When healthcare quality measures fail us all
Now that we are in the age of Pay For Performance ( P4P ) we are only beginning to learn how difficult it is to achieve the twin towers of
- Patient Satisfaction
- Quality Care
Patient satisfaction is a very controversial subject - with the counterintuitive "percent of top" as our measuring stick and the universal acknowledgement that patient demands should not always be honored carte blanche. ( "I need my #90 Rx of Oxy for my fibro, Doc. The pain is awful." )
Can we at least be clear on the definition of Quality?
You would think we could find more solid ground with respect to how to measure quality. But NO! Here comes a study showing just how hard it is to define and incentivize quality care.
I can assure you that situations where you follow a care protocol to the letter, the patient has a bad outcome and you are penalized despite deploying the "best practice" only add to the stress that drives the epidemic of physician burnout.
Full details below ... on a best practice protocol and quality incentive that failed everyone involved
... especially the patient
The evolution of DVT as an
"every once in a while is OK" event
Blood clots during hospitalization have become synonymous with imperfect care, in the same category as a sponge left behind in surgery. Estimates are 600,000 patients in the US develop a DVT while in the hospital each year and up to 100,000 die of this complication annually.
Regulatory agencies see these as preventable events for which they have zero tolerance and now levy significant financial penalties on physicians and hospitals every time a DVT occurs in the hospital.
In the logic of the regulator, DVT is bad, therefore it should never occur. DVT is the very definition of a "never event".
If you work this logic in reverse, they must also believe that DVT is also completely avoidable.
Slow their logic down even more and you eventually get to the premise,
"If we follow best practices, DVT is 100% avoidable, therefore, let's penalize any institution where DVT occurs for each instance of this avoidable complication."
This study exposes this whole line of reasoning as Magical Thinking
JAMA Surgery, Sept. 2015
"Preventability of Hospital-Acquired Venous Thromboembolism"
Elliott R. Haut, MD, PhD, et al
Chart review of 128 venous thromboembolism (VTE) cases at The Johns Hopkins Hospital found the following:
- Nearly 50 percent of the cases reviewed were not prevented by the current best practice care protocol
- These patients received perfect care according to the current ideal care protocol
- All appropriate preventive measures were taken, ideal medications prescribed and every dose administered correctly
- The blood clots still occurred
- The hospital was still fined
- (BTW, the other 50% of DVT cases did not receive ideal care and were fined in the exact same fashion)
These findings raise a couple of huge questions for me.
What is the purpose of financial penalties when case review shows ideal care was delivered?
Dr. Haut hits this nail on the head in his article at TheHealthCareBlog.com when he writes:
"Penalties had been applied equally to all VTE outcomes, regardless of whether or not the patients had received optimal care. This suggests a serious disconnect between financial penalties and the practices that would lead to the best patient outcomes because, in our study cohort, penalties for blood clots were applied in cases of perfect and imperfect care alike."
His logic is solid. If the purpose of the penalty is to drive the delivery of ideal care, then half of these cases of DVT should not have been fined.
What about the real elephant in the room here?
Do we know how to prevent DVT at all?
Dr. Haut misses this deeper question entirely. I shake my head as I read the results that 50% of DVT's happen in a setting of so called ideal care. That must means one of two things must be going on here.
- DVT is completely preventable and we have yet to identify "ideal care" even with today's protocols
- DVT is not completely preventable in all cases and we must eventually admit that perfection is an unattainable goal for this diagnosis
This would mean DVT is not really a "never event".
It is an "every once in a while is normal event" ... or something like that.
Let's not forget the patients here please
Remember they got DVT's despite all the protocol steps we put them through. I can tell you from personal experience that the pneumatic stockings putting a death grip on my calves every five minutes throughout my hospital stay did absolutely nothing to help me get a restful night's sleep. And subQ shots of anticoagulants sting like a bee and bruise for a week.
What are we doing here and why?
- Protocols that don't work
- Penalties when you do the "right thing"
- Patients getting sick and dying
I am so confused. All this raises is more questions.
- Is there a yet-to-be-identified best practice protocol that will eliminate some or all of the DVT's we see occuring here despite current "ideal care" delivery?
- Is DVT ultimately completely preventable? Is it actually a "never event"?
- What is the highest and best use of financial penalties linked to care outcomes?
- If we change the fines to only the DVT cases that did not follow protocol, are we looking at the best outcome we can expect right here?
And so many more.
PLEASE LEAVE A COMMENT:
What are your thoughts on this dog's breakfast?