The National Quality Forum is setting standards for primary care

A new quality initiative may result in standardizing differing performance measures and creating measures where none exist.

By Andis Robeznieks — Posted Jan. 12, 2004

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Working on the theory that reducing the underuse, overuse and misuse of medical treatments will result in fewer poor outcomes and unnecessary hospitalizations, the National Quality Forum launched an initiative to standardize performance measures for primary care doctors.

According to NQF, a Washington, D.C.-based organization with 200 members, including the American Medical Association, one goal of the initiative is to streamline the work load of a physician who may belong to several different health plans that all have different performance measures.

Although that may seem like a noble endeavor, NQF President Kenneth Kizer, MD, said his organization is prepared to take some heat for getting involved in promoting performance measures.

"I think they will be controversial because they involve doctors' offices, and that's an area no one has tread in yet," Dr. Kizer said. "There is not uniform acceptance of the use of performance measures among physicians."

Dr. Kizer said that a system in which performance measures are widely accepted and used by physicians and the public "does presage a new era in quality improvement."

"This is a tangible manifestation of the new era of health care in which performance measurement, public reporting, paying for performance and consumer activism are all part of the mill," Dr. Kizer said. "It's not out there in the distant future, it's going to happen before long."

The art and science

While not commenting specifically on the NQF initiative, the president of the St. Paul, Minn.-based Citizens' Council on Health Care, Twila Brase, RN, expressed concern that performance measures and best practice guidelines "put another person in the exam room" who comes between physicians and patients.

"Medicine is not only a science, but an art," Brase said. "Best practices and performance measures focus on science and leave out the art and, even then, they may only focus on the science that meets the researcher's or the committee's own agenda."

Brase is particularly concerned about an effort to legislate best practices into Minnesota's Health Care Cost Containment Act for 2004, but she also said initiatives like NQF's may slow down the use of new treatments because these discoveries will need to get a bureaucratic stamp of approval. Her biggest concern, however, is that mandated best practices will ultimately lead to penalties for doctors who think for themselves.

"I think it's perfectly acceptable to have [best practices] research available, but what's not acceptable is to attach financial incentives, disincentives or penalties to someone's idea of best practices," she said. "It's not OK to coerce doctors to comply with the directives of someone else who is not in the exam room."

Real world flexibility

Although he also expressed concern about best practices legislation, Dr. Kizer said standards can be made flexible enough so that they can be adapted to fit each individual patient's needs. He said Brase's concerns about coercion are part of an argument that has already been settled.

"I find that a little bit of a stretch and it's not an unfamiliar criticism: This is cookbook medicine," he said. "But this is what the evidence says works best. If you're not doing it you have to have a reason. Then you document it in the chart and move on and see the next patient."

These criticisms are often cited in discussions about best practices for diabetic patients. Guidelines call for eye tests and checking for sensation in the patients' feet, but diabetic patients may be blind or have had an amputation.

"Then you just put 'not applicable,' " Dr. Kizer said. "It's not a big deal in the real world and, in reality, it's not a basis for getting all excited."

Although it's too early to talk about specific measures, he said diabetes treatment is a likely candidate for the development of standard practice measurements. Others include end-of-life care, pain and medication management, and treatment for asthma, depression, hypertension and obesity. Issues such as coordination of care, controlling infection and addressing special needs may all be part of the project as well.

Striking the right balance

Dr. Kizer said the foundation for the effort will be 20 priority areas identified in the Institute of Medicine's "Transforming Health Care Quality" report released in January 2003.

For some of these priorities, such as asthma, Dr. Kizer said several differing performance measure sets exist, and the goal would be to forge a consensus on uniform measures. But for other priority areas, such as depression, the goal would be to create standards where there are none.

Dr. Kizer also stressed that the NQF is not looking to increase a physician's paperwork burden.

"We don't want to make life more complicated for doctors, but we're also in an era where doctors have to be more accountable than in the past, and the delivery of care has to be more transparent than in the past," he said. "How we strike that balance is why this ends up being controversial."

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Standard targets

The National Quality Forum has launched a project to build a national consensus on performance measures in primary care. The effort is expected to take four years. Likely areas for measurement development include:

  • Asthma
  • Coordination of care
  • Depression
  • Diabetes
  • End-of-life care
  • Hypertension
  • Infections
  • Medication management
  • Obesity
  • Pain management

Source: NQF President Kenneth Kizer, MD

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External links

"Priority Areas for National Action: Transforming Health Care Quality," Institute of Medicine report, January 2003 (link)

National Quality Forum initiative on ambulatory care performance measures, press release (link)

"HMO Guidelines or New Mandates?" article by Twila Brase, RN, discussing concern that care guidelines could lead to health care rationing (link)

Minnesota legislation and bill status, for text of proposed Minnesota Health Care Cost Containment Act of 2004, HF1681 (link)

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