American College of Physicians: Internal Medicine — Doctors for Adults ®

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Performance measures should help, not punish, doctors

From the November ACP Observer, copyright © 2003 by the American College of Physicians.

This past summer, the New England Journal of Medicine published a study showing that adults in the United States receive only about 55% of the medical care recommended for their conditions.

The Community Quality Index Study took note of established national guidelines for all phases of medical care—screening, diagnosis, treatment and follow-up—covering a range of common conditions, from asthma to congestive heart failure. Researchers then surveyed patients and their medical charts in 12 metropolitan areas to determine if guideline-based quality indicators were followed.

The study, which appeared in the June 26, 2003, issue, found wide variations from diagnosis to diagnosis. While only about 10% of patients with alcohol dependence received recommended care, for example, nearly 79% of those with senile cataracts received care that followed recommended guidelines. For conditions usually managed by internists, adherence to guidelines ranged from 68% for coronary artery disease to only 25% for atrial fibrillation.

The study team concluded that "the gap between what we know works and what is actually done is substantial enough to warrant attention," warning that these deficits "pose serious threats to the health and well-being of the U.S. public."

While the lay press quickly concluded that an adult patient has a 50-50 chance of receiving adequate medical attention for a given condition, an accompanying editorial pointed out that the study's various limitations made this interpretation inappropriate. However, even with 60-40 odds, the take-home message is sobering: Many adult patients are not receiving recommended care.

ACP's reaction

As ACP President, I was asked by the press to comment on the paper and the problems it highlights in American health care. As I told reporters, the role of the College is to improve quality of care. ACP's mission, after all, is "to enhance the quality and effectiveness of health care by fostering excellence and professionalism in the practice of medicine."

I also explained that the College has long been a leader in quality improvement. More than 30 years ago, we established evidence-based clinical guidelines through our Clinical Efficacy Assessment Program (CEAP).

And in the mid-1990s, in response to internists' growing need to have point-of-care, evidence-based electronic assistance in clinical decision-making, ACP began building the Physicians' Information and Education Resource (PIER). PIER is already helping internists identify and provide the "best care" for their patients.

I assured reporters that physicians want to provide the best care for their patients, but that they need quick and easy access to evidence-based guidelines. Gone are the days when the brightest doctors among us would know just about everything.

The role of technology

Fortunately for physicians and patients, new technologies now provide nearly instant electronic access to needed information. Information technologies can work in everyone's favor, giving patients easy access to information, establishing suitable expectations for care and educating patients about appropriate health management.

It's simply (simply!) a matter of finding the funds to make office-based electronic information systems widely available. But information technology comes with other challenges besides funding.

Even when systems literally put guidelines at the doctor's fingertips, physicians face the challenge of applying them. Practice habits must accommodate new approaches, technologies and information. And each patient must always be more than a diagnosis waiting for a physician to apply guidelines.

In addition, the burden of change rests as much with patients as with their physicians to work together to improve quality of care. But patients must be given information they can understand. Here again, professional organizations can take the lead in generating accurate, accessible patient information-and in educating physicians to be better information resources for their patients.

Growing unease

Still, the seriousness of the Community Quality Index Study's findings worries me.

It seems that public concern about health care quality—including worries about medical errors—is escalating rapidly. Increasingly, both the public and health care purchasers are demanding tangible quality improvements that can be demonstrated and measured.

What more can the College do on the quality front? The Board of Regents has recently taken several steps to focus ACP's efforts on improving both the quality of care and how quality is assessed.

The Regents established the Task Force on Performance Measures, chaired by Regent William E. Golden, FACP. The group has been charged with reviewing the state of quality assessment and making recommendations about how the College should proceed in this area.

In its 2002 report, the task force defined performance measurement as an effort to convert the recommendations of clinical practice guidelines or authoritative research into defined measures. This information can then be used to assess how physicians meet these recommendations.

The task force said that an ideal performance measure should be easy to measure, allow for risk adjustment in a patient population and, most importantly, be meaningful enough to motivate physicians to change their practice for improved patient care.

The task force recommended, among other things, that ACP become more actively involved in performance measurement, especially because this trend will increasingly affect College members' practice lives. The group also advised ACP to develop policy relating directly to performance measures, including their use both to improve practice quality and to ensure physician accountability. (For more on performance measurements, see "EMRs and performance measures offer promise—and problems.")

From that task force report grew ACP's Performance Measures Work Group, co-chaired by Kevin B. Weiss, FACP, Chair of the Clinical Efficacy Assessment Program Subcommittee, and Christel Mottur-Pilson, PhD, ACP's Director of Scientific Policy, to develop the performance measures initiative.

I recently sat in on serious, thoughtful discussions in both the Education and the Health and Public Policy committees of the work group's first report. (These committees will make recommendations to the Regents for new College policy about physician performance measures.)

It was exciting to consider just how performance measures, if used properly, can serve the best interests of patients and physicians alike. But there remain serious questions about the validity of some measures and their potentially inappropriate use for purposes of accountability and reimbursement.

As we move forward on this front, the College must be attentive to the perils—as well as the possibilities—of performance measures and look to avoid the pitfalls.

Here to stay

Experts believe that physician performance measures are here to stay. We hope and expect this approach will improve physician performance, help close the now unacceptable gap between best and actual practice, and upgrade the quality of patient care.

As ACP's Performance Measures Work Group has pointed out, demonstrating ongoing clinical competence is a core aspect of professionalism. And as we consider better ways to recognize and compensate physicians who care for patients with multiple and chronic diseases, performance measures could provide the mechanism by which we reward and foster higher quality care.

It's imperative, therefore, that the College be a player in the profession-wide effort to establish, refine, apply and assess performance measurement.

It is unlikely that ACP itself will ever create performance measures, because of expense. Rather, we will continue our close affiliations with groups involved in measurement development. They include the AMA, the Joint Commission on Accreditation of Healthcare Organizations, the American Board of Internal Medicine, the National Committee for Quality Assurance, the National Quality Forum and the Doctor's Office Quality Project.

ACP will also help formulate appropriate criteria to evaluate physician performance. These efforts should help internists, by making sure that only evidence-based measures are used—and by stressing that measurements should always reflect physician performance not system constraints.

In addition, we must make sure that measures do not impose additional burdens on practitioners. And, of course, the College must educate our members about the fundamentals of performance measures—and how such measures should foster quality improvement in everyday practice.

Finally, we will listen to practicing internists to ascertain whether quality of care and outcomes actually improve as a result of performance measures.

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