Top 10 issues in hospital medicine for 2009, issue 1: quality and safety

Quality has many dimensions and is not easy to define. Recently, though, it has been simplistically characterized as adherence to “best practice.” This has opened up an array of “measures” that can be publicly reported. This movement has really gotten into high gear over the past 5 years or so.

Safety means minimizing harm that comes to patients in the course of their care. Although the patient safety movement got started as a result of events following the Libby Zion case in the 1980s the release of the Institute of Medicine Report on patient safety a decade ago was a defining moment.

Hospitalists are positioned to be heavily involved in both quality and safety. It seems appropriate at the end of the decade to ask: “How are we doing?”

Quality
Although the news about quality is not all bad the quality movement overall has largely failed due to confusion between quality and performance. A focus on performance is more about institutional narcissism than about the well being of the patient. That said, let's look at some individual quality measures.

Acute coronary syndrome:

ASA: Evidence based and robust, but already widely done. Effectiveness of making it a performance measure doubtful.

Beta blockers, ACEI/ARBs: Evidence based, but the effect of the performance measure is probably weak. Hospital providers can play for the report card by starting a small dose at discharge, which may never get titrated to goal in the clinic.

Smoking cessation education: Weak at best. Although hospital providers could seize a unique opportunity to change the patient's lifestyle that would require spending considerable time with the patient. Instead, in order to play for the report card, busy hospital personnel are more likely to merely print off a few pages of information and hand it to the patient as s/he's on the way out the door. This and other performance measures may distract from non-performance but equally important measures such as statin therapy.

Time to reperfusion: Hospitals are scrambling to get their door to balloon times down. This is a strong measure that may be the one success story among ACS performance measures.

Heart failure:

Discharge instructions: Same as for smoking cessation above. In the studies which showed discharge instructions to improve outcomes a specialty nurse sat down and spent an hour or two with the patient and family. Hospitals, concerned about bed control and early discharge, don't feel they have time to do this and don't have to to play for the report card.

Evaluation for left ventricular systolic dysfunction: This is an important assessment which helps evaluate patients' candidacy for multiple therapies. Since most of these take place after the patient is discharged it makes little difference whether the test is done that admission. Moreover, it does no good at all if the results are not followed up appropriately in clinic. So, making it a hospital performance measure probably has little effect.

ACEI/ARB therapy: Just as for MI, these agents are likely to be prescribed in a small dose to satisfy the measure, then never get titrated to goal in clinic. Providers who are uncomfortable prescribing an ACEI or ARB can also satisfy the measure by finding and documenting any of several soft “contraindications” such as low blood pressure or elevated creatinine.

The heart failure performance measures may distract from more important therapies which are not performance measures such as beta blockers and devices.

It's not hard to imagine then why the OPTIMIZE database found no evidence of effectiveness of heart failure performance measures.

Pneumonia:

Pneumococcal vaccination: The pneumococcal vaccine approved for adults is weak and largely ineffective.

Blood cultures in the emergency room: This is an important measure for many patients with pneumonia. The evidence suggests it is not helpful in some others. Supplanting clinical judgment with a performance measure for this test is inappropriate.

Smoking cessation: A weak measure. See comments above.

Time to antibiotic: This measure has been found repeatedly to result in non-evidence based administration of antibiotics without clinical benefit and possible harm. It has been removed from the guidelines. Nevertheless it persists as a performance measure.

Appropriateness of antibiotics: Efforts to encourage guideline adherence in this area is laudable. However, performance measures may lag behind the latest evidence. What's more it may be all too easy to adjust the documentation to fit the antibiotic you gave rather than the other way around.

Influenza vaccination: This is evidence based and a much stronger measure than pneumococcal vaccination.

Safety
Evaluation of our progress in advancing the cause of patient safety has been controversial. Bob Wachter gave the movement a B-. I was not so optimistic. A leading consumer group characterized it as a public policy failure. I tried to resolve the controversy here and elsewhere.

According to Bob Wachter one of the problems with patient safety is that we've taken the no blame idea too far. I countered that we actually have, as an unintended result of the IOM report, a culture of blame which has damaged the patient safety movement and cited evidence that this culture of blame has damaged the cause of transparency. This year I also expressed the opinion that the idea of “accountability versus no blame” was a false dichotomy.