This week in JAMA Eve Kerr and Rodney Heyward wrote an important opinion piece about patient centered performance measurement. So here’s the problem with our current performance measurement paradigm: one size fits all. Guidelines have been bastardized into performance measures. Administrators/insurers/etc then hold us accountable to the measures. So what’s the problem?
Well guidelines were meant to be just that guidelines, not rules. When they are made into performance measures they become rules. Rigid rules that are applied to very variable patients. Deviation from the rules leads to the clinician being “dinged”. What this often leads to is inappropriate care. Patients have medication regimens inappropriately escalated to reach an arbitrary number. This often leads to harm either directly as an effect of that medication or through medication interactions. Patients get tests they don’t need (for example, colon cancer screening in patients with multiple comorbidities and limited life expectancy).
I have always felt that quality is very personal. What I view as quality will not be the same as someone else. This applies to all aspects of life, not just medicine. I have always felt that we should negotiate with our patients for what constitutes quality care FROM THEIR STANDPOINT. Aren’t they the ones who matter most? Why is it some administrator decides what constitutes quality care?
Let’s look at an example. Suppose I have a patient with diabetes who is on maximal oral therapy but her A1C is 9. It would be recommended to give insulin. What if the patient doesn’t want insulin no matter what. She understands the risk of longterm uncontrolled insulin. Is it poor quality care that I honor her request to only stay on oral therapy? Again from whose perspective should we evaluate quality?
I think we are slowly moving to including the patient in quality assessment. It needs to go further to patients being actively involved in developing their own quality report card. Then we can be measured for how well we meet quality.