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Priorities for quality metrics in primary care practice need revamping
Researchers have proposed a new set of priorities for quality metrics in primary care, saying that the current processes actually result in poorer quality of care.
Previous surveys that have assessed the prevalence of patient burnout have produced mixed results, but the researchers of this new study in Annals of Family Medicine suggest changing the quality metrics would be beneficial to physicians’ well-being.
“Well-aligned quality measures for primary care should promote accountable performance and boost clinicians’ motivation by rewarding them for managing complexity, solving problems, and thinking creatively when addressing the unique circumstances of each patient,” Richard A. Young, MD, associate program director and director of research, John Peter Smith Hospital Family Medicine Residency Program, Fort Worth, Texas, and colleagues wrote. “Instead, misaligned [quality improvement] metrics and other mandates [such] as EHRs have contributed to burnout among physicians, especially those in primary care, causing some to advocate for the Quadruple Aim by adding the goal of enhancing professional satisfaction and well-being to the Triple Aim. Most importantly, many primary care physicians believe the existing metrics may paradoxically encourage poor quality of care.”
According to researchers, traditional quality improvement processes applied to linear mechanical systems, such as isolated single-disease care, are not appropriate for nonlinear, complex adaptive systems, such as primary care, because of differences in care processes, outcome goals, and the validity of summative quality scorecards.
Young and colleagues new proposed priorities include: qualitative reviews of care patterns, practice infrastructure and intrapractice relationships that are led by peers; outcomes focused on the patients, eg, days of avoidable disability; attributes of primary care associated with lower costs and better outcomes;less priority on patient satisfaction scores; metrics that garner avoidance of excessive testing or treatment; quality goals not based on strict targets; and patient-centered reporting.
“At its heart, traditional [quality improvement] assumes there is a definitive and measurable right answer in a given situation. In contrast, primary care physicians often deliver high-value care by doing the best they can with the patient care cards they are dealt, knowing that perfection will never be achieved,” Young and colleagues wrote. “Adaptability rather than standardization should be the cornerstone of complex primary care and chronic disease care. The national trends of rigid metrics and simplistic noncomprehensive scorecards must be reversed for primary care to do an even better job of delivering better patient care at a lower cost. At a minimum, measures that better respect the complexity and value of primary care would help promote the sustainable primary care workforce that is desperately needed.” – by Janel Miller
Disclosure: Young reports no relevant financial disclosures. Please see the study for a full list of the other researchers’ relevant financial disclosures.
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"This is an important paper. For years, there has been a mounting dissatisfaction with contemporary efforts at measuring quality in primary care. This paper gives us a lens through which to understand why this is so — because we are disregarding the complex adaptive nature of high-quality primary care, in which hundreds of diagnoses and conditions are interacting with an ever-changing set of patient, family, social, and other “external” factors in ways that cannot be predicted and are not built into quality measures. By understanding primary care as a fundamentally nonlinear adaptive process, we can both understand our current quality improvement dilemma and find a way forward.
Young et al suggest new priorities and strategies. For example, it is usually inappropriate to measure quality at the level of multiple individual steps in a process, because a complex adaptive system can achieve the desired outcome in many different ways. Disease-specific measurement burden can compromise patient-centeredness and practice flexibility, and not improve outcomes. Outcome target ranges should be adjusted to account for variables outside the control of clinical interventions. Measures should include decisions to not do things that should be avoided. Patient satisfaction measures are sometimes associated with poorer health outcomes, and should not be blindly used as quality measures. Above all, measurement should include those features of primary care already known to be associated with improved outcomes: access, comprehensiveness, continuity, smaller practice sizes, and longer visit times.
These are solid, helpful suggestions that should be incorporated into primary care quality improvement efforts."
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"Initially, I was a strong proponent of quality measures and quality metrics. I thought that these provided a framework for feedback to providers and an element of accountability for outcomes. Like many of us, I have become increasingly disappointed in how this has evolved. The authors of the article point out many of the problems. Specifically, measures do not take into account the nuances such as taking care of patients who have complex, chronic illness who also might have different sociodemographic factors at play. In family medicine, these metrics only measure a small amount of what we do. The complexity of what we do is much different than the complexity of surgical procedures in terms of measuring outcomes, where there are far fewer steps. I think the authors correctly point out these problems. For the physician, it has created a tremendous burden of work, and we are spending more and more focus on a smaller amount of our practice. When payment is tied to these outcomes, physicians tend to spend an excessive amount of time documenting things that we’re not sure, in actuality, provide any meaningful benefit.
An example of this is the hemoglobin A1C test for diabetes. There’s a lot of debate about where that goal should be, and I think everyone agrees that the actual goal for a diabetic in terms of their hemoglobin A1C level really needs to be individualized to some degree and we have to take into account the other chronic illnesses we’re trying to manage in that patient. If you step back and say “What’s the goal here?”, we’re really trying to improve outcomes. Well, there are really only three outcomes. One is total cost of care, the second is quality of life, and third is mortality. If you’re not measuring one of those three as an outcome, all of the others are intermediate proxies for those outcomes measures. Over the years, we’ve learned it’s not as logical or as direct a path from these measures to one of those three outcomes as we really might think. It’s one of the reasons the focus on measuring these so-called quality outcomes has really not led measurably to improved mortality, lower cost, and improved quality of life. The authors rightfully say that we should be looking away from some of these measures towards other ways of looking at things, such as instead of looking at we did do, looking at what we didn’t do.
I think that this is a really important article, because there’s increased frustration from providers, especially family physicians about the documentation that we’re doing for a small subset of our entire practice. We don’t think that these measures actually reflect our entire practice. And we’re dubious as to whether or not we’re checking the boxes rather than really improving one of those three outcomes I mentioned. Despite these concerns, we see a tsunami of new measures being proposed. It’s my observation that a lot of these measures are what we would call convenience measures. We’re measuring things that are measurable, rather than things that are meaningful.”