Monday, May 21, 2007

Knowledge, Standards, and the Healthcare Crisis: Part 3

In the previous post, I discussed "terminology standards," which deal with the meaning and use of words (terms). In this post, I continue with the discussion of data standards, focusing this time on standards for diagnosing health problems, determining treatments, and assessing care quality and provider performance. This all relates to care measurement and process standards. [Click here for first post in series]

Care Measurement and Process Standards

Care measurement and process standards focus on:
  • Diagnosing health problems
  • Selecting and delivering treatments
  • Evaluating care performance and value.
Diagnosing Health Problems

Physiological (bodily) and psychological (mental-emotional-behavioral) measures are used to diagnose a patient’s health problems.

Physiological Measurement Standards

Physiological measurement standards include vital signs and lab test "reference ranges." For example, the standard measures for hypertension is systolic pressure consistently greater than 140 mm Hg, or diastolic pressure consistently 90 mm Hg or more and a standard measure for diabetes is fasting blood glucose level of 126 mg/dL or higher on two occasions. Genetic markers associated with illnesses may also be considered a type of biologic measurement standard. These standards not only help diagnose a patient's condition, but may also determine one's risk of developing a disease.

Psychological Measurement Standards

Probably the most common psychological measurement standard is the IQ test, which defines a score of 90-110 as being within the "normal" range of intelligence. There are also standardized tests that measure mental status (e.g., awareness, memory and other cognitive functions), as well as depression, anxiety, personality traits and other psychological factors.

Selecting and Delivering Treatments

The diagnostic measurement standards are useful if they help select a particular practice guideline identifying a particular treatment for a particular patient with a particular diagnosis. The guidelines provide recommendations for the prevention, treatment, and maintenance of many nontrivial illnesses, conditions, disorders and other healthcare problems. There are three thorny problems, however:
  1. Today's diagnostic systems often fail to point to the best treatment options.[1]
  2. Few guideline standards are specific enough to account for individual differences in patient with the same diagnosis. For example, a recent study found that a moderately high total cholesterol level is associated with higher survival in certain patients with heart failure.[2]
  3. Constantly evaluating and revising guidelines based on new knowledge is very difficult. But if they do not continually evolve, the guidelines are just "a record of the past, and little more-they should have an expiration date."[3]
Evaluating Care Performance and Value

At least three standards are related to clinician performance and care value:
  1. Process compliance standards
  2. Clinical outcome standards
  3. Care value standards.
Process Compliance Standards Process compliance standards measure provider's performance based on whether they followed prescribed guidelines reflecting preferred care processes. For example, typical Pay for Performance (P4P) programs reward providers who perform certain predefined procedures (processes), such as doing a Hemoglobin A1c test a certain number of times each year for patients with diabetes. These standards measure the degree of compliance to such established procedures.

Clinical Outcomes Standards

Outcomes standards define whether clinical goals are achieved for patients with particular conditions. For example, the Hemoglobin A1c test target goal for diabetic control of blood glucose is defined as less than 7.0%. Unlike process compliance standards, clinical outcomes do not focus on whether specific procedures were followed; instead, they measure the effectiveness of whatever treatments were delivered.

Care Value Standards

If our healthcare system was rational and guided by wisdom, a top priority of healthcare professionals and consumers would be:
  • Gaining valid knowledge about healthy living, the causes and diagnosis of physical and mental health problems, and the highest value treatments.
  • Understanding how to use this knowledge to maximize value by increasing the effectiveness and efficiency of care delivery and self-maintenance.
  • Continuously evolving this knowledge and using it to improve care quality and lower costs continually.
So, what is care "value."

Care value can be measured by dividing the quality if that care by its cost, i.e., V = Q / C:
  • Q (Quality) is defined as the degree to which care is delivered safely, effectively and equitably. The care may include conventional and alternative interventions for treating illness, as well as wellness intervention for prevention and health optimization. Quality can be measured based process compliance standards, clinical outcomes standards, or both.
  • C (Cost) is defined as the degree to which the care is delivered efficiently and economically.
  • V (Value), therefore, can be defined as cost-effectiveness ("bang for the buck").
If there is to be significant improvement in healthcare delivery, a useful and reliable quality standard must be established for every healthcare domain/discipline/field. Only then can care value be determined.

Potential Pitfalls of Care Quality Measurement

While costs can sometimes be tricky to calculate, measuring quality is the major challenge. The potential pitfalls of quality measurement are enormous! Consider the following:
  • We have a long way to go. According to HHS Secretary Mike Leavitt, "Medical associations and others have begun the work of developing quality standards and cost measurement, but we have many years of work ahead of us to achieve the wide-ranging and meaningful quality standards we need."[4]
  • No mater what quality measures are used, there are complex issues to be resolved, such as:
    • At what point is there sufficient confidence in an evidence-based practice guideline that there is no longer any need to spend time or money on the continuous evaluation of its reliable and validity?
    • When is a definition of quality too narrow, e.g., by focusing on cost or symptom reduction, but not considering prevention, recurrence, coordination and continuity of care, or the patient-physician relationship?
    • How do you measure quality when resources are scarce and optimal care for the community may require less than "the best" care for its individual members (e.g., delegating office nurses to perform certain activities that physicians used to do)?
    • What is the best way to measure quality if outcomes are more strongly affected by patient compliance than by physician orders? This may occur, for example, if certain providers have personalities that trigger greater patient compliance, and visa versa.
    • Is it poor quality care if a provider follows the recommended practice guideline, but the patient is atypical and responds poorly? [5]
    • Use of claims (administrative) data to measure care quality is grossly inadequate for many reasons.[6]
  • Assessing care quality using process data may not be valid since they do not necessarily reflect care outcomes.[7]
  • One thorny issue is how to avoid political and ideological biases when determining what evidence to use as the basis for establishing the guidelines. [8]
  • Many areas of healthcare lack care process standards and/or quality measures. Different healthcare disciplines and specialties require different types of data to evaluate quality. For example, it's foolish to measure the quality of mental healthcare services with data appropriate for evaluating cardiologists' performance; and the same is true for a podiatrist, dentist, chiropractor, etc.-each need different measures for determining quality, but they are often lacking.[9]
To summarize this post, it is critical to have useful, reliable standards to assist with diagnosing patient problems, selecting and delivering the best treatment options, evaluating clinical performance and identifying care value. Unfortunately, we have a long way to do before such standards become a reality.

This concludes by review of data standards. In my next post, I'll examine "technology standards," which focus on enabling the exchange, or interoperability, of information across healthcare systems.

References:
[1] Current Diagnostic Codes are Inadequate - WellnessWiki
[2] Reuters (Sep 20, 2006). Elevated cholesterol may benefit failing hearts.
[3] Gawande, A (2004). The Bell Curve. The New Yorker.
[4] Bush's Value-Driven Health Care Plan Gains Steam as More Employers Step Up (May 10, 2007)
[5] Donabedian, A. (2005). Evaluating the Quality of Medical Care. The Milbank Quarterly 83, 691-729.
[6] Use of claims data is inadequate - WellnessWiki
[7] HealthDay (July 5, 2006). Hospital Ratings Don't Fully Reflect Patient Outcomes. [
8] Healy, B. (Sep. 2006).Who Says What's Best? U.S. News and World Report. [
9] Need for specialy measures - WellnessWiki
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