THCB

Quality or value? A Measure for the 21st Century

One of the founders of the evidence-based medicine movement, Muir Gray

Fascinating, how in the same week two giants of evidence-based medicine have given such divergent views on the future of quality improvement. Here (free subscription required), Donald Berwick, the CMS administrator and founder and former head of the Institute for Healthcare Improvement, emphasizes the need for quality as the strategy for success in our healthcare system. But here, one of the fathers of EBM, Muir Gray, states that quality is so 20th century, and we need instead to shine the light on value. So, who is right?

Well, let’s define the terms. The Merriam-Webster dictionary defines quality as “the degree of excellence.” The same source tells us that value is “a fair return or equivalent in goods, services or money for something exchanged.” To me “value” is a holistic measure of cost for quality, painting a fuller picture of the investment vis-a-vis the returns on this investment. What do I mean by that?

Simply put, the idea behind value is to establish what is a reasonable amount to pay for a unit of quality. Let’s take my used 1999 VW Passat as an example. If my mechanic tells me that it needs to have some hoses replaced, and it will cost me under $100, and the car will run perfectly, I will consider that to be a good value. However, if my transmission has fallen out in the middle of Brookline Ave. in Boston (really happened to me once, many years ago and with a different car), and it will cost me $5,000 to fix, I may say that the value proposition is just not there, particularly given that the car itself is worth much less than $5,000. Given that my budget is not unlimited, I have to make trade-off decisions about where to put my money, so I may instead spend the money on another used Passat that has good prospects.

But in medicine, we routinely avoid thinking about value. There seems to be an overall impression that if it out there on the market, and especially if it is new, it is good and I am worth all of it. This impression is further enabled by the fact that CMS has no statutory power to make decisions based on value of interventions — they are legislatively mandated to turn a blind eye to the costs. Does this make sense? How toothless is our comparative effectiveness effort likely to be if it has to ignore half of the story?

Let us now look at my favorite sticky wicket, ventilator-associated pneumonia, or VAP. Now, the IHI bundle aimed at eliminating VAP consists of 5 points of intervention: 1). semi-recumbent positioning, 2). daily screen for readiness to get off mechanical ventilation, 3). daily sedation vacation, 4). prophylaxis against GI bleeding, and 5). prevention of clots. As I have mentioned before elsewhere, adherence of 95% to all these measures is deemed compliance and may be ultimately used as a quality measure by payers to determine levels of reimbursement. And while each of these interventions is basically “motherhood and apple pie”, applying them blindly and in toto to 95% of intubated patients may be a strategy for disaster. But what is even clearer is that, in order to implement this and all of the other quality improvement strategies, systems need to be put in place that will safeguard against failing to implement these quality measures. The time and resource expenditures needed to institute and maintain these systems, which have not been described in great enough detail as far as I am concerned, have never been quantified. So, what we are left with is a bunch of interventions that, while looking OK individually in clinical trials (until you really start looking at them critically), are likely providing small, if any, gains in quality at the margins, whose investment-return equation has not even been disclosed, let alone balanced. And because budgets are necessarily limited, as are clinicians’ time and cognitive capacities, we need to select a sensible menu of interventions from this practically unlimited feast.

This is the quality conundrum, a clear case of chasing our tails to achieve perfection at the expense of good enough. And while no one in their right mind will argue with the language of improved quality in healthcare, I do think that Muir Gray and his camp are on to something that has been a long time coming. At this time of shrinking budgets, competing priorities and tightening resources, does it not make sense to look at value as a package deal, rather than merely at quality in isolation from its context? Instead of being bombarded by ever-increasing volume of quality measures coming from many directions, would it not be more sensible to prioritize these interventions based on the value that they bring rather than merely on their projected outcomes benefits, so frequently estimated based on data that have very little applicability to the real world? Let’s start asking the question: how much quality and at what price? Without paying attention to this critical balance, we will not only bankrupt the system, but also worsen outcomes paradoxically, as we continue to overwhelm clinicians with infinite minutia that may or may not be generating helpful outcomes.

So, in my book, Muir Gray: score; Berwick: keep trying.

Marya Zilberberg, MD, MPH, is a physician health services researcher with a specific interest in healthcare-associated complications and a broad interest in the state of our healthcare system. She is the Founder and President of EviMed Research Group, LLC, a consultancy specializing in epidemiology, health services and outcomes research. Dr. Zilbergerg is also a professor of Epidemiology at the University of Massachusetts, Amherst. She blogs at Healthcare, etc.

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giant tittsMerlinCarlyInsurance employeeDavid Yanga, M.D. Recent comment authors
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giant titts
Guest

Simply wish to say your article is as astonishing. The clarity for your publish is simply nice and that i could suppose you are an expert in this subject. Fine together with your permission let me to take hold of your RSS feed to keep up to date with impending post. Thank you a million and please continue the enjoyable work.

Merlin
Guest

I’ll be short and just say: quality is the measure for value. Isn’t that right?

nate ogden
Guest
nate ogden

perceived value, different people will rate quality different but for the most part yes

Carly
Guest

So, in my book, Muir Gray: score; Berwick: keep trying.

I second

Insurance employee
Guest
Insurance employee

This is a false choice. What earthly good is quality without value or value without quality? There’s no “value” (which people interpret as low-cost) without a minimum level of quality. The point of having choices is being able to find the “sweet spot” for each person that balances the quality they can get with the value they can afford. And when it comes to health care, that’s almost always going to be what does the most good for the most people, not the tail ends of the bell curve. There would be no distinction here if each and every provider… Read more »

susan
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susan

Ask questions of your provider to find out about the value and to determine if you’re paying too much or getting unnecessary treatments. Here’s some ideas: http://whatstherealcost.org/video.php?post=five-questions

DeterminedMD
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DeterminedMD

I am not MD as Hell, but this commenter and I seem to think alike on most issues, because while I cannot and will not speak for anyone else but myself, doctors who think like me take the stands we do because they probably had a strong, solid training experience and gravitated to supervisors/mentors who did not believe physicians sell out to non providers for direction/control. Unfortunately, that it not the case for what I believe is the majority of colleagues, and certainly not of the graduates from medicine in general these past 10 or more years! Thank you Mr… Read more »

nate ogden
Guest
nate ogden

haven’t seen nearly as many spam post, haven’t been uncontrolably tempted to buy any vitamins read alternative medicine sites since the new system.

Are the Winstom Sock Pupperty trials over now or just beginning? Wouldn’t any self respecting sock puppet at least put in the effort to set up a dummy email account and spoof an IP? I think any dissenters from the prevailling ideology should be required to provide DNA at that least, right BobbyG? Either that or public dippings in NYT and Daily Kos to see if they float or sink.

Matthew Holt
Editor

BobbyG–Determind MD and MD as Hell are different people (or at least have different emails and different IP addresses!)

Matthew Holt
Editor

Guys. Sorry about the issues with comments. The new WordPress system shunts suspected spam into a “needs to be approved” file. Somehow it captured about 20 or so from your regulars (as well as a ton of spam). The new system is easier to manage than the old one, but it’s not perfect yet. Hang in there please! Lots more improvements will arrive….

nate ogden
Guest
nate ogden

“As far as I know, Dr. D, illegal immigrants cannot vote, Democrat or otherwise, whether they have access to health care or not.”

Their kids can, and they have the highest birthrate of any Americans. Further they have engaged in election activity, while not the same as voting enfluencing voting should also be a problem, foreigners should not be impacting our elections.

While the legally can’t vote that hasn’t stopped them from doing so

http://www.fairus.org/site/News2?page=NewsArticle&id=16957&security=1601&news_iv_ctrl=1010

nate ogden
Guest
nate ogden

To bad Stupidty can’t get you banned. For Determind MD and MD as Hell to be the same person they would beed to be bi-polar or suffer from multipersonality disorder. Their writing styles, diction, and experiences are noticebly different. Finally its THCB and they are just posters why the heck would they need to engage in sock puppetry? Its common when people are posters and use it to agree or advance their original post or they use it to make it appear like multiple people feel the same way. How often do you see the two of them post in… Read more »

BobbyG
Guest

“To bad Stupidty can’t get you banned.”
___

You’d be gone, that’s for certain. I know that “excapes” you and your own brand of “Stupidty.”

Peter
Guest
Peter

“So far, no”

LOL, I would think Nate, above anyone, would have to have his comments reviewed for “moderation”.

BobbyG
Guest

I would also like them to look into whether the always hyperbolic and untraceable “Determined MD” and “MD-as-Hell” are a Sock Puppet duo (i.e., the same person posing as different posters). That will get you banned from most reputable blogs.

Margalit Gur-Arie
Guest

No, but I had a problem with comments vanishing into thin air. I rebooted my router, thus obtaining a new IP address and the problem was resolved.

Barry Carol
Guest
Barry Carol

” Anyone else had this problem?”

So far, no but I liked the old format better.

Peter
Guest
Peter

Can somebody tell me why my comment is not being posted and has this at the top: “Your comment is awaiting moderation”

Moderation from what? I’m assuming there is a site “moderator” or administrator? Why has this happened more than once? There is no way to report site problems with this new format. Anyone else had this problem?