Topics in Health: Lessons From The Field
How to Report on Health Care Quality
Like the residents of the mythical Lake Wobegon, patients in surveys regularly rate their doctors as above average. In general, patients rely on personal recommendation from friends to choose doctors. Also, they prefer caregivers whom they have previously seen over those who are rated higher on quality measures.
Since patients find it notoriously difficult to judge the quality of their medical care, it appears, they often give up trying.
As nationwide efforts to improve the quality of our medical care have gotten underway, hospitals, insurers, and other groups increasingly measure health care quality. The emerging data are quite sobering and offers tremendous opportunities for good health reporting, analysis, and public education.
Unfortunately, popular coverage of health care quality often features "Best Doctor" lists that hinge on a particular physician's cult of personality, rather than measured quality outcomes. Here is a quick primer for journalists looking to do better reporting on health care quality:
Moving beyond the "best" lists
Now that many authorities are measuring doctors' performance, it is clear there are major variations in practice patterns and quality among health providers. These data are publicly available if you know where to look.
For example in 2001, the Institute of Medicine published a magisterial report on quality problems in medical care (summarized succinctly here). Subsequent studies from RAND Corporation have further dramatized the problem.
In 2007, a team of RAND researchers reviewed thousands of pediatric medical records from 12 major American cities and found that fewer than half of children got proper medical care during doctor visits, for problems are basic as management of diarrhea, sexually transmitted diseases, and asthma. In 2003, another RAND study of adult outpatient care found similar problems, with almost half of all patients failing to get recommended care for diabetes, cholesterol problems, headaches, pneumonia, and hip fractures.
Examining quality in your state
Many state health departments also now track individual and hospital performance on several quality indicators, such as death rates from heart surgery, the risk of patients getting an infection, leaving stuff in patients during surgery, and so on. (In general, state health departments focus on potential medical errors, rather than adherence to standard guidelines.)
For example, Minnesota has an excellent searchable database of many foul-ups here and New York remarkably released hospital and surgeon-specific death rates for heart surgery here. A nice round-up of various state efforts to measure medical quality can be found here.
These resources offer a treasure trove of local data for enterprising reporters, especially in an era in increasing patient choice and consumer-driven health.
Some hospitals have taken the lead in analyzing their own care patterns and now are reporting quality measures on everything from pediatric health to dermatology care. The Cleveland Clinic, in particular, has an widely praised program where all manner of health outcomes are tracked publicly and made available online, including their autism screening rates, complications from surgical procedures and hundreds of other measures.
Beginning in 1997, the federal government though Medicare also created a large database called HEDIS, which tracks a small number of key performance measures. Numerous researchers now analyze the dataset, and have found fascinating trends in proper and improper use of mammograms, dialysis, and eye exams. A user-friendly federal web site for these measures is here. (Using HEDIS data, I wrote about racial disparities in health quality, for example.).
As a result, many insurers and hospitals are considering tying payment to better performance on such measures. There are also major variations in medical costs nationwide, as documented by the user-friendly, searchable Dartmouth Health Atlas, but that's a somewhat different issue.
Finally, federal government agencies like the Centers for Disease Control also mandate that certain doctors, such as fertility specialists, must report their success rates and patient volume. (In other words, it's easy to tell what centers do a good and poor job in these specialties.) These reports about medical quality are also public and can support analytical reporting on numerous topics.
Mine "gold standard" treatment guidelines for stories
To measure the quality of medical care, one must first have a "gold standard" of proper medical practice, known as a practice guideline (for example, how to properly treat a heart attack). These guidelines will increasingly control medical care.
Because medical care is so complicated - tens of thousands of studies are published annually - no doctor can keep up. As a result, several groups have assumed the responsibility of combing through the data to help doctors. The existence of these guidelines is often very surprising to the lay public, since they serve as a sort of Rosetta stone for all manner of medical issues.
The federal government maintains a public archive at the National Guideline Clearinghouse, which is an excellent starting point. Here, reporters and the public can find recipes to take care of everything from ingrown toenails to complex heart problems.
In addition, several federal agencies, like the National Heart Lung and Blood Institute, compiles detailed and data-driven reports on the proper treatment of conditions like asthma, or the prevention of urinary tract infections. These are essential for reporters interested in a specific disease.
Good subspecialty organizations, like the American Heart Association, produce detailed guidelines-essentially, recipes for care-that can help reporters understand the recommended treated of many problems. Similar guidelines are produced by many specialty societies.
Of course, private interest groups and companies also produce clinical guidelines, and their motives may be clouded by commercial pressures. For example, in 2006, a group of Texas cardiologists wrote a guideline that promoted expensive CT scans as a screening test for more widespread use of statin medications, and published their findings with grant support from a drug manufacturer.
As a result, reporters should also pay careful attention to who's writing the guidelines. (For a critical look at some guidelines, see here.)
From database to story: some ideas
There are many under-reported and potentially fascinating stories on health care quality. Such stories could take a variety of angles, ranging from consumer health focused pieces (so-called "news you can use") to larger federal and state policy pieces. Here's a brief list of ideas to get started.
1. Why do some hospitals perform so much better than others, even in the same locales? Do their advertising materials bear any relation to their reported quality measures?
2. How do people choose their doctors? Does quality information ever really change their minds? Why or why not? (Here's one article I wrote about how a former president probably didn't make the best choice for his doctor.)
3. Why do certain specialties, like cardiology and cancer, outpace others like psychiatry and orthopedics, for example, in measuring and improving quality? How does medicine compare to other industries, like automobile manufacturing, in this arena?
4. How should an infertile woman considering treatment choose a good specialist to help her get pregnant? (This could be expanded to any number of medical conditions, like cancer, heart disease, asthma, or diabetes.)
5. How well do commonly used consumer web sites, like WebMD, Wikipedia, and others, adhere to the "ideal care" outlined in respected clinical practice guidelines used by doctors?
6. How well do doctors in your area practice medicine? One could survey various patients in your area to see how well their care conforms to guidelines. Or, for the truly enterprising reporter, consider visiting various doctors or hospitals like a "secret shopper" and assess how well they do with medical problems like migraine headaches or other standard problems.
7. Have quality measures affected personnel decisions by major hospitals (for example, do they ever fire people who seriously underperform or have higher rates of serious complications)? Why or why not?
8. Why have some states or hospital systems taken a much more aggressive lead in demanding better quality medical care than others? What are the politics of this new kind of transparency? Who stands to win and who stands to lose with greater accountability?
9. What are the ethical responsibilities of hospitals to report their success, volume, and complication rates from procedures like cardiac or other major surgeries to patients at the point-of-service, especially if a nearby competitor performs better?
Darshak Sanghavi, the chief of pediatric cardiology at the University of Massachusetts Medical School, writes and speaks frequently on NBC's Today show and NPR's All Things Considered. He is also Slate's health care columnist, a contributing editor at Parents, and the author of A Map of the Child: A Pediatrician's Tour of the Body.