The Daily Dose • Tuesday, May 1

Healthcare Quality Infrastructure: Too Much Stick, Not Enough Carrot

By Dr. Nawal Ragheb-Mueller, from the IARS 2018 Annual Meeting*

Social constructionism is grounded on the idea that groups and individuals produce their own perceptions of reality, and the knowledge produced is the result of social dynamics. And so it goes in medicine.

Dr. Michael O’Connor capably laid the groundwork for this entertaining and provocative panel on quality metrics that he conducted with his colleagues Drs. Nunnally, Tung and Kavanagh.

(Can a panel discussion on quality metrics be entertaining? Yes, it can. It was also completely engrossing. And sobering).

No one refutes that there has been an exponential increase in the medical literature over the past two decades. As busy clinicians tried to keep up, the spectrum of protocols emerged in medicine.

Dr. Michael O’Connor dissected this recent history in a convincing manner as he described “the problem of the modern era”. The medical community engaged in an almost reflexive adoption of guidelines, menus, pathways, checklists and detailed algorithms in an effort to keep up with the literature and take good care of patients. As the protocols emerged, “the problem of influence” and the “modern era of money laundering” surfaced in tandem as Big Pharma funded trials and influenced the guidelines.

And then, the guidelines became incorporated as part of quality improvement efforts that were adopted by government agencies without adequate consideration of the consequences. Most of us know about the beta-blocker metric and tight glycemic control debacle, and Dr. O’Connor reminded us of them in his discussion.

Dr. Avery Tung took to the podium and began with a simple truth. The definition of a quality measure can be very difficult. Then he asked some basic questions: How do we define or agree on a good outcome measure? IS it possible to consistently measure anything related to patient care in an accurate manner?

He then easily backed his argument that there are unintended consequences to quality metrics. As an example, he described a scenario related to patient safety indicator 11 (PS11), the code for post-op respiratory failure. This is triggered when a patient is re-intubated after surgery during the same admission. He described the case of a 73-year-old male undergoing mediastinal chondrosarcoma resection as an example. Coders assigned the case to musculoskeletal disorders rather than cardiac surgery and avoided respiratory failure by coding to respiratory insufficiency. They thus avoided triggering the reportable PS11 patient safety code. And gamed the system.

Dr. Tung’s tongue-in-cheek advice: if you have to re-intubate, do it in the OR, not the PACU or ICU – or else it’s reportable. When you’re unsure, use Sugammadex.

The final speaker on this panel, Dr. Brian Kavanagh, skillfully and methodically dissected evidence-based medicine (EBM) studies. “Designers of EBM studies assume sufficient numbers will yield worthwhile findings, but in fact, their conclusions are often not worthwhile. They omit ‘content expertise’,” noted Kavanagh. Those who promote EBM make the guidelines and then grade them. Kavanagh added that this grading system is a “self-congratulatory” method of assessing research. How is it, he asked, that a system that is so inconsistent can be promulgated so widely?

Concluding his remarks, Dr. Kavanagh provided an epilogue. “The Tyranny of Guidelines” (Annals of Internal Medicine, 2015, A. Sarosi) describes the story of an independent 86-year-old man who had mild hypertension and diabetes. He suffered a hip fracture and subsequent stroke as the unfortunate “end result of a relentless downhill medical care spiral fueled by interventions to tightly control both his blood pressure and diabetes”. This octogenarian farmer whose older brother with dementia relied on him, got up in the middle of the night to urinate, felt dizzy and fell, thus beginning his demise. Felled by a stroke as his treatment ensued, his brother who depended on him ended up institutionalized and Mr. O lost his home. The “one size fits all” approach to the guidelines ruined this man’s life, said Kavanagh.

Summing up, Dr. Kavanagh reminded the audience that the answer to quality is professionalism. Make sure that people are highly trained. Recruit interested, talented people. “There is a great danger in checklists dumbing down expertise. It removes the professionalism and expertise that people bring to bear. You want to be many orders of magnitude better than a checklist.”

*Coverage from the Panel session, Healthcare Quality Infrastructure: Too Much Stick, Not Enough Carrot