Quality of Care

Dr P: It’s the end of the day, and now we have breathing room. Any thoughts about what we did today?

MS3: Something you said got me thinking—about that patient who was seeing an endocrinologist, a cardiologist.

Dr P: Right. And a hematologist, nephrologist. She even saw a rheumatologist and an orthopedist a couple of years ago—we didn’t talk about that. Anyway, you were saying?

MS3: Well, I’m not convinced that her care was improved that greatly by seeing all these doctors. I’m confused about quality of health care. We have so many resources, like this patient who is able to see so many experts, and yet, I read an article in an online journal that stated that the quality of health care in the US is very poor

Dr P: I know what you mean about the complexity of health care. And it’s hard to manage that complexity. I didn’t refer that patient to all those subspecialists. The whole process got out of my control a bit. Let’s pull that article up on the Web. While we’re on the subject: How would you define quality?

MS3: I’m not sure. Standards of care are met?

Dr P: I like that, as long as you throw in something about delivery, too. So, I use this definition: “delivery of treatments, technologies, and medical services known to be effective, to patients who need them.”

MS3: Makes sense.

Dr P: So how well does the US health care system do in delivering effective health care services to patients who need them?

MS3: For lots of patients with common chronic diseases, like hypertension, diabetes, and asthma, the US health care system delivers about 50% of effective treatments to patients who need them.

Dr P: 50%, only. Interesting. How does our system compare to the systems in other industrialized countries?

MS3: According to the article, the US ranks very low, almost last among industrialized countries in many areas of health care quality.

Dr P: I agree with you—it is a paradox. Such wealth and richness to our system, and yet we score poorly in quality compared to the systems in other nations. We have trouble delivering helpful care to everyone who needs it. And we make mistakes in delivering the care. More than 40,000 patients die in the US annually due to medical errors. So why do we have trouble delivering care?

MS3: Miscommunication can contribute to errors. Sometimes information gets dropped or garbled during transitions, like when a patient goes from one care setting to another, from the nursing home to the hospital or back. Or the order is not understood. That’s why we aren’t supposed to use certain abbreviations in the chart.

Dr P: Excellent. Can you think of any patient we saw today where that issue of transitions came up?

MS3: We saw that one person who was following up after a hospital admission. There was no note in the chart. We had to call the team who cared for him in the hospital to find out what they had done. I’m not happy to be training in a country that performs so poorly compared to other countries. So, the US doesn’t do much of anything right when it comes to health care quality, right?

Dr P: Well, hang on. It’s not that bad. In most states, more than 90% of eligible children have received part or all of the required immunizations. Vaccination rates have been a bright spot in US health care quality. Also, partly because of national campaigns aimed at blood pressure and cholesterol control, the US cardiac death rate has declined in the past several years. So there are some programs that have improved quality.

MS3: I still don’t get it, though. If the US is such an advanced country, why do we have such low health care quality?

Dr P: I think there are different factors that contribute. The US lacks a uniform, standardized health care information system. Lack of information about a patient can lead to expensive duplication of medical services or failure to provide needed services. Some authorities feel that the decline in the number of primary care physicians, compared to the number of subspecialists, has led to increasing health care costs and decreasing health care quality in the US.

Some physicians resist programs that seek to improve care, because they fear that a system of care threatens their professional autonomy. We also know, in general, that innovations and new knowledge take a long time to get incorporated into regular use. New medical technologies take about 17 years from discovery to application for patients.

Some authorities cite “defensive medicine” as a cause for some of our health care quality problems. Add this information to the fact that more than 40 million people in the US lack health care access due to inadequate or no health insurance and you can see why the US health care system has trouble with quality.

MS3: Now you are depressing me.

Dr P: (smiles) I’m sorry. You can do something about it, though.

MS3: Like what?

Dr P: Exactly what you are doing right here, right now, is the best first step. Get informed.

One of the best, most current information sites in this area is the Institute of Medicine’s Web site, www.iom.edu. Keep questioning what you are doing, and keep looking to improve the systems of care around you—for example, improve the system for coordinating care among a set of subspecialists—so, we now have an electronic health record that contains the notes from all these consulting physicians, and that has improved my understanding of that patient’s care greatly. And we’ll look into what happened to the usual hospital discharge system for that other patient. Why didn’t the discharge summary get into his chart?

MS3: I do need to learn more about this topic. When I start my residency training, I will look for a training program that emphasizes systems of care and practice improvement.

Dr P: You should consider the residency program at Brigadoon, Nebraska. They will help you learn how to set up a system to look continuously at practice outcomes, as well as work with your hospital’s quality improvement programs.

Paul Paulman, University of Nebraska, Author
Alec Chessman, MD, Medical University of South Carolina, Editor

Reference

  1. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348(26):2635-45.
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