Here’s what happens when you give so much attention and influence to such a crude instrument.
Following quality measures can make or break a hospital’s reputation, especially if they are being widely advertised. Patients often make health care choices based on whether doctors following quality measures.
However, as these measures are currently constructed, they often ignore the nuance surrounding many cases.
Emergency physician WhiteCoat cites two examples where he failed to follow quality measures, and was labeled “out of compliance” with the guidelines.
In one case, he took the time to perform a CT scan prior to giving clot-busting medications within the specified time of onset of having a potential stroke. Not doing so could have killed the patient, for instance, if the stroke was due to a cerebral bleed.
The second case involved a penalty for not giving aspirin or a beta-blocker after a heart attack, which occurred five days into the hospital admission.
I understand that these quality measures are a work in progress, and to Medicare’s credit, they are constantly adjusting the measures. But it’s important to note that they cannot account for all the decision making that surrounds an individual case.
That means, in some cases, that “bad” doctor may be the only one taking the necessary time and thought that can save a patient’s life.
Related posts:
- Adopting hospital quality measures too quickly can harm patients
- Quality measures . . that can kill
- Do physician quality measures tell patients who’s a good doctor?
- Are quality measures doing more harm than good?
- Quality measures
- Another brand name beta-blocker?
- Pre-operative beta-blocker dogma
{ 8 comments }
What is your point? Are you just attempting to be sensational or are you really trying to show a problem. If you are attempting to highlight a problem then you have failed to do so. You may want to amend your post to better illustrate your point. I will comment on how you failed.
1. “Patients often make health care choices based on whether doctors following quality measures.” The data would suggest that this is completely the opposite. In fact, less than 7% of patients make their choice based on known quality measures. The majority of patients make their choices based on referrals from other physicians or based on close friends/families opinions.
2. Your first example of being “out of compliance” only highlights a problem with lack of resources that can appropriately flag what the problem is. When these cases pop up as “out of compliance” then a further review of the details is required to find out if there is a valid clinical reason to not follow the standard of care. This is the real issue (lack of resources to appropriately document why a treatment pathway was/was not followed).
3. Again, on the first example. If in fact the patient doesn’t have a cerebral hemorrhage, and the CT scan delays the administration of appropriate thrombolytics, then in fact, there is a problem. That the physician has to take the hit for it may or may not be appropriate based on why.
The big stink for me is, can there be anything done by the physician to appeal any these cases?
4. Your last example doesn’t actually explain the issue at all, and it certainly doesn’t lead to quality measures killing patients. What the ASA/B-blocker example does highlight is how what seems to be a very simple metric, leads to some very stupid implementations of looking at data. That is definetely true.
The bottom line is quality measures do not kill patients. Lack of following them appropriately does. I think your headline is irresponsible. But once again, it does get me to read what you write.
JFS
Thanks for the two anecdotal examples of patients who would have died (very dramatic) if the great doctor had followed protocol. We need to suck up the fact that their are too many rogue MD’s out there who practice to the beat of their own drummer. Of course, not all patients can be lumped into the same treatment options. But, trends need to be tracked on those “rogue” physicians who constantly practice outside standard of care, and increase the cost of health care.
RR
Just how can “Quality” kill patients? Eight lives were saved in the last year at our hospital because of the sepsis protocol. Quality measures and “bundles” are derived from research-based best practices and data supports that practicing in accordance with these measures produces better patient outcomes. Isn’t that the goal of medicine?
Healthcare providers have brought these changes on themselves from sloppy work. In 1998 the IOM conducted a study that found 98,000patients die every year from preventable deaths. That is equivalent to a 747 crashing every other day killing everyone on board. You would never see 98,000 airline passengers dying every year because the airline industry has instituted standardized safety procedures and the pilots are “on board.” Isn’t it the goal of physicians to save lives?
The “art” of medicine is being replaced by proven “best practices.” Take a look at a few results posted on the Institute for Healthcare Improvement’s website:
15% mortality reduction and 60% reduction in HAIs (VAPs/CLBSIs) achieved across 5 hospital system in FY2008
WellStar Health System, Atlanta, GA
No central line infection since November 2006
Hilo Medical Center, Hilo, HI
15 consecutive months with no MRSA in our ICU
Pacific Hospital of Long Beach, Long Beach, CA
Reduced C. difficile by 90% from 2004 to 2006, including a reduction of 75% antibiotics-associated diarrhea
Tustin Rehabilitation Hospital, Tustin, CA
One ventilator-associated pneumonia in 742 days in 2006, a rate of 0.13%
Fauquier Hospital, Warrenton, VA
March 2007.
35 surgical site infections in 3,732 procedures in 2006, a rate of 0.94%
Fauquier Hospital, Warrenton, VA
March 2007.
2 years VAP free in the Medical/Surgical ICU
BryanLGH Medical Center, Lincoln, NE
2 years without a central line infection in Neuro/Trauma ICU
BryanLGH Medical Center, Lincoln, NE
SSI Bundle Score of 97.83% achieved in July 2006
Boston Medical Center, Boston, MA
February 2007.
Mortality rate decreased by 15% in 2006
Albany Memorial Hospital, Albany, NY
Mortality rate decreased by 13% in 2006
Samaritan Hospital, Troy, NY
Mortality rate dropped from 2.40% in 1998 to 1.95% in 2005
Missouri Baptist Medical Center, St. Louis, MO
December 2006.
Mortality rate dropped from 2.88% in 2000 to 1.72% in 2005
Wheaton Franciscan Healthcare – St. Joseph, Milwaukee, WI
December 2006.
Rate of codes decreased from 23.8 per 1,000 discharges to 8.1 per 1,000 in 17 months
Veterans Affairs Western NY Healthcare System, Buffalo, NY
December 2006.
Number of cases between surgical site infections has reached 185 over 43 days
Tallahassee Memorial Hospital, Tallahassee, FL
December 2006.
No cases of ventilator-associated pneumonia since October 2004
Dominican Hospital, Santa Cruz, CA
December 2006.
Cardiothoracic ICU has been “VAP-less” since January 2005
United Hospital, St. Paul, MN
December 2006.
Only one case of VAP in two-and-a-half years
Kaiser Permanente Bellflower Medical Center, Bellflower, CA
December 2006.
The rate of adverse events decreased from 98 per 1,000 patient days in 2004 to 35 per 1,000 patient days in 2006
OSF Healthcare System, Peoria, IL
December 2006.
Perfect care for AMI patients has increased from 96% to 98.98%.
Charleston Area Medical Center, Charleston, WV
December 2006.
Deaths from heart attacks decreased from 15.4% in 2002 to 6.4% in 2005
Immanuel St. Joseph – Mayo Health System, Mankato, MN
December 2006.
Mortality from heart attacks decreased from 7.9% in 2004 to 4.5%in 2006
East Alabama Medical Center, Opelika, AL
December 2006.
Average “door-to-balloon” time reduced to 61 minutes
Advocate Good Samaritan Hospital, Downers Grove, IL
November 2006.
Zero Catheter-Related Bloodstream Infections (CRBSIs) for 17 months in our ICU, 15 months in our CVICU and over two years in our NICU
DuBois Regional Medical Center, DuBois , PA
November 2006.
75% reduction in central line associated blood stream infections. Longest duration without a central line associated blood stream infection is 359 days.
Beth Israel Medical Center, New York, NY
November 2006.
In a statewide ICU collaborative, participating New Jersey hospitals have achieved a 55% reduction in ventilator associated pneumonia and a 73% reduction in central line infections
New Jersey Hospital Association, Princeton, NJ
June 2006.
The list goes on. I don’t know about you, but this makes feel proud of the hard work on behalf of so many healthcare providers that have achieved these great results. So you have to document a little more? So what! The measures developed by the Joint Commission and CMS are working. Lives are being saved and healthcare costs are being reduced.
So Kevin, MD, can you justify your statement that quality can kill patients, please?
I would say that the take home message is that the guidelines are weak, and serve to reward the lazy, punish the careful. Opinions may vary.
Kevin, you need to go back and read WhiteCoat’s post, as you have the first story wrong, in a very important way. I can’t imagine any quality guideline that says that stroke patients should receive thrombolytics before head CT, and frankly, I’m surprised that you can. The patient in the first story passed out at home and hit his head. Upon arrival at the ED, he was found to be having an acute MI. Because WhiteCoat was worried about the possibility of intracerebral hemorrhage from the head injury, he opted to CT the patient before administering thrombolytics. This action sufficiently delayed administration of the drug that the patient did not fall within the quality indicated “door-to-needle” time for thrombolytics in acute MI.
The second story confuses me, and I wish that WC would explain more thoroughly; I have to wonder if it isn’t the result of a bureaucratic error or misunderstanding.
Now, I can imagine a situation in which you would delay thrombolytics to an AMI patient to rule out traumatic bleeds in other areas of the body. That doesn’t mean that I think the quality indicator is a bad one; it simply means that, with regard to individual patients, it must be enforced with intelligence. As to WC’s actions in this instance, not having seen the patient and the injury in question, I can’t say whether he made a prudent, potentially life-saving choice or a wimpy, unnecessary order that cost the patient heart muscle. I’ll give him the benefit of the doubt and say it was the former.
Matt, do you really think the indicators will be “enforced with intelligence”? Usually the two words don’t belong in the same sentence.
After reading White Coat’s post, I went over to HospitalCompare and looked at the stats for 4-5 different hospitals in my area. What I fail to understand is why HHS does not weight results by sample size. This seems misleading – apples are being compared to oranges. The hospital nearest me (”Unpopular Hospital”)scored better overall than the next-nearest hospital (”Popular Hospital”). The numbers of patients w/qualifying events at UH were much lower (generally under 50 in each category) compared to PH’s numbers (generally over 150).
I suspect PH might have more WhiteCoat-type “bad doctors”, as well as some just plain bad doctors…
With the best set of quality indicators that the state of the art can produce, I think all the best doctors will have at least a few “non-compliance” letters in their files. It is sort of like patient complaint letters–you shouldn’t have a lot but if your don’t have any at all you aren’t saying “no” enough to be providing excellent care.
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