Correspondence

Number of Medical Conditions and Quality of Care

N Engl J Med 2007; 357:1350-1351September 27, 2007

Article

To the Editor:

In their article about the relationship between the number of medical conditions and quality of care, Higashi et al. (June 14 issue)1 found that quality of care does not decline among patients with increasing numbers of chronic conditions. However, it would be premature to abandon the burden of chronic disease as an important consideration in quality-measurement programs. Many measures of quality used in the study by Higashi et al. reflect history taking, patient counseling, and other care processes assessed through chart review and patient interviews.2,3 In contrast, quality measures used by large-scale health systems are usually far less robust, focusing on a limited set of care processes assessed with the use of clinical or billing databases.

For example, a frail, elderly woman with multiple medical problems and stage 1 hypertension may be appropriately evaluated and counseled about her blood pressure but may reasonably decide to forgo drug therapy. The measures used in the study by Higashi et al. may in part capture the high-quality workup and decision making. In contrast, a typical pay-for-performance system would probably focus on the uncontrolled blood pressure and the absence of drug treatment.4 Despite the findings of Higashi et al., patients with multiple chronic conditions may remain at a disadvantage in typical performance-measurement systems.

Michael A. Steinman, M.D.
San Francisco Veterans Affairs Medical Center, San Francisco, CA 94121
mike.steinman@ucsf.edu

4 References

1. 1

   Higashi T, Wenger NS, Adams JL, et al. Relationship between number of medical conditions and quality of care. N Engl J Med 2007;356:2496-2504
   Full Text | Web of Science | Medline

2. 2

   McGlynn EA, Asch SM, Adams JL, et al. Technical appendix to: McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348:2635-2645http://www.rand.org/pubs/working_papers/2006/RAND_WR174-1.pdf
   Full Text | Web of Science | Medline

3. 3

   Shekelle PG, MacLean CH, Morton SC, Wenger NS. Assessing care of vulnerable elders: methods for developing quality indicators. Ann Intern Med 2001;135:647-652
   Web of Science | Medline

4. 4

   Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA 2005;294:716-724
   CrossRef | Web of Science | Medline

Author/Editor Response

Dr. Steinman states that our finding of an increase in the overall quality score with an increasing number of medical conditions may be sensitive to the types of quality measures used. We agree. As we note in our article, “Our results may not be generalizable to quality indicators based on outcomes or quality indicators that are less clinically detailed or that assess a smaller percentage of the care received.” In particular, Dr. Steinman believes our results may not be found if blood-pressure control is used as a measure of quality. We are already on record as opposing in general the use of blood-pressure control as a measure of quality, since there are many factors that contribute to blood pressure that are beyond the control of the health care system.1 We expect that process measures will be less sensitive to this type of problem. Whether less clinically detailed measures of processes of care will similarly show an increase in the overall quality score as the number of health care conditions increases is a hypothesis worth testing.

In a separate analysis of the Assessing Care of Vulnerable Elders (ACOVE) data, three authors of our article (along with other coauthors) examined the relationship between multiple conditions and quality of care in an elderly population.2 Although different analytic methods were used, the results were similar to the ACOVE results reported in our article. We regret our error in judgment in presenting overlapping findings in two reports and our failure to provide cross-citations in the articles.

Takahiro Higashi, M.D., Ph.D.
Kyoto University, Kyoto 606-8501, Japan

Neil S. Wenger, M.D., M.P.H.
University of California at Los Angeles, Los Angeles, CA 90024

Paul G. Shekelle, M.D., Ph.D.
Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA 90073
shekelle@rand.org

2 References

1. 1

   Shekelle PG. Socioeconomic inequalities in indicator scores for diabetes: poor quality or poor measures? BMJ 2004;329:1269-1270
   CrossRef | Web of Science | Medline

2. 2

   Min LC, Wenger NS, Fung C, et al. Multimorbidity is associated with better quality of care among vulnerable elders. Med Care 2007;45:480-488
   CrossRef | Web of Science | Medline