Tuesday, May 11, 2010

Why Linking Quality & Process Is So Difficult: Do Primary Care Physicians Have a Point About Elements of the Patient Centered Medical Home?

Who can blame the primary care physicians for their discontent?

They are loved by their patients, but their patients with heart problems or cancer love their cardiologists or oncologists more. They work hard for their patients, but not as hard as emergency room docs and general surgeons. They command respect, but not as much as nurses. They make decent amounts of money, but not as much as their ex-college roommates. They take good care of their patients, but not as much as insurers, government, academics and policymakers say they should.

No wonder they’re cranky. Some policymakers believe this vexation could explain some of the PCPs' reluctance to adopt information technology (IT) or the patient centered medical home (PCMH). The Disease Management Care Blog disagrees: PCPs are unhappy but they're also hardened realists.

This paper in the latest issue of Health Affairs helps explain why. Eric Holmboe, Gerald Arnold, Weifeng Weng and Rebecca Lipner, all of the American Board of Internal Medicine (ABIM), did a deep dive into the practices of a representative sample of 202 primary care internists’ practices. Physicians completed a “Physician Practice Connections Readiness Survey” that assessed their use of Chronic Care Model (CCM), which in turn forms much of the basis of the PCMH. In addition, trained abstracters used the “Comprehensive Care Practice Improvement Module” to review a year’s worth of representative medical records.

The composite practice CCM survey score averaged 48 points on a scale of 0-100. Average clinical performance scores on chart review ranged from 45% to 59%. Like the DMCB, readers may be unfamiliar with the details of the survey and the module scoring. The DMCB isn’t surprised, however, that the ABIM would use a difficult set of measures resulting in less than 100% scores. But that’s not what’s important about this paper.

Since the authors didn’t use the “Lake Wobegon” approach, there was useful a “spread” of physician and patient measures. This allowed the authors to assess whether higher physician CCM-based survey scores should lead to better chart review outcomes, right?

That's not what was found.

The only characteristic that seemed to correlate with improved patient outcomes was the use of “reminders” that prompt doctors to use evidence-based care. For other CCM-based processes such as quality improvement, a registry, teaming, patient centeredness, enhanced access and clinical information systems, there was no correlation with patient outcomes.

The authors speculated that many of their CCM survey measures were too dependent on information technology that missed the impact of patient-physician relationships or local physician leadership. They also pointed out that their sample size may have been inadequate to detect small yet important changes, that they could have missed aggregate improvements at a practice or group level and that their results could have been biased by an overreliance on self-reported physician measures.

Keeping those weaknesses in mind, this is still another study that shows that processes of care may not be associated with better patient outcomes. But this paper is important at a more fundamental level: it reminds the DMCB that the ability to link process and outcomes at an individual physician level is very very difficult. While having registries, teaming, patient centeredness, enhanced patient access and clinical information systems may make a difference on a group, regional or national basis, the difference is difficult to detect in the average physician’s office.

This means that insurers, government, academics and policymakers may not be able to expect local process improvements to lead to observable local quality improvements. Thinking that practice by practice, physician by physician redesign will add up to population-based improvement may make sense, but it won’t be detectable at the individual clinic level.

The next time physicians say they don’t “get” the link between the push to redesign the delivery of primary care practice and what it means for their patients, maybe they’re not being obstructionist. They're being realists. They're not seeing it.

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