I tend to “batch read” medical journals. I usually set aside some time on Sunday mornings, after the New York Times and before the Giants kick-off to skim the cardiology journals that I still get. This past Sunday I saw something in Circulation that caught my eye.
The title of the article was “Medication initiation burden required to comply with heart failure guideline recommendations and hospital quality measures,” and it was apparently deemed important enough by the editors to have an accompanying editorial called “Rethinking the focus of heart failure quality measures.” Both were authored by luminaries in the field. The punch line? Lots of patients admitted to the hospital with heart failure need to start 1 or more new medications to meet guideline recommendations and hospital heart failure quality measures. This is, of course, hard to pull off, because of the challenges associated with “managing polypharmacy” and “heart failure transitional care.”
In other words, meeting guideline derived quality measures places complex demands on hospitals, which are increasingly on the hook for large numbers of “process of care” measures, as well as on patients, for whom “guideline directed care” often means being on a lot of medications.
Some of this, of course, is good. Hospitals have often done a poor job of preparing patients for discharge, and many heart failure patients are not on medications that are of proven efficacy in reducing symptoms and improving mortality. Fixing both of those deficiencies would benefit many patients.
Here is the problem. Our current approach to quality measurement and improvement seems to be all about “adding more stuff.” Every shortfall in care is approached as an isolated problem, to be assessed with its own quality measure and fixed with a specific solution. The result is a blizzard of quality measures that provider organizations struggle to prioritize and recommendations for care that are predicated on the false premise that each patient has only 1 problem, for which there is a single good cocktail of treatments.
The only way I see out of this is to move as quickly as possible to abandoning large sets of process measures, and holding provider organizations accountable for the health outcomes of the patients they serve. Not easy, but a lot better in the long run than the mess we have now.
What do you think?
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.