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The Inadequacy of Traditional Primary Care Quality Measures

October 9, 2011

At the TAFP conference I attended last weekend, almost all the clinically oriented speakers showed data from their EMRs they felt proved they were providing high quality care. I’m sure their quality is excellent, but this won’t make healthcare more affordable.

The measures most everyone showed included: how many diabetics had their hemoglobin A1Cs checked in the last 6 months and how many of those were under a target number, how many had an annual eye exam, and how many had their LDL cholesterol checked and was below some target.

There were other measures such as LDL targets for the general adult patient panels, immunization rates, and success in lowering hypertensive patients’ blood pressures. This is all well and good, but almost none of these interventions lower healthcare costs.

It is widely believed that the old childhood vaccinations, particularly the MMR and DTAP, save money (but not the newer ones); and also influenza vaccinations in high-risk elderly and pneumococcal vaccinations in the general elderly population. That’s about it. None of the other chronic disease measures commonly used to rate primary care practices save money in the long run.

Therefore, the efforts of the current generation of EMRs and their built-in quality metrics encourage physicians to do more interventions to patients that add costs to the greater healthcare system. We need measures that really capture the factors that explain how family physicians deliver better health at a lower cost: comfort with uncertainty, management of complex patients, use of time as a diagnostic tool, fewer tests, fewer treatments especially at the end of life, reduced ER visits, and reduced hospitalizations.

I hear many politicians and pundits these days say we must raise quality and lower costs. Unfortunately, sometimes these goals are in direct opposition. Low tech approaches to process improvements for sick people can deliver both. An example is not starting anesthesia in the OR until the anesthesiologist has given the higher-risk patient his pre-op antibiotics. Otherwise, the answer to making healthcare more affordable is more difficult than the politicians seem to believe.

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