Tuesday, December 9, 2008

Some Thoughts on Quality

Recently in response to a post (somewhat tongue in cheek) about renaming primary care physicians "prehospitalists" Mathew Mintz commented:

Don't like it. Pre-hospitalist implies that everyone will eventually go to the hospital. Though we certainly do our best to prevent patients from needing hospitalization, this doesn't capture the bulk of what we do: screening, prevention, counselling, chronic disease management,etc.

Mathew's comment really made me think. While he is right....keeping people out of the hospital does not describe the bulk of what we do. He misses the point. Our ability as primary care physicians to cut down on admissions may be the single best indicator of physician quality.

The physician who keeps his patients out of the hospital probably:

Is an excellent diagnostician
Manages chronic disease states well
Is timely
Calls his patients back promptly
Likely is highly active in screening and prevention
Sees urgent appointments on the same day

The list goes on and on. Sure there has to be an adjustment for patient age, socioeconomic status, and overall health of the patient population (a clinician who treats esrd, end stage copd, end stage cad...will have a higher hospitalization rate then others).

But I like hospitalization rate as an overall indicator. It certainly is hard to game this one...unlike the other quality indicators that have been used (a1c, colonoscopies, etc.).

So what do you think?


Dr. Matthew Mintz said...

"Our ability as primary care physicians to cut down on admissions may be the single best indicator of physician quality."

I once again have to respectfully disagree. Admission rate is both a valuable and hard outcome. Given that cost of health care is through the roof, and one of the biggest contributors to health care costs is hospitalization, using this as a benchmark is thus very important.
However, most patients dont' get hospitalized. The average primary care physician with a panel of 2500 active patients likely has one to two patients in the hospital per month. This is why the hospitalist movement makes so much sense: the PCP (yes, I hate the term too) is much more efficient and effective in managing chronic diseases which they see regularly, but less so for the hospitalized patient which they only see a handful a year and thus often rely heavily on consultants.
Death is another hard outcome, but death is inevitable.
We in primarily care try to prevent morbidity and mortality on a daily basis. This is the bulk of what we do. Whether it is the screening colonoscopy for the otherwise health 50 year old, or lowering the A1c of the type 2 diabetic. Reduced morbidity leads to improved quality of life.
How to brand this is another issue (of which I still don't have the solution).

Jordan Grumet said...

Matthew...I hear you and see your point. By the way...1-2 hospitalizations per month? Wow that's pretty good. We have a lot more hospital work then that! Possibley becuase I take care of an elderly population. Over 50 percent medicare (lots of people in their nineties) and very few below the age of 50. On an aside I will never give up hospital care if I have the choice. I really do enjoy it!