Discussions of healthcare quality tend to blur the distinction between preventing medical errors and ensuring the best care is given. The former attempts to end bad medicine, aka malpractice. The latter is an effort to eliminate mediocre medicine by using evidence-based care guidelines instead of the haphazard treatment so often provided in hospitals and physician offices.
Recent events have brought this idea of standardized care to center stage, as Modern Healthcare has reported in the past two weeks. Rhode Island's health department last week began forcing the state's 10 acute-care hospitals to show how well they are adhering to protocols for treating heart attack, heart failure and pneumonia, the three most common reasons people land in hospitals.
A number of studies have added momentum to the movement. The most recent was done by researchers at Duke University Medical Center. The study of 257,000 patients found that adhering to a prescribed set of actions and interventions in the minutes and hours after a heart-attack victim enters a hospital lowered death rates by 40%. Those actions can be as simple as giving patients a dose of aspirin within 24 hours of a heart attack or as challenging as administering an electrocardiogram to a suspected heart-attack victim within 10 minutes of arrival in the emergency department.
Two other studies released this year have found that angioplasty, when performed by an experienced cardiologist in a high-volume catheterization laboratory within three hours of the onset of symptoms, reduces death rates by almost 50% compared with administering thrombolytic drugs in heart-attack victims. Hospital stays are shorter and complications are fewer.
This is why the Joint Commission on Accreditation of Healthcare Organizations in January will begin reviewing hospitals' clinical track records on treatment of heart attacks, heart failure, pneumonia and pregnancy as part of its accreditation process.
And yet most providers so far have eschewed care guidelines. An ongoing survey of 48 hospitals around the country by the Center for Studying Health System Change has found that "many hospitals' quality-improvement activities remain in a relatively early, developmental stage."
Physicians traditionally have derided clinical guidelines as "cookbook medicine" that limits their latitude in dealing with individual patients. Hospitals, always ready to cater to their doctors, haven't forced the issue by establishing comprehensive systems that cover all the clinical bases.
Clinical protocols aren't carved in stone. Some patients will be clinical outliers. Guidelines also reflect the current state of the art, and are designed to be amended as new research reveals better treatment options for medical conditions.
With research-based evidence of the value of clinical guidelines mounting, however, providers' reluctance or intransigence on this issue not only doesn't make medical sense, it simply won't pay.
As Rhode Island implements its system, the National Quality Forum is coming out with a final set of clinical guidelines next month at the request of the Centers for Medicare and Medicaid Services. Kenneth Kizer, the NQF's chief, told reporter John Morrissey that those guidelines likely will be tied to reimbursement. Put more bluntly, if you like getting Medicare revenue, you had better build a rock-solid platform to carry forth a care protocol system.
Private payers are interested as well. The employer-backed Leapfrog Group and the Washington Business Group on Health already have said they are going to take a long look at the NQF recommendations. You can count on the big managed-care payers following suit.
This is why we saw so many provider organizations jump on the quality information-sharing bandwagon last week.
When money is at risk, intransigence suddenly seems a less appealing option.