Monday, January 01, 2007

Top 10 issues in hospital medicine for 2006---issue 1: enthusiasm versus skepticism in quality and patient safety

With great fanfare, and with the help of the media, the Institute for Healthcare Improvement (IHI) this year announced the “success” of its campaign to save 100,000 lives. But a more sober assessment of the campaign cited methodological flaws and problems with the analysis of “lives saved” with the conclusion that the true impact of the campaign is unknown. This point-counterpoint illustrates the growing tension between the enthusiasts and the skeptics, and at the end of 2006 the skeptics are winning. The debate was nicely framed in a recent JAMA commentary by Robert Wachter, M.D.

Let’s look at some recent evidence.

Measured against Medicare’s performance measures, the difference in mortality between the top and bottom performing hospitals was of statistical, but questionable clinical significance. (JAMA editorial comment here).

Rapid response teams, recommended by the IHI and being considered for a Joint Commission initiative, are not supported by high level evidence. [1] [2]

Computerized Physician Order Entry was associated with an increase in mortality in a pediatric hospital population.

The four hour antibiotic mandate for pneumonia, a widely promulgated quality measure, is associated with unnecessary antibiotic use and has not been proven to improve outcomes.

Pneumococcal vaccination, another core quality and P4P measure, does not prevent pneumonia and is not cost effective with the preparation now licensed for use in adults.

What does it all mean? It means the quality and patient safety movements should move forward but individual measures should withstand scientific scrutiny before they are mandated by federal agencies and advocacy groups.

1 comment:

Sid Schwab said...

this is an excellent, if disturbing, post. Once again, we see that the estimable goal of quality improvement is made nearly laughable in the bureaucratic execution. It's good to shine light on it, as you continue to do