Heart & Vascular Institute Physician eNewsletter - Fall 2012
Quality measures that are designed to improve patient care actually may cause greater risk and unintended consequences. In other words, what looks good on paper could pose high risk to patients when put into practice. “That’s why careful analysis of quality measures is critical to ensure that newly implemented processes and standards will truly benefit patient outcomes,” says Umesh N. Khot, MD, Chief Quality Officer for Cardiovascular Medicine at Cleveland Clinic.
“There has been a proliferation of quality measures that have been introduced, and while we think these measures seem reasonable and appear to be in the best interest of patients, what we are finding is that these measures are multidimensional.,” Dr. Khot says.
Potential Consequences of Quality Measures
Some quality measures could cause more harm than good. For instance, quality measures that focus on mortality can result in denial of care to high-risk patients. An article published by Dr. Khot in the Journal of the American College of Cardiology shares how a well-intentioned program in the state of Massachusetts to improve the public reporting of percutaneous coronary intervention-related mortality negatively impacted access to care. In Massachusetts, the proportion of patients treated for cardiogenic shock – a life-threatening condition – dropped nearly 50 percent, from 2.28 to 1.29 percent from 2003 to 2005 with the program. “These highest-risk patients would have received the greatest benefit from the treatment, but they also presented the highest risk of mortality because of the severity of their condition,” Dr. Khot explains.
This concept of risk avoidance can serve to negatively influence quality patient care, Dr. Khot emphasizes. “The quickest way to reduce the death rate is to stop taking care of patients with cardiogenic shock because they are at immediate risk of dying,” he says. In this example, physicians improved the mortality rate and performance measures—but very sick patients who may have benefited from a potentially risky procedure were left untreated.
Meanwhile, providers who are diligent about diagnosing disease could be discouraged by quality outcomes that are dependent on the level of surveillance. For example, medical centers with lower utilization of ultrasound to diagnose deep venous thrombosis may improve their diagnoses rates. They are performing fewer ultrasounds, and therefore diagnosing fewer patients. As Dr. Khot points out in the article: “Quality measures that focus on an outcome that is dependent on the level of surveillance may adversely impact providers who are more attentive to diagnosing disease as opposed to those who are less diligent.” But to what benefit is this for patients whose condition may be overlooked as a result of lessened surveillance? In this case, a decrease in diagnosis rates may not be true improvement in care but rather indicate under-diagnosis of disease. Improved diagnosis rates may instead point away from true improvement in care, and instead indicate in improvement in avoidance of risk.
Then there are issues with clinical documentation and how quality measures could tempt clinicians to “game” a reporting system to avoid negative consequences. Documenting a non-system delay can exclude a case from public reporting. Now, take patients undergoing primary percutaneous intervention for ST-segment elevation myocardial infarction (STEMI). Between 2005 and 2010, the proportion of patients with a door-to-balloon time of less than 90 minutes and a documented reason for delay (so no public reporting) increased from 3.7 to 8.1 percent. Are some clinicians trying to avoid potential negative professional, reputational or financial consequences associated with measure reporting? Possibly.
With today’s focus on quality measures, the medical community must tune in to potential consequences and verify that the “quality” is indeed intact if the measure is put in place. “It’s important to look at these measures systematically and to fashion solutions that do not have negative consequences,” Dr. Khot says. Otherwise, quality measures may be proposed and implemented before there is a complete understanding of their solutions.
The problem with many quality measures is that they do not necessarily explore the complex and dynamic interrelationships with other measures of quality: access to care, appropriateness of care and surveillance rates of diagnostic testing. If the purpose of a quality measure is to drive better results, these pieces of patient care cannot be left out of the puzzle. Ultimately, awareness plays a key role in shaping quality measures that drive improvements in patient care. Dr. Khot writes that any quality improvement project should be accompanied by a well-designed protocol of clinical follow-up and statistical analysis to assure that a true improvement has occurred.
“As a general rule, it is our mission to take care of the very sick, but we are coming under the same pressures as everyone else with increased monitoring,” Dr. Khot relates. “As physicians, the challenge is to identify which quality measures will lead to a true improvement.”
At Cleveland Clinic, patient care is the first concern of each and every caregiver. Transparent reporting of results is undertaken in each institute systemwide: the product of this annual effort is Cleveland Clinic’s Outcomes books. The series of books reports on numerous quality and safety indicators and is made widely available. The 2011 Outcomes books are now online at clevelandclinic.org/outcomes.