1
Douglas P. Olsen. (2011) When Being Good Means Looking Bad. AJN, American Journal of Nursing 111:10, 63-65
CrossRef2
Kurt C. Stange, Paul A. Nutting, William L. Miller, Carlos R. Jaén, Benjamin F. Crabtree, Susan A. Flocke, James M. Gill. (2010) Defining and Measuring the Patient-Centered Medical Home. Journal of General Internal Medicine 25:6, 601-612
CrossRef
