Clinical Inertia, Quality Metrics and Healthcare Improvement Part I
Treatment Inertia
Treatment, or clinical inertia is well documented in the medical literature. Practice administrations struggle with methods for overcoming this barrier to effective care. The tendency of physicians not to change a treatment plan when a patient is not moving toward or reaching a treatment goal is a problem for large medical organizations, for healthcare centers and for small group or solo practicing physicians. Nevertheless, the audacious declaration by this physician that her documented, continuing poor treatment outcomes only makes this physician hold those who design quality measures in contempt is a new twist in treatment inertia, a twist for which there is no obvious solution.
Healthcare delivery in America must change and the attitude reflected in this perspective is one illustration of why that change may have to come from political pressure, if the medical profession does not effect real change internally. When I started my medical career in 1969, there was no effective way of measuring quality other than by tedious chart reviews which were expensive and time consuming. Now, due to technology, we can measure performance in real time. To ignore that measurement is not an acceptable alternative.
Quality Metrics
No one would argue that quality metrics are the only solution to healthcare improvement. Those who grapple with the design of quality metrics do not sit around thinking up new ways to aggravate healthcare providers. Using scientific methodology and a growing body of medical literature on quality metrics, these pioneers look for leverage points in identifying potential for real change in healthcare-delivery processes, which will reflect real change in the quality of patient health. Unfortunately, quality metrics are not static such that once you identify one metric that it will have permanent relevance to quality improvement. Once processes are in place, such that the outcomes are virtually totally dependent upon the process, rather than healthcare provider performance, new metrics must be found to move the system further toward excellence.
A single quality metric for a complex disease process will have little if any impact upon patient safety and health. And, all quality metrics of value should point to treatment change which will improve patient health. Though a single metric is of extremely limited value, a “cluster,” or a “galaxy” of quality metrics can effect real change in healthcare quality and in patient health. A “cluster” is defined as a group of quality metrics (seven or more) which define quality treatment standards in both process and outcomes for a single disease process. “Comprehensive quality measures” for diabetes are a good illustration. Unfortunately, PCPI, NQA, NCQA Diabetes Recognition, AQA, PQRI, HEDIS and Joslin Diabetes Center, all have comprehensive quality measures for diabetes; and, they are all different.
A “galaxy” of quality measures is a group of “clusters” which relate to the health of a single patient. When “comprehensive quality measures” for diabetes, hypertension, dyslipidemia, CHF, Chronic Stable Angina, Cardiometabolic Risk Syndrome, Chronic Renal Disease Stage 1-III and then Stages IV-ESRD are identified and measured for a single patient, the successful meeting of those metrics, which may exceed 50 in number, WILL reflect quality treatment and WILL result in improved health.. Quickly, physicians will say, “But, that will take a two-hour visit for each patient.” That would be the case if we were using paper records; if fact, two hours by paper may not be enough time to accomplish all of this. However, with electronic patient management via a well-designed electronic patient record, and with a well-trained and highly functioning healthcare team, this “galaxy” of metrics can be met within in the time and economic constraints currently existent in healthcare in the United States.
