Healthcare Town Hall

What follows is excerpted from “The convergence of quality and efficiency,” by Helen Blumen and Lynn Nemiccolo. Today’s discussion continues where yesterday left off, explaining resistance to the convergence concept.

One of the major barriers identified in the NEJM study was physician resistance. In the hospitals surveyed, 36% of those who did not have an EHR stated that physician resistance was a barrier.34 Physicians resist the use of CDS tools for a variety of reasons, but the main reason is the belief that the use of an EHR and CDS tools will decrease clinical productivity and affect financial reimbursement. Other reasons range from not wanting a computer system to infringe on their decision making to something known as alert fatigue. Alert fatigue is when physicians have been exposed to poorly implemented EHRs that warn them continuously of possible problems as they access the system. Moreover, many of the CDS tools used today have been developed without clinician input, increasing resistance to their use. But if guidelines can be used to fine-tune EHR, and EHR can inform the creation of more user-efficient guidelines, what can emerge is a usability feedback loop that results in a self-improving system that avoids the dynamic of alert fatigue.

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Efficiency, Electronic Health Records, Evidence-based Requirements Convergence, Helen Blumen, Lynn Nemiccolo

What follows is excerpted from “The convergence of quality and efficiency,” by Helen Blumen and Lynn Nemiccolo.

Unfortunately, even when guidelines score well using the AGREE instrument, providers may still view them negatively. One example of this is an examination of guidelines conducted by researchers at RAND. One of the questions within the AGREE rigor-of-development domain requires that experts in both clinical content and guideline methodology who are external to the organization that has developed the guidelines review them, but it does not provide detailed specifications for the review. RAND researchers examined a set of guidelines for common, expensive diagnostic testing and treatment for musculoskeletal disorders of the spine and extremities. The researchers gave these guidelines high scores using the AGREE instrument. Then they asked a panel of providers (recommended by their specialty societies as leaders in their clinical field) to rate the relevance of the guidelines to common clinical situations and consistency with clinical understanding of existing evidence and expert opinion. The expert panelists thought that the guidelines did not address common clinical situations, and reported that they often disagreed with the experts’ interpretation of published evidence and clinical experience. In the face of findings of this nature, it is not surprising that guideline adherence in real-world situations may be imperfect, or that implementation of guidelines in healthcare systems may be met with resistance.

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Efficiency, Evidence-based Requirements, Quality of Care Convergence, Helen Blumen, Lynn Nemiccolo

What follows is excerpted from “The convergence of quality and efficiency.” Click here to read the full paper or view citations.

Clearly, acquisition of high-quality evidence is essential to improving the quality of healthcare and reducing costly errors. Tools such as evidence-based guidelines exist to deliver the evidence to providers so they can easily use the information in clinical practice. Such guidelines can reduce the variation in care generated by differences in practice style, especially when uncertainly about the best treatment approach exists.

Independently developed, evidence-based guidelines can standardize the delivery of healthcare to best practices. This means that only efficacious treatments and tests are recommended, and only for patients likely to benefit from them. It also means that patients are treated in hospitals only for as long as needed, reducing the hazards of infections, falls, and medication errors. By recommending care for which there is evidence of appropriateness, and dissuading care that the evidence shows is inappropriate, providers can improve quality and efficiency at the same time.

Of course, acceptance of guidelines and wide implementation depend on providers’ confidence that the guidelines are developed by truly independent arbiters of what defines appropriate healthcare. To date, unfortunately, acceptance has been slow to develop. Thus, the promise of guidelines to influence practice style and change providers’ behavior has not been realized.

One reason for lack of acceptance is that the evidence base is incomplete, and multiple competing standards exist, leading at times to uncertainty about best care practices. A natural question to ask, then, is, “Are there ‘standards for the standards’”? How can policymakers, payors, and providers determine which guidelines and standards should be adopted? In response, guideline developers have created a set of standards, the AGREE instrument, by which to judge the quality of healthcare guidelines.

Cost, Efficiency, Quality of Care, Reform Convergence, Helen Blumen, Lynn Nemiccolo

What follows is excerpted from “The convergence of quality and efficiency.” Click here to read the full paper or view citations.

The Appraisal of Guidelines Research & Evaluation (AGREE) instrument consists of 23 items organized into six domains, each of which captures a separate dimension of guideline quality. The domains are scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, applicability, and editorial independence.

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Cost, Efficiency, Evidence-based Requirements, Quality of Care, Reform Convergence, Helen Blumen, Lynn Nemiccolo

What follows is excerpted from “The convergence of quality and efficiency,” by clinicians Helen Blumen and Lynn Nemiccolo. 

In contrast to how inappropriate care often leads to worse healthcare outcomes, there is evidence that appropriate healthcare leads to better outcomes. An examination of the use of tonsillectomy is a good example of the positive relationship between appropriateness and efficacy. Tonsillectomy is the most common surgical procedure performed in children, and a randomized, controlled trial has demonstrated its efficacy in decreasing the incidence of throat infection. These results justify the choice of tonsillectomy for children who met the very stringent eligibility criteria of clinical trials.

A subsequent clinical trial, conducted by the same researchers, considered children who were less severely affected by throat infections. This study found that both the control and surgical groups had relatively low rates of severe infection. And of those children treated surgically, nearly 8% had complications.

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Cost, Efficiency, Evidence-based Requirements, Quality of Care Convergence, Helen Blumen, Lynn Nemiccolo

What follows is excerpted from “The convergence of quality and efficiency,” by clinicians Helen Blumen and Lynn Nemiccolo. 

Evidence has accumulated showing that more healthcare expenditures do not always mean better care. In some cases, healthcare interventions do not improve health. In other cases, they may worsen health, even to the point of causing death.

Clinical examples of this phenomenon abound. For instance, results of one large randomized trial conducted in the United States showed that screening for prostate cancer using blood testing for prostate-specific-antigen (PSA) plus digital rectal examination did not change the death rate from the disease. A European study, published on the same date, concluded that PSA-based screening reduced the rate of death by 20%, but at the cost of significant overdiagnosis. What should we take from these seemingly conflicting results? The first study suggests that prostate cancer screening has no benefit in terms of outcomes, and presumably is an inefficient use of healthcare dollars. While the second study may suggest some benefit, the 20% reduction is offset by the accompanying cost and risk of invasive diagnostic testing for men who do not have prostate cancer. Another way of looking at the results of the second study is that, in order to prevent one death, 1,410 men would need to be screened to find 48 additional cases of prostate cancer for treatment.

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Cost, Efficiency, Quality of Care Convergence, Helen Blumen, Lynn Nemiccolo

David Brooks penned an editorial yesterday about healthcare cost inflation and how the current health reform efforts do not go far enough in addressing this crucial problem. Cost inflation is indeed a big problem—this year’s 7.6% increase is the lowest in years yet is still staggering, amounting to a $1,162 increase in costs for families this year.

How do we reverse the cost curve? A look at the sources of wasteful spending can help clarify the problem and inform a solution. What follows is excerpted from a new report by Helen Blumen and Lynn Nemiccolo.

There are three types of inappropriate care that have a negative impact on quality and efficiency in the U.S healthcare system: overuse, underuse, and misuse of care.

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Efficiency, Quality of Care, Reform cost inflation, Helen Blumen, Lynn Nemiccolo

Milliman clinicians Helen Blumen and Lynn Nemiccolo have published a new healthcare reform research report about the relationship between improving healthcare quality and finding new efficiency in the delivery of care.

Q: How much waste is present in today’s healthcare system?

A: Milliman’s actuaries have concluded that the amount of waste in the U.S. healthcare system is in excess of 25% of total healthcare spending, or more than $600 billion in 2008 dollars. These estimates square with the numbers put forward by other prominent sources.

Q: How does Milliman define waste?

A: Milliman has defined inefficiency or waste within the healthcare delivery system as unnecessary, redundant, or ineffective treatment (and the costs associated with such treatment). This includes treatment that is contrary to, or not demonstrably associated with, healthcare quality and outcomes. Looking beyond the care delivery system, inefficiency also includes costs that are not demonstrably associated with a sound approach to enabling full access for everyone to appropriate healthcare coverage.

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Convergence, Efficiency, Quality of Care Convergence, Helen Blumen, Lynn Nemiccolo, Milliman Care Guidelines