Patients need to be involved in quality metrics

I recently heard from an aging and respected physician the old adage that “what is good for the doctor is good for the patient.” The room full of physicians of all ages and specialties nodded their heads in agreement. This saddened me, as it represents a physician-centric system that oftentimes leaves the patient’s needs and desires completely out of the equation.

An area of emerging importance in medicine, whose impact should be broadened in order to ensure the patient’s place in the equation, is quality improvement.  “Quality” health care is defined loosely by hundreds of very specific measurements, such as consistent testing for hemoglobin A1C in patients with diabetes mellitus or the timing of antibiotics for surgery, which perpetuate this physician-centric paradigm within our health care system.  Consistent hemoglobin testing and proper timing of antibiotics in surgery are absolutely important for the health of the patient, but may not hold meaning for patients as metrics for choosing a quality physician or hospital. Quality measurements need to be meaningful and understandable to patients if they are to use them to improve their well-being and to select doctors who share their vision of health.

Multiple studies have shown that most patients desire a competent, knowledgeable, and caring physician. They want to know that the advice and care they receive is based on what is best for their health, as opposed to what is best for the physician’s bottom line.  And patients repeatedly say they are most interested in providers they can trust, who have an easy and approachable bedside manner, and who properly communicate with them. But such traits, including empathy, kindness and patience, are not currently considered essential measures of quality by anyone but the patient.

While hospital performance scores are slowly becoming available for potential patients to consider, reliable quality measures on outpatient primary-care providers (PCPs), where there is much greater need and variation, are severely lacking. And because the majority of metrics used to define a quality provider, when they are made available, have little meaning to the average patient, patients often fail to see the importance of seeking out a “qualified” physician or how to do so.

The combination of multiple, provider-centric metrics of quality and the difficulty for individual patients to access and understand this information has led to a sense of confusion among patients and physicians alike as to what quality health care actually is. Most measures do not apply to most patients, and those that do apply typically show that most providers are good at some metrics and poorer at others. But most importantly, the issues that tend to be of most concern to patients, such as the above-mentioned trust and bedside manner, are not included. This provides little help to patients in their search for a quality PCP to assist them in achieving optimal health.

There is legitimate concern that based on current quality measures patients may seek out multiple providers for separate and relatively simple issues. A patient may select one provider who is better with diabetes and another who achieves better scores in hypertension. Or a patient may seek costly care from a specialist over an acceptable PCP for a given condition. This could lead to further degradation of the physician-patient relationship through less continuity of care, while increasing cost and time for patients and providers, even though the “quality” of care will appear improved.

In order to make the measured quality accessible to patients, patients need to be involved in the creation and implementation of quality metrics that have meaning to them. The primary method by which patients participate in the quality process now is via patient satisfaction surveys. Medical practices or independent organizations often solicit patient feedback on what could make things more patient-friendly. These forums, however, are often misleading as they have inherent selection bias of both extremes – either very good or very bad isolated experiences are most commonly shared, with multiple confounders. And in these surveys, patients are reacting to existing constraints as opposed to creating patient-centered experiences. What’s more, feedback from these surveys is typically considered a “patient satisfaction” issue, which is separate from quality. The patient satisfaction survey treats the patient as merely a customer in a business instead of an integral part of the physician-patient relationship. But patients react best when they feel that their provider has their best interests at heart and is not acting out of motivations for improved numbers or increased income, as one would in a business-client relationship. Instead of treating patients as customers, patients should be treated as equal partners in quality improvement for their own health.

Certainly patients should not control every aspect of quality measurement to the exclusion of important health-related factors. Providers should still be expected to take the lead and act as educator and coach. But if it is going to produce any fruitful results, it must be a partnership with patients and not a dictation to them. This concept continues to gain importance as medical practice redesign moves towards patient-centered medical homes (PCMH) and accountable care organizations (ACOs), and their increased emphases on primary care. Patients need to feel that it is their medical home, as opposed to being told what and where their medical home is. Otherwise we can expect patients to continue to seek care from multiple providers, leading to duplicate tests and visits, increased costs, wasted time, and further alienation of patients from the care they want and need.

The emphasis on quality in health care is extremely important, but if we continue to focus only on the physician end of the equation, then we will fail to learn the fundamental lesson of effective medicine: that what is good for the patient is good for the doctor.

Kyle Bradford Jones is a family physician who blogs at Primary Care Progress.

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