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The Medical Professionalism Blog

Another Unintended Consequence of Clinical Performance Measures?

I highly recommend reading the “Less is More”  series in the Archives of Internal Medicine edited by Rita Redberg if you have not already done so.

A recent article by Brenda Sirovich, et al, entitled “Too Little? Too Much? Primary Care Physicians’ Views on U.S. Health Care” included the results of a survey of primary care physicians that assessed their beliefs on whether their patients were receiving too much care.

  • 42% said their patients were getting too much care and only 6% were getting too little care
  • 62% said diagnostic testing would be reduced if it did not generate revenue for medical subspecialties
  • The most important factors leading them to practice aggressively were:
    • Malpractice claims (76%)
    • Clinical performance measures (52%)
    • Inadequate time to spend with patients (40%)

In “Nice Work If You Can Get It”, a commentary that follows the study in the same journal, author Calvin Chou turns the malpractice argument on its head by drawing attention to the paucity of evidence that more diagnostic tests and procedures reduce malpractice. He cites a study by ABIM Foundation Trustee Wendy Levinson that indicates disparate communication skills resulted in differential claims among physicians. According to Levinson’s study, physicians who used active listening, facilitated patient participation in conversation, used humor and spent more time with patients, were less likely to be sued.

As illuminating as these findings are, I am not convinced they will assuage physicians’ fear of missing something because they didn’t order enough tests. A mindset of this nature is ingrained in medical students and residents, and later reinforced by a poorly constructed reimbursement system. But fear of malpractice cannot be blamed as the sole reason for increased testing. There is also a multitude of clinical and system skills and attitudes, and financial conditions causing this overuse.

What I find even more interesting and what I can’t fully understand, is the notion that clinical performance measures are causing too much care. To me, this sounds like another unintended consequence of performance measures.

Since the inception of the Health Effectiveness Data Information Set (HEDIS) in 1998, I have heard that physicians and health systems are often driven to focus on and excel in specified measure sets at the expense of areas where there were quality gaps or those that are more relevant and salient to the population being cared for. Physicians are increasingly becoming cynical about the multiple measure sets for accreditation and certification processes. Rather than an accountability system that engenders creativity and purpose, it feels unilaterally imposed (even though medical specialty societies have taken more of a leadership role).

I believe primary care physicians think that clinical performance measures lead to too much service because:

  • Physicians are being asked to reduce levels of blood pressure and hemoglobin, for instance, for patients where it is inappropriate for patients with multiple co-morbidities or because of age.
  • Some measures don’t align with practitioners views on what is important to the care of a particular disease (e.g., foot care for diabetes).
  • Many physicians feel these measures impose on their ability to make their own decisions, and are prone to blame them for a number of ills facing our health care system.

I welcome your thoughts…

2 Comments to Another Unintended Consequence of Clinical Performance Measures?

  • October 19, 2011 at 4:20 pm | Permalink

    Is there a tyranny of performance measurement?

    It is concerning that performance measures can lead to overuse and I believe it’s true.

    I remember a conversation with a primary care physician who described a dilemma he faced with a patient. The “rules” said he should perform a certain test. His expertise as a clinician and his long-standing relationship with his patient led him to conclude that the test would be an intrusive burden and not necessary.

    Yet he had every incentive — including a financial one — to do what the system wanted him to do. This is a terrible dilemma that is put upon physicians.

    It also makes it harder for patients to say “no”, when, in fact, “no” might make perfect sense in some cases.

    Tyranny of performance measurement must be guarded against..

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