Metrics that Matter

As a family doctor in a community health center, I’ve seen a major shift toward measuring what we do. For most of my patients, this would be a surprise. They assume we have data on what we’re doing, what works, and what doesn’t. And then we act to improve.

Our patients rarely see behind the curtain of bean-counting. But they might notice they’re increasingly prodded by a whole team toward certain goals over others. They also might notice they wait endlessly while we finish prodding the preceding patient and documenting our prodding.

All of this would be fine if the prodding wasn’t tied to cash bonuses (conflict of interest) or often based on shaky evidence or all-too-often unrelated to the patient’s goals.

Like it or not, we’re in the early stages of knowing what to measure in clinical practice, and how to use it.

That’s why you’ll want to read a thought-provoking piece just published in PLOS Medicine:
Care that Matters: Quality Measurement and Health Care.

This bold piece—whose authors include NPA members—challenges our current “metrics.” Further, it proposes a framework for measuring how we can do better by our patients. The authors’ chief concern is that many quality measures have modest or no evidence linking them to health outcomes that matter to patients.

Why should we care about this? Because there are enormous costs to getting our metrics wrong: quality costs, financial costs, and most importantly, “opportunity costs” (diversion of limited clinical resources to measuring the wrong things). Even when we get the measures right, there are some articles suggesting that these changes wash out after the short-term push to focus on them.

Measuring things like hospital-acquired infections and publicly reporting them as a means of decreasing harm to patients is a vital project that we must continue to support. We can’t return to the bad old days of doctors and institutions dodging quality assurance. And not just the quality indicators, but any related bonuses paid out by public insurers should be fair game for public viewing.

At the same time, the measures have mushroomed. This poses the biggest challenge in primary care. Measures have been poorly vetted yet are already tied to various “incentives” (bonuses). These bonuses are driving higher costs of care through tech investment and staffing to collect, compile, and report. Particularly in community health centers, this can directly drain resources from providing care. As one example, patient-centered medical home (PCMH) certification diverts physician, nurse, and administrative attention all up and down the line. This is time that we could be engaging more with patients, in person, by phone, and by email.

This is time we could be using for richer conversations with patients so they come to a decision that they’re most comfortable with.

We see over and over again that many patients would choose less intervention if they had more chance to discuss pros and cons of their options. But we’re rarely “incentivized” to work in this way.

When clinic staff feel like they’re sidetracked from engaging patients in order to complete forms, this leads to burnout. Unstaffed clinics mean no care for any patients. Let’s remember that better access to primary care means is connected to better health outcomes at lower cost and better equity. And this was true for the average primary care provider, before the age of measurement.

For all these reasons, what we measure in health care is a key issue. I urge you to read, share, and discuss: Care that Matters: Quality Measurement and Health Care.

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