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Measuring Quality of Health Care Matters

by jamesking
Measuring Quality of Health Care Matters

I have an elderly health patient who I see a couple of times a year. Each visit he says the same thing to me: “Getting old isn’t for the faint of heart.” And I always say the same thing back to him: “Getting older may be tough, but it beats the alternative.”

But, his point is a fair one. His health problems have required frequent hospital stays. Sometimes, he is only home (or at a rehabilitation facility) for a few days or weeks before having to return to the hospital. He has asked me whether there was more his doctors could do to prevent his frequent readmissions.

And, his insurance company is wondering the same thing. In fact, some health insurance plans have begun penalizing hospitals with high readmissions. The logic is that hospitals will deliver higher-quality care if they have the incentive to do so. But these efforts to discourage readmissions have raised some important questions:

  • How good are measures of health care quality?
  • How can we improve care by using quality measures?
  • Is it a myth that health care quality can always be readily measured?

The answers may surprise you.

Can We Prevent Hospital Readmissions?

Many patients with serious and incurable health problems return to the hospital because the treatments aren’t very effective. A good example is congestive heart failure. That’s a condition in which the heart does not pump forcefully enough. ED medications may be of limited benefit. A heart transplant is an option, but there is a shortage of donor hearts. And an elderly person with several other medical problems may not be eligible.

But, clearly, some readmissions are preventable. Many are due to inadequate communication. For example, a patient may go home without enough information about a new condition. Or instructions about a new medication aren’t clearly explained to the patient. Sometimes the need for follow-up care isn’t clearly communicated to the patient’s primary care doctor.

It’s these types of “revolving door” admissions that some health insurers have targeted as sources of preventable harm and cost. Reducing them could improve medical care and save millions of dollars for insurance companies and the patients they cover.

How To Reduce Hospital Readmissions

Medicare recently came up with a plan to reduce readmissions to the hospital. Hospitals that readmit patients “too often” will face big fines. Estimates suggest that about two-thirds of facilities receiving Medicare payments were fined a total of nearly $300 million in the first year of this program.

The idea is that a financial penalty would encourage hospitals and doctors to take action to cut readmission rates. These include:

  • Coordinating outpatient care before discharge
  • Communicating with the patient’s outpatient doctor
  • Making sure tests results that aren’t available at the time of discharge are tracked down after the patient goes home (and followed up, if necessary)
  • Keeping a patient in the hospital a bit longer to be sure they are ready for discharge

Clearly There Are Limits!

Not every readmissions can be prevented, even with the best discharge planning. So, there was a concern from the start that this program could be particularly costly to hospitals that took care of sicker patients, as well as those who didn’t have resources (such as medication coverage) to help them after discharge.

Still, it’s fair to say the threat of a financial burden got the attention of hospital administrators and doctors. They started new programs to help prevent unnecessary readmissions.

Some Unintended Results

Recently, it became clear that something unexpected was happening with this program. Some hospitals had higher-than-expected readmission rates even though their death rates were lower than expected.

Is it possible that the readmission rates of these very sick patients were higher because the patients were living longer? Were the deaths of patients at other hospitals reducing these hospitals’ readmission rates?  After all, you can’t be readmitted if you’re dead.

Although more analysis of this program is needed, my interpretation is that some hospitals providing outstanding care could look bad on measures of quality because how we measure it is imperfect. In the case of hospital readmissions, it’s even possible that the better the hospital’s care, the worse the quality score!

Starting in October, 2013, Medicare began factoring in the rates of death among its beneficiaries when calculating hospital payments.

It’s Harder Than it Looks

It is difficult to come up with definitions of high-quality health care and ways to measure it for all situations. Reducing preventable hospital readmissions is a good example.

Here’s another example. Hospitals have been working hard to reduce delays in providing antibiotic treatment to people with pneumonia. Study after study has shown better results when people with pneumonia get prompt treatment. But it turns out that some hospitals were giving patients antibiotics even before a chest X-ray confirmed the diagnosis.  Those with a normal chest X-ray (no evidence of pneumonia) received antibiotics they didn’t need. So, here’s another measure of quality that, in some cases, led to worse, not better, care.

The Bottom Line

It’s not a myth that measuring quality matters. And, defining and measuring the quality of medical care can be done. But, this is a relatively new area of medicine and we don’t know yet how to do it right in every case.

The new program by Medicare to discourage readmissions to the hospital is an attempt to solve an important problem. But it is also a good example of how good intentions don’t guarantee getting the result you want. In this case, two different measures of quality (a low death rate and a low readmission rate) moved in opposite directions with a bizarre result: rewarding hospitals with low readmission rates that might be, at least in part, due to their patients’ shorter survival.

This is important to keep in mind as you read about measures of doctor or hospital quality in the future. Increasingly, the rates of complications, deaths, readmissions and other outcomes will become available on websites and other public venues. How it’s done matters. And I’m not sure we’re very good at it yet.

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