In our modern, competitive health care environment, hospitals, clinics, physicians, and other providers use various metrics pertaining to health outcomes in an effort to promote their services. These statistics are encountered often in everyday life, ranging from television commercials touting higher cancer survival rates at certain institutes to billboards advertising low hospital wait times. But from a patient’s perspective, how valid are these claims, and what does the data really reveal about health care competence, quality, and value?
On this episode of Kentucky Health, host Dr. Wayne Tuckson welcomes a surgeon with the University of Louisville to discuss the best practices for determining quality and value in health care, and what patients can do to gain knowledge about the best health care options available to them.
Dr. Michael Egger is an assistant professor of surgical oncology at the University of Louisville School of Medicine. Egger says that he’s always been interested in issues relating to quality of health care, but the topic became even more important during his residency and fellowship training.
“We all want to do well and do right by our patients – that’s always been our number one goal and why we put in the time and effort and hours into training,” he says. “But then as I would step back and think about how you could impact more than the patient in front of you and their family, and think about the systems we can build. How do we do quality improvement, how can we promote health and well being and good safe practices beyond our office and operating room and affect the greater community?”
Criteria for Health Care Quality: A Useful Model
How does Egger define quality in heath care? “I like a simple definition by the Agency of Healthcare Research,” he says. “What they basically say is, ‘It’s doing the right thing at the right time for the right individual to achieve the desired outcome.”
Egger presents a slide of a classic model for modern health care systems developed by a physician at the University of Michigan in the 1960s. Named the Donabedian model after its creator, the framework is broken into three categories – Structure, Process, and Outcomes.
The Structure category is “the 30,000-foot view of quality,” Egger says. The structural data is quantitative, which means its typically easy to measure and its reliable. For example, “A 500-bed hospital versus a 100-bed hospital. Also, specialization – the board certification of your providers, the type of training your providers have had.”
Egger says that certification and training are good quality metrics, but they do not ensure that a physician holding a particular certification will do a better job at a task than one who doesn’t have that certification. He does acknowledge that research has shown doctors who have performed more of a specific task throughout their career have improved outcomes with patients as opposed to those with less experience. But Egger says that there are factors aside from the doctor’s actual skill that also influence better results – such as the initial consultation, the hospital amenities, the quality of nursing, the thoroughness of post-procedural care, and so on.
“There are holes in these structures, and that’s why we’ve sort of moved along the continuum and tried to narrow down our focus, and that’s where we get to what I think are the two more important measures of quality,” Egger says.
Process measures are the discrete events or tasks a physician and his/her team undertake, the collective sum of which is the delivery of health care, Egger explains, using the common sight of a doctor carrying his checklist board and pen.
“For surgery, it’s tasks such as, did the patient get antibiotics within 30 minutes of surgery? Did they get prophylaxis to reduce their risk of blood clots?,” he says. “For primary care physicians treating diabetics, is there a measure of hemoglobin A1C or a measure of their long-term blood sugar control, is that being measured on a yearly basis?”
Achieving good Outcomes is obviously crucial for the health care system to work, Egger says. But outcomes are the hardest data to measure in a systematic, standardized way, and they’re very hard to adjust, he adds.
One key variable that complicates things is the overall health of the patient. A patient who receives a particular service such as a medical regimen or a surgery, but who also has several co-morbid conditions, may not reach the desired outcome from the service, through no fault of the physician, staff, and hospital, Egger explains. To allow for this, Egger says health researchers apply what is called risk adjustment, which considers factors relative to the patient population in a particular area (rural, inner city, etc.) when tabulating health outcomes.
“There are a million ways to risk adjust and compare apples to apples,” he says, “and if you can somehow figure that out, then it does make sense to compare those end results and outcomes measures, because that’s what the consumer cares about.”
How Patients Can Become Empowered
Egger says that there is no comprehensive repository on patient outcomes for doctors and hospitals. Information related to physicians is largely protected by doctor-patient confidentiality. But it’s easier to get data on hospital services and compare them, he explains, through online services such as Hospital Compare which is run by the Center for Medicare Services.
A patient using Hospital Compare can enter their ZIP code online and get data on hospitals in their area comprising a wide variety of process measures as well as some outcome measures such as re-admission and mortality rates.
“That system does not necessarily publish a number for those hospitals – a lot of times what they’ll do is say they are at their average or expected level or above or below,” Egger explains. “And as we measure quality on a hospital level, it’s the idea of [measuring] observed results over expected.”
As far as value in health care is concerned, Egger explains that arriving at an accurate measurement is very difficult. He presents an equation via a slide showing that Value = Outcomes divided by Cost. This equation is applicable to most financial exchanges, Egger says. A consumer can research a product, determine its quality, and then measure that quality against its cost to arrive at the accepted value. But the requisite amount of information about quality is lacking in health care, he says, making it hard for patients to predict value.
“If we become a value-based health care system, if we’re going to drive towards value, what that equation tells you is that you can improve value in two ways – either improving the quality of the outcomes, or decreasing the costs,” he says. “Either way, you’re going to drive that value up and improve the care delivery for the patient.”
Balancing quality of care and keeping costs under control has proven to be difficult in the modern health care system, Egger admits, especially given our commitment to fund complex research in search of the next medical breakthrough. New drugs are constantly being developed that may extend the lives of patients with terminal illnesses for months or years, but remain very expensive. The specter of government “death panels” was used for political gain a few years ago by opponents of the Affordable Care Act, but the question of balancing quality of services versus cost of services is one that our medical system will have to answer going forward, Egger says.
“We talk about quality-adjusted life years,” Egger says. “I talk to my patients about this all the time. There are ways to maximize the time they have left, the quantity of time they have left, but often, in cancer care especially, we’re dealing with end of life issues. And so we start to talk about maximizing the quality of life that’s left.
“And that’s hard to put in an equation,” he adds, “but that’s where a little bit of the art comes in with medicine, that’s where the personal relationships come in, knowing what your patient values, what their family values, and we’ve all had those conversations before.”
Egger says that there are several aspects of care every patient should make sure their provider – physician, clinic, or hospital – matches when researching for a particular medical service. Viewing physician ratings online can give patients information about more experiential factors in heath care such as keeping appointments and wait time, but on the technical side, patients need to check the professional certifications for their doctor. If the physician in question is a specialist, patients also need to make sure the doctor has training in that specialty.
Perhaps most importantly, patients need to develop a trusting relationship with their physician. To that end, asking friends for recommendations is still important. “I do think there is some value in peer experience,” Egger says.
