Making quality measures more meaningful for doctors
Dr. Clancy speaks out on why doctors—and patients—need better outcomes research
From the June 1997 ACP Observer, copyright © 1997 by the American College of Physicians.
By Jennifer Fisher Wilson
As health services research gains momentum, federal organizations like the Center for Outcomes and Effectiveness Research (COER) promise to take on a growing role in shaping how physicians practice. At the center of many of those efforts is Carolyn M. Clancy, FACP.
Earlier this year, Dr. Clancy was named director of COER after having served as acting director for almost a year. COER, which is part of the Agency for Health Care Policy (AHCPR), has an ambitious mission: to improve health care quality through clinical outcomes and effectiveness research. As its director, Dr. Clancy hopes to go one step further and provide physicians with tools that not only measure health outcomes, but also take into account patients' perspectives on their treatment.
Dr. Clancy explained that without good data linking actions and their outcomes, quality cannot improve. What's required, she said, is a knowledge base that links outcomes and various treatments. Ideally, physicians and patients working together would use this knowledge to pick the best course of action for a given condition.
Dr. Clancy is no newcomer to the field of health services research. She arrived at the AHCPR in 1990, where she served as director of the Center for Primary Care Research. In addition to running COER, she also practices one day a week at The George Washington University School of Medicine, where she is an associate clinical professor in the department of health care sciences.
Before coming to Washington, Dr. Clancy taught at the Medical College of Virginia and the Hospital of University of Pennsylvania, and she served as an attending in emergency medicine at Thomas Jefferson University Hospital. She earned her medical degree from the University of Massachusetts School of Medicine and did her residency at the Memorial Hospital in Worcester, Mass.
ACP Observer met with Dr. Clancy to discuss COER's goals—and the promise of outcomes and effectiveness research.
ACP Observer: Why was COER created?
Dr. Clancy: What inspired the creation of the agency was the work that had been done at the National Center for Health Services Research, which demonstrated extensive practice variations across the country.
The general idea was that COER will use the existence of practice variations to identify areas where better knowledge can be developed and then translate that into interventions to improve practice.
Q: Why do variations exist in practice?
A: The most compelling reason is that variations exist where there is a lack of professional consensus about the best thing to do. The reason for the lack of professional consensus is that we don't have a very good knowledge base.
Take variations in hysterectomy rates, for instance. It turns out that if you separate hysterectomies that are done for cancer and those done for noncancerous reasons, the variation rate for hysterectomies done for cancer is very small. For noncancerous conditions, it is much larger. On some level that makes sense. We know that if you have a cancer of the uterus, you need to have your uterus removed. It's those other areas physicians are not so sure what to do, where the knowledge base is not as good.
Q: How will your agency help practicing physicians?
A: If we can collect data on patients with a particular condition across a big enough population, physicians can get a kind of feedback they've never had before. For instance, some of the earlier studies on patients with prostate surgery for benign prostatic hypertrophy found that there was a much higher rate for reoperation than physicians ever realized.
This kind of research often gives physicians a tool to present the information about alternative choices to patients in a way that can help make a decision. Whether or not to have surgery for prostatic disease is a pretty personal decision and depends a lot on what you value.
Q: How will outcomes research bring patients into the decision-making loop?
A: Outcomes research offers a way to identify the important outcomes of care from patients' perspectives. It also allows clinicians and patients to work together to examine alternative treatment strategies. It provides a tool for clinicians to provide science to patients in a way that makes sense to them. We have a lot of evidence that patients who participate actively have better outcomes.
Someone once told me that as a doctor, I should do for patients what they would do for themselves—if they knew what I know about medicine. I think that the products of our research are going to allow that.
Q: What types of research is COER currently conducting?
A: We fund a number of studies that are taking place in physician-based practice networks. Many physicians—particularly as they accept capitated contracts—now have to look at practice variations in a new way. Decisions that were left to individual physicians before become more compelling when you've got a fixed budget to provide care for patients. Suddenly it becomes more interesting to know there's a big difference across you and the six other people you practice with in terms of how often you order certain tests or procedures, or under what conditions you make clinical recommendations.
In some areas of the country, larger and larger physician groups are forming, and again, they are going to have more reason to look at how they are providing care.
Q: Will this research change the way physicians practice?
A: Ultimately, I hope it will help physicians manage the change from providing care for individual patients to actually managing the care of populations of patients. But we have a lot of work to do to get there. Our research has produced important publications and research tools for assessing patient-reported incomes. Our next important challenge will be identifying strategies to translate these tools into clinical practice. Until these kinds of measures have as much meaning to physicians as laboratory tests—which are the kind of measures they're used to seeing all the time—then these measures won't be incorporated into practice.
One of the first steps is to make available some of the disease-specific outcome measures that we have developed in a number of our projects. If you're taking care of patients with asthma, for example, you can measure how they're doing by using certain kinds of breathing tests or blood tests, or you can have well-developed instruments to ask patients how they're functioning, how often they have to wake up at night, how often they need specific types of medicines, if they are missing school or work, and so forth. We have those tools now; what we have not done is make those part of routine practice.
Q: What is the role of managed care in this research?
A: Managed care organizations say that quality is very important to them, but they also say that it's really the purchasers who are pushing for it. Many of the leading purchasers say that they're not just interested in lowering costs, that they also want to know what value they are getting for the investment in health care that they're making.
With so many Americans now enrolled in some kind of managed care arrangement, our ability to move the outcomes research agenda forward will depend on collaborations between researchers and health plans. Some plans—Kaiser and Harvard Pilgrim, for instance—have a long tradition of conducting research and publishing results. For many others, which are among the most rapidly growing plans, research is not yet a critical component of their organizations.
That's where our research comes into play. A number of products produced by our research can generate quality measures that report cards can use to evaluate the quality of care being provided.
Q: Are physicians ready to accept the results of outcomes research?
A: Clinicians are worried that reports from outcomes research tend to focus on the average patient, while they are finely attuned to the individual characteristics of their patients. For instance, we have funded work that shows that a fairly high proportion of people have atrial fibrillation and if they were anticoagulated, that would significantly decrease their risk of stroke. But this treatment is not embraced because there's lot of disagreement about its safety.
Clinicians' other fear is that outcomes research will count things that aren't important. That's why we need better measures, so we can do that. If you're going to be evaluating practice, you might as well do what patients and clinicians think is important, and not just count what's available.
We need tools to figure out if patients think they're better off as a result of this treatment, particularly for people with chronic diseases. Right now, in our rush to try to demonstrate value in health care, we tend to measure whatever we can easily count.
Somebody from a large, well-known, for-profit health plan said that the motto there is, "If you can't count it, it doesn't count." But the truth is that a lot of what we can count easily right now isn't all that important. We can count visits, we can count procedure rates, but what we need to know is if people are better off.
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