Dr. Mosley is the medical director of the emergency department and residency education, the director of quality improvement, and the director of operations management at a medical center in Wichita, KS.
‘Quality” has been supplanted by reimbursement for quality measures. The culture to which we have all acquiesced has redefined quality in a way that is misguided and dishonest. At the end of the day, this cannot be a discussion about business. It is and should be a discussion about scientific integrity. It must begin with the widespread acknowledgement that quality in the ED has nothing to do with CMS quality metrics or other quality metrics put forth by corporations. The science proves this.
This was also well summarized in a recent article, “Increasing Demands for Quality Measurement:” “[U]ntil measurement truly reflects clinical reality and data acquisition no longer distracts from the process of care nor requires extra effort, barriers will remain resulting in compromised quality, safety, and accountability (my emphasis). (JAMA 2013;310:1971.)
These recent articles should give pause to anyone interested in quality medicine.
Shorter Door-to-Balloon Times of No Benefit: We now have excellent large-scale data (N>95,000) that proves shorter door-to-balloon times make no difference in clinical outcomes. We must seriously consider the billions of dollars and unimaginable human resources needed to maintain cardiology interventionalist lists, 24-hour cath labs and teams, STEMI protocols, cardiac quality coordinators and committees, and the potential negative impact of not using these resources toward other medical care. (New Engl J Med 2013;369:901.)
Stents Increase Morbidity in Surgery: Some celebrate the door-to-balloon process as successful even if clinical outcomes are not better, but the potential harm in paving a cardiac superhighway through your ED is that all cars begin to look like a heart. This process leads to an abundance of cardiac stents. Stents, especially the drug-eluting ones, have shown to increase adverse cardiac events among patients who go for other surgeries within the next six months to two years. (JAMA 2013;310:1462.)
No Significant Improvement with IV tPA for Stroke: After 20 years of debates surrounding selection bias and conflicts of interest, the whole world awaited the International Stroke Trial (IST-3) to answer definitively the value of IV tPA for stroke in the real world. With an N>3000, the conclusion was that IV-tPA had no significant improvement in stroke and actually increased mortality in the 3–4.5 hour time period. (Lancet 2012;379:2352.)
Mechanical Devices and IA tPA of No Added Benefit: Two recent studies showed that mechanical devices and IA tPA for stroke are no more beneficial than IV tPA. These three studies, questioning the significant value of any aggressive therapy, did not provide the anticipated answer or the desired one for hospitals that had built very aggressive and expensive stroke programs. (New Engl J Med 2013;368:893.)
Sepsis — No Significant Changes: Xigris, cortisol levels, steroids, and tight glucose control have all come and gone through the drug company-sponsored Surviving Sepsis Campaign, and we are back to where we started. Few therapies make a difference besides fluids, antibiotics, and more nurses. (New Engl J Med 2013;369:840.)
Therapeutic Hypothermia No More Effective than Normothermia: This is not connected with CMS “quality” measures, but it is yet another example of a small study or two that catapulted into business opportunities only to find out now that it doesn't work. (New Engl J Med 2013;369:2197.)
The greatest travesty is not that we have failed to be as good as we had hoped, for this is the history of medicine and the humility of fighting sickness and death. It is also no shame that quality initiatives, quality measures, quality metrics, and pay-for-performance have failed to produce quality clinical outcomes. God knows it was not for lack of effort, money, and resources. The greatest travesty is that few people trying to accomplish “quality” seem to know these dismal facts. And those who do don't really want to have the discussion. There is no serious thought of doing less, scaling back, or stopping a STEMI squad, a stroke team, a sepsis team, or a therapeutic hypothermia protocol, regardless of new science. The train has already left the station, and its name is business.
Today, in most hospitals, the vast majority of daily emails and meetings are not physician-led groups discussing how to do quality medicine grounded in quality science but rather hospital employees who are nurses or people with business degrees leading committees to see if we are meeting “quality metrics.” This could be acceptable but only if CMS quality metrics in some way helped patients and did not just generate payments to hospitals. And then there is the regrettable idea that some of the quality metrics could be harming patients.
Physicians are angry not just because of change or even because of money; they are angry because good medical science is misunderstood and even ignored by business and government. Making physicians employees of hospitals “so they are more invested in the culture” is not constructive. We don't need more people in medicine who are leaders in business, capitalism, and marketing. We need more physicians who stand up for a profession that is grounded in the scientific method and rooted in a sacred call to first of all do no harm.
The answer is straightforward: be accurate and honest with definitions. This is the way we were taught. This is the way we should practice. CMS metrics (and other corporate metrics) are not measures of quality. These metrics should be called “reimbursement metrics” or “business metrics,” and should not be attached to the word “quality.” On the other hand, when we use the word “quality,” it should represent an approach toward medicine that has proven scientifically to improve outcome more than it harms. The hospital will certainly continue to report CMS reimbursement metrics, but no one should be allowed to confuse one goal with the other.
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