Evidence-Based Medicine, Clinical Pathways & Quality

Posted on by
image_pdfimage_print

With all the developments and improved treatments in every area of medicine, it can be difficult for physicians to keep up with the most current and effective therapies in their areas of specialization. So how can a patient know whether they are getting the highest level of quality of care?  After all, patients rely on the expertise of their doctors.  This is one reason why health plans and other healthcare organizations are asking physicians to develop and use Care Pathways, sometimes called Clinical Pathways.

These pathways use evidence-based medical guidelines as their foundation.  With such an approach, appropriate diagnostic testing and treatments for a clinical situation are determined by a team of expert specialists based upon the most recent, scientifically valid medical research that is relevant to the situation.  For example for cancer care, a team of oncologists, usually representing their national specialty board, review the medical studies of the latest cancer research and judge the value of the different tests and treatments for the most common kinds of cancer.  They then make recommendations or guidelines that are published and shared with the rest of the oncology specialists throughout the country to guide them in providing their patients with care that will more likely produce better outcomes.

These evidence-based care recommendations and guidelines sometimes can’t be easily applied in clinical practice as written.  That’s where Care Pathways come in.  Physicians and other clinicians who practice together take these evidence-based recommendations and turn them into a practical approach that they can use where they practice.  These are the Care Pathways that everyone in the practice or hospital follows to make sure that the best care is delivered.  The more innovative and quality-focused practices and healthcare organizations use computer systems to track how well these pathways are followed.  Then they routinely look at these as quality measures to gauge how well they are doing and make improvements to their processes to improve their outcomes.

I think that these Care Pathways hold the promise of increasing quality at the practice level faster than any other quality improvement methodology.  What do you think?  Leave a comment.  After all, it’s your healthcare we’re talking about.

For Your Health – Dr. Bob

More On Healthcare Quality

Posted on by
image_pdfimage_print

In my last post about using the healthcare system, I talked about patient satisfaction surveys as a way to measure its quality.  But measuring satisfaction is only part of health care quality.  You may be satisfied with the care your physician provides, but is it medically appropriate and up-to-date?

Another kind of measure looks at how well all the doctor’s patients with certain common characteristics stack up against some specialty recommendations.  This approach works well for preventive measures for patients of a certain gender and age, such as, immunizations for children or mammography rates for women.  It’s also used to measure care delivered to patients with certain chronic conditions, such as diabetes or heart failure.  These measures cover whether certain tests have been performed on a regular basis and whether certain medications proven to be effective in managing the condition are being taken by the patient.  They also may include what percentage of the patients with the condition are under control by attaining certain standards, such as blood pressure or the A1C level for the diabetic.

There are certain problems with these measures.  First, sometimes more than one medical organization releases conflicting recommendations for the same test or procedure.  For example, the United States Preventive Services Task Force (USPSTF) recommends screening mammograms for women every other year after the age of 50, whereas the American Cancer Society (ACS)  recommends that it be done every year after the age of 40.  Which should be used?  Another problem with some of these measures is that they don’t always accurately reflect the physician’s practice.  With most of them, the physician may order a test or a medication, but the patient must follow through and have the test done or fill the prescription and take the medication.  Another weakness of these measures is that while they can work for primary care and some specialties, they can’t be applied to all specialists.  With time more specialty-specific measures may be developed.  Finally, gathering the data to do the calculations can be a problem, though as more and more practices adopt an electronic medical record, that problem may be reduced.  More about that in the next post, when I discuss clinical pathways.

Some health plans publish some of these kinds of measures for their physician network.  Have you ever seen them or used them?  Please share your experiences with healthcare quality by leaving a comment.

For Your Health – Dr. Bob

Am I Getting Quality Healthcare?

Posted on by
image_pdfimage_print

This is a complicated question since it goes beyond your satisfaction as the patient.  Certainly your satisfaction with the services you receive is extremely important, but since you are probably not an expert in every aspect of medicine, you may not know whether the test or treatment you receive is the most appropriate for your condition.  In most instances, you are reliant on the physician to give you the correct diagnosis for your medical problem.  Today, I want to talk about the importance of satisfaction in assessing the medical care you receive.

Over 20 years ago, in 1990 the Institute of Medicine (IOM) gave a definition of quality of care that has been useful ever since.  In their publication, Medicare: A Strategy for Quality Assurance, they defined “quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”  Though referencing Medicare, this definition works for all healthcare.  I feel that if you are not satisfied with your experience, whether it is an office visit with your PCP, an x-ray procedure or a surgical procedure, it can lead to your questioning the appropriateness of the other aspects of your care where you aren’t the expert.

I would suggest you measure each part of your healthcare experience by asking this simple question: “Did this encounter meet or surpass my expectations?”  When evaluating your experience, for example a PCP office visit, consider everything about it:

  • Courtesy of the front desk staff
  • How long you waited in the waiting room
  • Courtesy of the person who escorted you to the examining room or doctor’s office
  • How long you waited to see the doctor
  • How well the doctor communicated with you
  • The thoroughness of the examination
  • The clarity of the diagnosis and treatment plan
  • Your comfort level of being able to communicate with the physician should you have any questions

Please submit your comments, such as, how would you rate your satisfaction with your physician and other health care providers you’ve seen?  How can things be improved from your perspective?  I’ll talk more about other quality measures in my next post on Using the Healthcare System.

For Your Health – Dr. Bob

When Your Doctor Doesn’t Believe You – Or So It Seems

Posted on by
image_pdfimage_print

Recently a friend of mine, I’ll call him Ed, had a surgical procedure to treat his gastroesophageal reflux (GERD) which intense medical therapy could not control.  He was having severe, almost continuous heartburn and nausea.  The procedure was done by means of an endoscope that went down his mouth, through his esophagus and into his stomach.  Ed experienced considerable relief after the procedure. But several weeks later he started having a different kind of pain that started in his mouth, went down his chest and down through his abdomen below his navel.  When Ed explained this to his surgeon, I’ll call him Doctor Adams, the doctor said it couldn’t be due to the surgery and he was stumped.   He could only suggest Ed continue his pain medication for the time being.  My friend felt the doctor didn’t take him seriously, and so he went from doctor to doctor.  It wasn’t until his pain became more localized to his right upper abdomen that he felt one doctor who believed him, ordered tests that showed the problem was his gallbladder.  Ed then had his gallbladder removed and now is recovering smoothly.  What happened?  What went wrong?  Why did Ed have to search for another doctor to help him?

The answer is that the pain Ed first experienced didn’t match any pain Dr. Adams expected.  In fact, it sounded weird.  While Dr. Adams  may have thought the pain was all in my friend’s head, let’s give him the benefit of the doubt and assume that Dr. Adams believed Ed but didn’t know what was going on and decided to wait to see whether the pain would go away on its own or become more identifiable.  But, if that’s what he was thinking, this is where his communication with Ed broke down.  He didn’t explain his thinking to Ed and tell him that even though it wasn’t clear what was going on at the time, he wanted to keep in touch with Ed especially if any of his symptoms changed.  Instead Ed left the doctor’s office feeling like Dr. Adams didn’t believe him.  So, even as his symptoms became more localized, Ed was not inclined to go back to Dr. Adams.

The lesson to be learned is for both physician and patient to maintain open lines of communication in challenging cases like this one.  The physician needs to encourage the patient to report any new, changing or worsening symptoms.  Just as important, the patient needs to understand that the initial symptoms of a condition may be vague and confusing but with time they become better defined and point more clearly to the ultimate diagnosis.

How comfortable are you with your communications with your doctors?  Have you ever had problems similar to Ed’s?

For Your Health – Dr. Bob

A Few Comments on Your Submitted Comments

Posted on by
image_pdfimage_print

Given the fact that I do little in the way of promoting this blog, I get a good number of comments to my posts and I wanted to make a few comments about them in general.  About 99% of the comments I get are complimentary but without any further discussion of the topic.  I appreciate the kind words and thank those of you who submit these, but I hope you understand that I don’t post most of these since I believe the readership is more interested in further discussion of the topic rather than just seeing these flattering statements.  I do enjoy getting the positive feedback, though!

Another group of comments consists of questions about the mechanics of writing a blog.  Again, I am flattered to be asked those questions, but I’m still a novice myself and would refer you to a great book on the topic by Susan Gunelius, Blogging All-in-One For Dummies and the WordPress website www.wordpress.com.  You will notice my blog is “Powered by WordPress.”  I simply used the tools they provided to choose this theme and layout.  They make it easy to post and moderate comments as well.  There are other books and blog publishers out there, but these are the resources that helped me get started.

Finally, I do get some comments from spammers thinking that I don’t moderate what they submit.  I do & trash these immediately.

Thanks for your readership & comments.  I’ll be posting more content related to the blog’s topics within the next few days.

For Your Health – Dr. Bob