AGA Task Force on Quality in Practice: A National Overview and Implications for GI Practice
2005; Elsevier BV; Volume: 129; Issue: 1 Linguagem: Inglês
10.1053/j.gastro.2005.05.028
ISSN1528-0012
AutoresMartin Brotman, John I. Allen, Stephen J. Bickston, Donald R. Campbell, Jeanne M. Huddleston, Laura E. Peterson, P Schoenfeld, Cary Sennett, Jeff R. Willis,
Tópico(s)Economic and Financial Impacts of Cancer
ResumoIn an effort to improve the digestive health of patients and to quantify and demonstrate the value provided by gastroenterologists, the Governing Board of the American Gastroenterological Association (AGA) convened a Quality in Practice Task Force. The AGA Governing Board, concerned about inadequate focus on clinical quality improvement nationwide, charged the Task Force to address the following: 1Review emerging national quality standards because they might be applicable to gastroenterology (GI).2Identify the highest priorities for our field and tactics to address them.3Define key quality of care indicators in the treatment of digestive diseases.4Determine how the indicators/outcomes will be measured.5Assess the feasibility of AGA increasing adherence to the indicators. (This may include adherence to existing AGA or other relevant position statement protocols.)6Assess how adherence, or increased adherence, to the indicators could be linked to improved reimbursement for gastroenterologists.7Identify programs and/or tools AGA can offer its members to assist them in increasing adherence to quality indicators. The Task Force urges the AGA to make its interest and activities in quality and safety very visible to demonstrate that gastroenterologists add value through improved outcomes, increased efficiency, and enhanced cost effectiveness. This report summarizes the Task Force's review of the marketplace, and its findings and recommendations. The United States' health care delivery system, although one of the most sophisticated in the world, does not always do what is best for patients. Quality health care is multidimensional; difficult to define and measure. Numerous potential stakeholders, including the patient, family, treating physician, referring physician, payor, employer, regulatory agencies, health care interest groups, and malpractice attorneys (as examples) are involved in every physician-patient interaction. Comprehensive quality measures that will satisfy all stakeholders are difficult to define and often reflect compromises among competing interests. Despite these complexities, consensus is emerging that poor quality in the health care system contributes to adverse patient outcomes and increases overall costs. Employers and governments, who pay the majority of health care costs, are escalating their demands for quality benchmarks, outcomes reporting, and a link between quality and reimbursement (Pay for Performance [P4P]). Employers will educate their employees to seek care from providers that deliver high-quality care at reasonable costs. This escalation was catalyzed by the Institute of Medicine (IOM) reports, "To Err Is Human"1Kohn L.T. Corrigan J.M. Donaldson M. Institute of Medicine, Committee on Quality of Health Care in AmericaTo Err is Human Building a Safer Health System. National Academy Press, Washington, DC1999Google Scholar and "Crossing the Quality Chasm,"2Institute of Medicine, Committee on Quality of Health Care in AmericaCrossing the Quality Chasm A New Health System for the 21st Century. National Academy Press, Washington, DC2001Google Scholar demands by organizations such as the Leapfrog Group (see Acknowledgement section) for increased accountability and higher quality, media focus on errors in health care and an increasingly consumer-driven health care marketplace supported by information technology. Payors' increasing commitment to measuring and supporting providers of cost-effective, high-quality care is well summarized by the following excerpt from the 2004 America's Health Insurance Plans Board of Director's Statement of Priorities:3A Commitment to Improve Health Care Quality, Access, and Affordability. America's Health Insurance Plans 2004 Board of Directors Statement. Accessed January 14, 2005. http://www.ahip.org/content/default.aspx?bc=39}343}428.Google ScholarTo enhance the health of all Americans, make evidence-based medicine the standard for health care and advance quality and transparency to improve outcomes, eliminate errors, reduce costs, and help consumers make informed health care choices; and by comments (February 10, 2005) by members of the House Ways and Means Committee that they … "are ready to scrap Medicare's payment formula and consider tying payments to physicians to their job performance." This report focuses on patient safety-medical errors and adverse events. The IOM defined medical error as "the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim." An adverse event was defined as "an injury caused by medical management rather than by the underlying disease or condition of the patient."1Kohn L.T. Corrigan J.M. Donaldson M. Institute of Medicine, Committee on Quality of Health Care in AmericaTo Err is Human Building a Safer Health System. National Academy Press, Washington, DC1999Google Scholar As many as 44,000 to 98,000 people die in hospitals each year as the result of medical errors, making medical errors the 8th leading cause of death in this country—higher than motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516). Imagine the response of the American public if the commercial airline industry reported similar results—the loss of an almost-fully loaded 747 each weekday of the year. Medical errors carry a high financial burden not only in terms of health care costs but also lost income, lost household production, and disability. The IOM report estimates that preventable medical errors cost the United States approximately $17 billion per year, likely an underestimate since most studies are from hospital-based patients. A nonquantifiable cost is the loss of trust in the health care delivery system. The Task Force urges the AGA to offer its practice guidelines recommendations to electronic medical records (EMR) vendors to provide web links for clinical order sets. The American Medical Informatics Association or Healthcare Information Management Systems Society could provide expert advice on such linkages. 1Recognizing the importance of patient safety, AGA should endorse national patient care safety standards and define safety priorities for GI practice. The AGA Clinical Practice and Economics Committee should determine methods for education of members on the topic of patient safety.2To reduce avoidable medical errors and adverse events, AGA should partner with EMR vendors to link clinical order sets to recommendations contained in AGA practice guidelines.4Perlin J.B. Kolodner K.M. Roswell R.H. The Veterans Health Administration quality, value, accountability, and information as transforming strategies for patient-centered care.Am J Manag Care. 2004; 10: 828-836PubMed Google Scholar In this report, the IOM's Committee on Quality of Health Care in America suggested fundamental innovation and redesign of our health care delivery system. Table 1, Table 2 summarize the proposed Aims and Rules for the 21st century health system.Table 1Six Aims for the 21st Century Health Care System ("STEEEP")Health care should be:SafeAvoiding injuries to patients from the care that is intended to helpTimelyReducing waits and sometimes harmful delays for both those who receive and those who give careEffectiveProviding services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse, respectively)EfficientAvoiding waste, including waste of equipment, supplies, ideas, and energyEquitableProviding care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic statusPatient-centeredProviding care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions Open table in a new tab Table 2Rules for Health Care RedesignCurrent approachNew ruleExplanationCare is based primarily on visitsCare is based on continuous healing relationshipsPatients receive care whenever they need it—24 hours a day, every day. Access is not just face-to-face visits, but also utilizes technology for information exchangeProfessional autonomy drives variabilityCare is customized according to patient needs and valuesThe system is designed to meet the most common types of needs, but has the flexibility to respond to individual patient needsProfessionals control careThe patient is the source of controlPatients should be given the information necessary to participate in shared decision makingInformation is a recordKnowledge is shared and information flows freelyPatients should have easy access to their own medical recordsDecision making is based on training and experienceDecision making is evidence-basedCare should be based on scientific knowledge, and there should not be any illogical variation in care deliveredDo no harm is an individual responsibilitySafety is a system propertyTo reduce risk for patients, systems must be designed to prevent and mitigate errorsSecrecy is necessaryTransparency is necessaryInformation should be provided to patients so that they may make informed decisions. This includes practice's performance on evidence-based practice and key safety indicatorsThe system reacts to needsNeeds are anticipatedSystem should anticipate patient needsCost reduction is soughtWaste is continuously decreasedHealth care should not waste resources or timePreference is given to professional roles over the systemCooperation among clinicians is a priorityProviders and institutions should collaborate to ensure best exchange of information and coordination of care Open table in a new tab Most physicians associate quality of care measurement in terms of the clinical care they provide for an individual patient. Increasingly, quality is defined by the consumer/payor, focusing on aspects of care delivery that physicians have traditionally overlooked such as access, wait time, office staff interaction, patient education, comfort during procedures, and cost. In the future, quality measures should reflect both perspectives (traditional physician perspective and those important to patients.) Concerned about rising costs and perceived variability of the quality of medical care received by their employees, large American companies are collaborating to support a number of initiatives, including Mercer Care's Focused Purchasing Initiative and the Leapfrog Group. All are designed to improve the quality of health-care services in the United States. Future directions have been articulated clearly by the National Business Group on Health (NBGH), a coalition of the largest US employers dedicated to improving the return on investment that employers commit to their employee benefits. (The NBGH website [www.wbgh.com] describes their Institute on Health Care Costs and Solutions and lists the two tracks they will use to implement change.) Track One focuses on pragmatic solutions to controlling costs, based on best practice and best ideas, which can be implemented in the near term. Track Two centers on strategic and structural changes in the health care delivery system that potentially will change the health care value equation over the long term. Pursuant to the first Track, the NBGH has directed large national health plans to develop specific measures to assess quality at the physician level. They have mandated that plans have measurement tools in place by January 2006 in order to continue to bid/compete for their benefit business. In turn, health plans have requested that physician groups (specifically specialty societies) develop specific clinical measures derived from evidence-based guidelines. If specialty societies and other clinical experts do not develop such measures, plans will develop their own, using claims data and clinical guidelines of their choosing. 3AGA should accept leadership responsibility for assuring uniform, documentable excellence in quality of clinical care and GI practice by forming a Center for Quality (CQ), which in collaboration with the Committee on Clinical Practice and Economics will: aSupport the 6 major aims for health care set forth by the IOM's Crossing the Quality Chasm report.bConduct continuous review of emerging national quality and patient safety standards as they might be applicable to GI diseases.cIdentify key quality of care indicators in the treatment of digestive diseases and how they will be measured.dDevelop programs and tools for members and training programs to assist them in implementing evidence-based guidelines and measuring and reporting adherence to quality indicators.eDevelop patient education materials to ensure that patients have appropriate expectations regarding high-quality, patient-centered, evidence-based care. At least 70 organizations and 40 private managed care organizations (MCOs)5http://ir.leapfroggroup.org/compendiumselect.cfmGoogle Scholar are focusing on quality initiatives in health care. Seeking possible role models, the Task Force reviewed emerging national quality programs to determine their applicability to GI practice, eventually focusing on the National Diabetes Quality Improvement Alliance (NDQIA), American Board of Internal Medicine (ABIM), National Committee for Quality Assurance (NCQA) [including the Health Plan Employer Data and Information Set (HEDIS)], Department of Veterans Affairs (VA) health care system, Department of Defense medical systems, and a number of managed care organizations and leading academic institutions. Many current quality initiatives are focused on common, costly chronic diseases with measurable quality outcomes such as diabetes mellitus, cardiac disease, and stroke. Few focus significant attention on digestive disorders. A model for consideration by AGA is the Diabetes Management Initiative implemented through the NDQIA. This is a coalition of the American Diabetes Association, NCQA, the Centers for Medicare and Medicaid Services (CMS), the American College of Physicians, and additional organizations that are charged to evaluate, recommend, and maintain evidence-based diabetes management performance and outcomes measures by which managed care plans, physicians, and clinics can be assessed. The goals of the NDQIA are to improve care of patients with diabetes by identifying physicians/groups providing quality care and to motivate other physicians/groups to improve and document their care. The initiative includes a Diabetes Physician Recognition Program, an assessment instrument utilized by payors, and monetary awards for excellence. The ABIM seeks to insure quality in GI practice through its board recertification program, which requires completion of 5 open-book self-evaluation examinations. This component may include collection of patient/peer satisfaction and practice improvement data in the near future. Additionally, practice improvement modules (PIMs) require review of a series of medical records in order to determine if a physician is following established high-quality practices in the management of specific disorders. Currently, PIMs exist for cardiac care and disease prevention, but not for GI-related topics. Also required is completion of a proctored examination. At the present time, there are no data linking successful completion of ABIM recertification in gastroenterology to quality of gastroenterology care. The process for gastroenterologists to maintain their ABIM certification is likely to become more challenging in the near future. It is also likely that employers, managed care organizations, and the public will rely on Board Certification as an indicator of quality for gastroenterologists. Recent studies6Choudhry N.K. Fletcher R.H. Soumerai D.B. Systematic review the relationship between clinical experience and quality of health care.Ann Intern Med. 2005; 142: 260-273Crossref PubMed Scopus (1053) Google Scholar, 7Weinberger S.E. Duffy F.D. Cassel C.K. "Practice makes perfect"… or does it?.Ann Intern Med. 2005; 142: 302-303Crossref PubMed Scopus (24) Google Scholar suggest that physician practice quality (though not specifically gastroenterologists' practice quality) declines over physicians, practice lifetime. This suggests that medical societies will want to encourage and support their members' efforts to demonstrate that they are maintaining their professional knowledge and skills. The Veterans Affairs Medical Centers (VAMC) tracks the percentage of veterans who receive appropriate colorectal cancer screening, with individual VAMCs determining their preferred screening method. They do not track appropriate colon polyp surveillance rates. Nationwide, the system tracks the percentage of veterans who see a subspecialist within 30 days of request. Currently, no quality indicators specifically for the practice of gastroenterology exist in the military medical system. The NCQA coordinates collection of quality care indicators through their HEDIS program. HEDIS quality of care indicators may be used by purchasers and consumers of health care to choose among health plans. Currently, no HEDIS indicators address GI topics, other than colorectal screening-fecal occult blood testing every 12 months, flexible sigmoidoscopy or barium enema every 5 years, or colonoscopy every 10 years. These focus on the performance of primary care physicians. Kaiser Permanente of Northern California tracks the percentage of patients who undergo colorectal cancer screening, but not colon polyp surveillance. Among leading academic institutions, the Mayo Clinic (Rochester, MN) tracks multiple quality measures in the performance of colonoscopy, including the percentage of colonoscopies with successful cecal intubation, anus to cecum insertion time, cecum to anus withdrawal time, patient discomfort level, average dose of sedation medications utilized, and complication rates. Each endoscopist is provided with an annual report that includes personal quality measures for colonoscopy and the mean results for the Division of Gastroenterology. Although JCAHO does not promote any specific GI quality initiatives, during JCAHO evaluations of endoscopy centers, they may investigate if: aEndoscopists have documented qualifications for use of moderate sedation;bPre-procedure sedation evaluation is completed;cPatients are informed about preparation, the results of their procedure, and are referred seamlessly to other appropriate services after their procedure. In summary, few GI-focused quality initiatives currently exist, leaving a clear opportunity for AGA to take the lead in their coordinated development. 4AGA should establish and lead a coalition to develop and implement evidence-based quality measures in the management of GI disease. Existing models such as those used by the NDQIA and American College of Cardiology (ACC) should be explored.5In view of the potential for using certification and recertification as criteria for quality of care assessment, credentialing, and reimbursement, AGA's Public Policy Committee should become involved in discussions of such issues with ABIM and other relevant agencies influencing these decisions. Furthermore, AGA should explore with ABIM opportunities to document the relationship between certification and quality of care, so as to maximize the value of ABIM Certification and Recertification to members of AGA and the patients we serve. In a highly competitive, informed-consumer driven health care marketplace, the value of health care services will be increasingly influenced by measurable quality and affordable costs. Payors, influenced by consumers, will require benchmarked outcomes measurement and reporting, and justifiable costs. "Usual, customary, and reasonable fees" as the foundation for reimbursement is rapidly being replaced by the value equation (Value=Quality/Price). In the past, most measures of quality utilized by health plans, governments, and accrediting bodies focused on hospitals and physician groups and to a lesser degree, on individual practitioners, but not particularly specialists. MCOs, insurers, and accreditation bodies are now focusing on physician-specific parameters as they select individual providers for their networks and themselves. Although numerous initiatives have been developed and implemented by health plans throughout the country to enhance the quality of care their members receive, virtually none of these is specific to gastroenterology, and none focus on the practice of gastroenterologists. In the past, health plans purported to assess physician "quality" by "profiling" and "benchmarking" physicians using readily available administrative information as surrogate measures of quality (eg, length of stay, cost of hospitalization, utilization, years in practice, board certifications, licensure sanctions, and liability claims). However, these measures, when aggregated into a score, were more representative of utilization (and possibly efficiency) than quality. Measures of physician clinical performance are better proxies for quality than these other surrogates. Physician clinical performance is better measured by outcomes of care and/or physician adherence to evidence-based processes of clinical care. Currently, the most frequently used quantifiable factors in private sector quality initiatives evaluate: 1Patient satisfaction2Access to care3Performance (eg, clinical processes such as those measured by HEDIS)4Use of evidence-based clinical guidelines5Information technology measures (eg, information technology connectivity) Other factors used by health plans to grade quality include: staff and patient complaints, peer review, patient turnover, and patient education initiatives. Other more indirect measures of quality include generic prescription patterns and affordability/cost efficiency. Specialty quality of care assessment has been focused on measurable discrete care episodes such as cardiovascular surgery, cardiology (acute myocardial infarction and congestive hearth failure), diabetology, and pulmonary (pneumonia). It is difficult to predict the quality measures that will be focused on clinical gastroenterology practice. To date, little attention has been paid to quality of care assessment in gastroenterology practice. It appears that evaluation of quality in gastroenterology by health plans will focus on key care processes rather than health outcomes and will include measures of: 1Patient satisfaction/experience2Service quality/access to care (appointment availability, waiting room time, procedure-related experiences)3Use of evidence-based medicine guidelines and clinical processes4Use of generic medications (eg, proton pump inhibitors) Evaluation and measurement of performance by individual gastroenterologists through chart review and electronic data submission will likely be delayed since technology integration and comprehensive measurements for clinical processes have not been developed. Using the 5 aforementioned categories for measuring quality, many health plans have already implemented direct and indirect incentives to physicians and patients to reward quality care, most being confined to primary care physicians. Some provide direct financial incentives to physicians or physician groups, with reimbursement increases or incentive payments in the 5%–15% range (P4P). Others reduce patient co-payments for selected physicians (effectively directing patients to physicians and physician groups with high-quality scores). Some programs have tiered fee schedules, reimbursing high-quality physicians or physician groups at a higher rate. Increasingly, public disclosure of outcomes and costs is affecting patient selection of care.8Frisch B, Gallagher T. National Trends in Healthcare Consumerism: The Quality-Conscious Consumer. Third Annual Report to Solucient, LLC. September 2004.Google Scholar Less commonly used incentives include tiered referral systems in which consumers may bypass the referral process to access the highest quality physicians. Some organizations provide additional resources for information technology connectivity for physicians and practices that exceed benchmarks. At least 17 health plans are already measuring and reporting quality, as well as providing incentives for quality care.9Physician Quality Performance Measurements.Association of American Medical Colleges Keynotes on Health Care. 2004; 35: 1-15Google Scholar, 10Accessed January 14, 2005. http://www.leapfroggroup.org/ircompendium.htm.Google Scholar 6The AGA should facilitate the development and distribution of materials to assist gastroenterology practices in evaluating quality. An AGA Quality Package would assure standardized data collection and would include tools to evaluate customer satisfaction, service quality/access to care, and information on measurable evidence-based guidelines, and clinical processes.7AGA should identify physicians and groups that take pride in, evaluate, and document high-quality patient care and patient safety initiatives and disseminate their best practices.8AGA should create a quality resource section on its website to include links to relevant articles, services, and tools. In order to learn from the experience of other professional societies in quality assessment and improvement, the Task Force contacted the American College of Surgery (ACS), the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), the American Society for Gastrointestinal Endoscopy (ASGE), the American College of Gastroenterology (ACG), the American Association for the Study of Liver Diseases (AASLD), the Society of Gastrointestinal Nurses and Associates (SGNA), the American Medical Informatics Association (AMIA), the Society for Surgery of the Alimentary Tract (SSAT), the American Society for Bariatric Surgery (ASBS), and the American College of Cardiology (ACC). The responses revealed, unsurprisingly, that all societies uniformly embrace the concept of quality. However, the degree to which the concept is translated into tangible activity was highly variable. A majority of the surveyed societies offer position papers and practice guidelines, but few offer any infrastructure to facilitate their implementation or track outcomes. Some societies consider quality to be part of the job description of their members, while others have robust national programs in place to allow tracking of outcome measures. A subset of the societies (most notably the ACC, ADA, ACS, and SAGES) has succeeded in creating national databases to track outcomes. One example is the National Surgery Quality Improvement Program (NSQIP), which began with Veterans Administration hospitals and has now expanded to approximately 50 non-VA hospitals. As reported at their website (http://www.acsnsqip.org/program/information.asp), the NSQIP prospectively collects data on 40 preoperative risk factors, 20 postoperative complications, and mortality on all patients undergoing major operations under general, spinal, or epidural anesthesia. The data are collected, validated, and transmitted by a highly trained surgical clinical nurse reviewer (SCNR). Data are entered via an Internet-based system, and transmitted to the ACS NSQIP Data Analysis Center at the University of Colorado Health Outcomes Program where software programs check for completeness, consistency, and out-of-range values. Potential errors are identified and corrected, if needed, after consultation with the participating site. The data are analyzed and an O/E ratio (observed number of deaths or complications divided by the expected number) is calculated for each facility. An O/E ratio greater than 1 indicates that the hospital is experiencing more deaths and complications than expected. An O/E ratio less than 1 indicates that the hospital is having better results than expected on the basis of its patient characteristics. Benchmark reports are available on line. A more complete report is distributed to participating centers annually. These reports allow each facility to compare its volume, patient risk profiles, and risk-adjusted outcomes to the national average and to the averages in their peer group of hospitals. Once a year, panels review the non-identified data and make recommendations for specific hospitals. Hospitals with consistently better outcomes are encouraged to share with the ACS NSQIP the processes and structures that they consider to have contributed to their success. The Task Force agreed that the evolving national mandate for assessment of quality of clinical care makes it essential and urgent that AGA take the lead in developing a national outcomes database. Furthermore, the initial focus for such a database in gastroenterology should be those conditions highest on the list of the 2001 Gastroenterology Burden of Disease Report,11American Gastroenterological AssociationThe Burden of Gastrointestinal Diseases. The American Gastroenterological Association, Bethesda, MD2001Google Scholar namely GERD, gallbladder disease, colorectal cancer, and peptic ulcer disease. Several tangible hurdles exist to creating such a database, namely funding, hard- and software, the role of minimal standard terminology, and the appropriate model for data entry. By using lessons learned from programs like the NSQIP, AGA may be able to shorten some evolutionary steps in tracking quality measures in gastroenterology. 9The AGA should utilize ACC, ACS, and SAGE's databases as role models for our own data collection. A quality measure (also known as quality indicator) is a mechanism that enables the user to quantify the quality of a selected aspect of care by comparing it to a criterion.12http://www.qualitymeasures.ahrq.gov/resources/glossary.aspx.Google Scholar Quality measures typically address one or more of the IOM STEEEP domains, assessing the
Referência(s)