Patients want to receive health care that is of the highest quality. Physicians want to provide it. But what is “high-quality health care?” On that, few agree.
Ask most Americans and they’re unsure where to find it. They know they want to be kept healthy, have rapid access to personalized care whenever they need it and be charged only what they can afford.
Ask the leaders of the national medical and surgical societies, and they are likely to define quality as having access to the latest — and often the most richly reimbursed — procedures, diagnostic imaging, and genetic testing.
Ask physicians themselves and, well, they’re already overwhelmed by the exponential growth in clinical measures of quality developed for public and private pay-for-performance formulas.
Even so, medicine is coming closer to a definition of high-quality health care — and also to a system for evaluating how physicians and medical groups perform. The Institute of Medicine (IOM), a highly regarded independent organization established by Congress to advise on health care issues — the gold standard on improving our nation’s health – recently released a report: “Vital Signs: Core Metrics for Health and Health Care Progress.”
The IOM panel of experts identified 15 measures, narrowed down from hundreds, with the best potential for improving health, including reducing the overall rate of preventable deaths.The consensus: If the U.S. systematically raises its performance in each of these 15 domains, the quality of life for millions would improve dramatically.
This IOM report is important, even though it received surprisingly scant media attention. It should serve as a starting point and a road map about how clinical practice can most effectively lift the quality of care delivered to patients.
But let me come back to the report itself in a minute.
The quality conundrum
A little context about the issue of quality might help here. At last count, the number of health care quality measures in place was in the thousands. The Joint Commission has 57 just for inpatient care at hospitals. The Healthcare Effectiveness Data and Information Set has about 81. The National Quality Forum currently endorses more than 630. The Centers for Medicare & Medicaid Services has no fewer than about 1,700.
That may explain why keeping track is such a challenge for all parties involved.
Perceptions of quality are of course subjective. According to the Merriam-Webster Dictionary, quality is “how good or bad something is; a characteristic or feature that someone or something has; a high level of value or excellence.” The Oxford Dictionary says quality is “the standard of something as measured against other things of a similar kind; the degree of excellence of something” It cites this example: “The hospital ranks in the top tier in quality of care.”
The upshot here is a paradox: a definition that is itself ill-defined – and as such, leaves plenty of uncertainty and doubt.
7 actions physicians can take
That’s why the IOM report is so valuable and welcome. It cites 15 “vital signs,” but let’s focus on the seven that relate to direct health care delivery and better care for patients.
1. Overweight and obesity. Physicians should help their patients exercise regularly, eat a healthy diet and maintain their weight within a normal range. More than two-thirds of Americans are overweight or obese. Specifically, physicians can make diet and weight management a vital sign and counsel every patient on the options available.
2. Addictive behaviors. Eliminating smoking and alcohol abuse, along with reducing the percentage of people who are overweight, would dramatically lower the incidence of diabetes, lung cancer, and cardiovascular disease. Physicians should engage and educate patients about approaches to take to quit smoking and alcohol abuse, and provide advice and resources toward that end. Today, addiction to nicotine, alcohol, opiates and other psychoactive drugs continues at unacceptably high rates.
3. Preventive services. Physicians should urge patients to take the recommended screening tests and stay current on their vaccinations. Preventive screenings alone could dramatically lower the risk of dying from cancer, heart disease, and strokes.
Combining this with smoking cessation and exercise could help avoid 200,000 heart attacks and strokes in the U.S. each year, and reduce the mortality from cancer by tens of thousands yearly, based on an internal analysis done by The Permanente Medical Group’s Division of Research.
Screen for colon cancer in fewer than 50 percent of patients, rather than in 80 percent to 90 percent, and you double the chances of dying from an invasive adenocarcinoma. Smoke at the national average of 18 percent, rather than at under 10 percent, and you dramatically increase lung cancer, emphysema, and heart attacks.
Preventive services present a valuable opportunity for both improving health and reducing health expenditures.
4. Patient safety. Physicians and nurses can, through rigorous practice, help patients avoid hospital-acquired infections, pressure ulcers, medication errors and wrong-site surgery. Even a decade after the 1999 IOM report, “To Err is Human” — with its estimate that 100,000 patients die each year from medical errors, the equivalent of a jetliner crashing each day — these so called “never events” still occur too frequently.
And when patients develop infections like sepsis, or suffer an adverse drug reaction, they face a higher chance of dying in the hospital, and experiencing problems long after hospital discharge. Avoiding harm has been a core value of the medical profession from the time of Hippocrates, and is “first among equals” when it comes to the principal responsibilities of the health care system. Yet medical errors with adverse outcomes are still far too common.
5. Unintended pregnancy. Physicians should take the opportunity to focus on ensuring the health of an expectant mother in order to increase the chances for a healthy baby and safe delivery, whether a pregnancy is unintended or the result of careful planning.
An estimated 50 percent of pregnancies in the US are unplanned, and occur in women across the spectrum of child-bearing years, and among women in every socioeconomic demographic. Unintended pregnancy results from social, behavioral, cultural, and health factors, including — and perhaps most especially — women’s lack of knowledge about and access to tools for family planning.
Research has demonstrated that medical care soon after conception is critical, and identified ways to reduce the risks of a maternal or fetal complication. Good nutrition, along with avoidance of drugs, alcohol and cigarette smoke, are essential. After birth, comprehensive medical care and early diagnosis of problems can prevent longer-term health problems and future complications.
6. Access to care. Access to health care is one of the most powerful determinants of clinical outcomes. The ability to access care when needed is a vital precondition for a high-quality health system.
Physicians in integrated, multi-specialty practices have advantages in ensuring patients get all the care needed thanks to comprehensive electronic health records. But in today’s fragmented health care system, with close to 15 percent of the population still uninsured, health care still remains beyond the reach of all too many Americans. Policy makers are relentlessly pursuing affordable access.
7. Evidence-based care. Physicians should see to it that patients receive medical care based on the most current scientific evidence for what is appropriate and effective, rather than on an anecdote or an “in my experience” approach. Physicians working in hospitals with electronic health records can do so, deciding about care according to scientifically validated protocols for complex problems like heart attacks, strokes, and hip fractures.
In the not-too-distant past, when physicians lacked many of the current diagnostic tools and access to sophisticated information technology, medical practice was far more art than science.
Even today, variation in how physicians treat patients with the same problem is unwarranted, and leads to system-wide under performance and less-than-optimal clinical outcomes.
Fortunately, medical practice today is far more science than art.
What patients should do
The best quality, then, according to the IOM, is not based on using a robot, providing transplantation or completing genetic sequencing. The reality is that, contrary to what some might assume, these often advertised technologies have minimal impact on mortality.
And quality is not a result of individual technical excellence in performing procedures such as heart surgery, neurosurgery or hip replacement surgery. The variation from surgeon to surgeon is far less than people assume. In fact, many health care experts now perceive overuse of these high-intensity surgical interventions to be a problem that sometimes results in associated complications and minimal improvements in clinical outcomes.
The list, in short, is more practical than exotic or “sexy,” offering the interventions which have the greatest impact on human life.
The IOM committee concluded that leadership “at nearly every level of the health care system” will be required to adopt, implement, refine and maintain these core measures. And among the many stakeholders, physician leadership will be key.
Patients should make health choices based on these 15 vital signs from the IOM. They enable people to distinguish the most important quality measures from all the “noise” about what are the newest and most exotic tools and approaches available. More specifically, patients would be wise to select a personal physician or medical group whose practice philosophy incorporates these approaches — and whose clinical results in each area are superior.
We physicians are obligated to heed the IOM recommendations on behalf of our patients, the better to fulfill health care’s promise of easing suffering and extending lives. This is where American health care should invest its efforts. The IOM is a gift to both physicians and patients. Taking our eyes off what will most impact the health of all would be a mistake our nation can ill afford.
Robert Pearl is a physician and CEO, Permanente Medical Groups. This article originally appeared in Forbes.