In healthcare, no mantra is repeated more often than the need to improve quality. But more than a decade after studies showed wide variations in practice patterns, medical groups have yet to achieve quality nirvana.
"We're not there," admits David Blumenthal, director of the Institute for Health Policy at Massachusetts General Hospital in Boston. The institute studies healthcare quality, access to physicians and other health policy topics.
Crippled by attitudinal, financial, organizational and other barriers, providers are years from taking the critical steps toward actually improving care on a large scale, Blumenthal and others say. Even though consumers, employers and insurers demand proof of the quality of the health services they are paying for, physicians are taking only baby steps toward improving patients' medical outcomes.
Blumenthal says widespread improvement probably won't occur until economic and other incentives in healthcare encourage physicians to know and practice the most efficacious treatment.
To achieve improvement, he says, "you need to invest heavily in changing behavior, and (you) need to create tension in the lives of providers that can be ameliorated. This means feeding back data and finding ways of making data salient to them." Doctors also need more peer pressure and review to change, he says.
Employers and capital markets need to reward quality, Blumenthal says. Employers generally look for the lowest premiums, not the best quality, and stock markets reward companies based on short-term profits rather than long-term quality enhancement, he says.
Payers encourage overuse of provider services through fee-for-service compensation or under-use through capitation, says Mark Chassen, chairman of the department of health policy at the Mount Sinai School of Medicine in New York. Chassen studies healthcare quality issues.
One effort to reward doctors for new behavior is unfolding at the University of Pennsylvania Health System through disease management programs that seek to improve healthcare quality, says David Shulkin, M.D., chief medical officer and chief quality officer. The university has invested $11 million in disease management, with part of that funding earmarked for incentive payments to doctors.
Each disease management program consists of patient education, treatment and other guidelines, including five quality measures. For example, there are four process quality measures for diabetes. They include whether the patient received a hemoglobin A1C test four times a year, an annual visit to an ophthalmologist for a retinal exam, a urine exam to measure microalbumin and a foot exam twice a year.
Doctors are rewarded for improving quality based on the percentage of their patients enrolled in programs and on the number of patients who have a hemoglobin level of 7.0 or less, Shulkin says.
Target thresholds and graduated payments have been established for adhering to best practices, but Shulkin would not reveal what they are. Even clerical staff can participate in the program; they receive additional compensation if they flag charts of patients eligible to join a program.
In addition, Shulkin says, physicians can use extensive computerized data systems to see in real time which patients are enrolled in the programs. Through these methods, he says he hopes to enroll 80% of patients in the University of Pennsylvania system in disease management programs by 2000.
The university also is making its disease management programs available to members of VHA, a national alliance of some 1,800 hospitals. Shulkin notes, however, that making the guidelines available is the easiest part. Getting doctors, administrators and others to implement them, he says, "takes a significant amount of local leadership."
Among the litany of barriers doctors cite is figuring out what constitutes an effective measurement of quality -- whether it's outcomes assessments or adoption of standard practice patterns.
"Outcomes may not be the most appropriate or effective measure" of quality, Chassen says. He explains that using outcomes as a measure must be "modified by specific practices and processes of care."
Practice patterns as indicators of quality also have their limitations because of high levels of unexplained variation, says Janet Corrigan, director of the healthcare services division at the Institute of Medicine of the National Academy of Sciences in Washington. "Even in areas that we know are best practices, like prescribing beta blockers after (myocardial infarction)," Corrigan says, there is a great deal of unexplained variation.
Another problem, Chassen says, is most physicians don't have access to meaningful data. For example, they don't receive important follow-up information, such as whether patients actually received medication from a pharmacy or refilled their prescriptions.
Doctors are frustrated by this lack of accountability. They know that patients who have lumpectomies for breast cancer should receive follow-up radiation treatment to keep the recurrence rate low, Chassen says. But about half don't get radiation because the doctor and hospital don't coordinate follow-up care to make sure patients come back repeatedly.
Robert Goldberg, M.D., a Miami Beach, Fla., internist and gastroenterologist, also points to a lack of relevant quality data. Most of the data from managed-care companies are financial in terms of patient hospitalization days and are not related to real quality measures, says Goldberg, who is president-elect of the Dade County (Fla.) Medical Society. "The only thing you get back (from managed-care companies) is an attempt to compare your patients' length of stay and expenses. It's very primitive and rudimentary." Goldberg, who is also an associate professor of medicine at the University of Miami School of Medicine, says most of his colleagues share his opinion.
Patient attitudes are also critical to improving quality, Chassen says. For example, most doctors know antibiotics are ineffective for treating colds, but half of patients with colds receive prescriptions for them from their doctors anyway. "Patients are perceived by some (doctors) to demand that treatment, so doctors either give in or don't have the time to explain that antibiotics are ineffective," Chassen says.
Despite the considerable hurdles to improving quality, some notable pioneers are making progress, says Michael Goldberg, M.D., professor and chairman of the orthopedics department at Tufts New England Medical Center in Boston. Goldberg cites several specialty societies that take patient information their members submit and feed it back to doctors. That information gives them an overall view of how well they are improving the health of their patients.
The American Academy of Orthopedic Surgeons, the American Academy of Otolaryngology and the American College of Cardiology are among the organizations doing this, Goldberg says.
He also cites the Maine Medical Assessment Foundation in Portland, which has been collecting data from orthopedic surgeons and neurosurgeons for 10 years. The foundation has found wide variations in spinal surgery and Caesarean-section rates in different geographic areas of the state.
Goldberg says physicians examine the information the foundation gathers and use it to improve their practices. Recent data about surgical, recovery and other rates "unequivocally show how physicians have changed their behavior" and improved quality, he says.
On the other coast, the Pacific Business Group on Health also is pushing innovations, says Sheldon Greenfield, M.D., a professor of medicine at Tufts University.
Greenfield says the San Francisco-based group, which he consults with, sent out a questionnaire on diabetes asking more than 56 health plans and physician groups about how they treat patients. The questionnaire asked whether respondents perform an A1C test and survey patient data to see if sugar levels decreased over time. As was the case with doctors in Maine, the group found wide variations among plans and doctors.
But Greenfield predicts that when physicians examine the data, they will change their behavior and adopt best practices. He adds that the American Diabetes Association is also compiling data from its members on their patients' health.
Over the long term, such cooperative efforts involving doctors and payers have the most chance of success, says the University of Pennsylvania's Shulkin. "I think there is a recognition that integrated delivery systems can (improve quality), and it takes away a lot of the friction" between doctors and HMO medical directors, he says.