Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Can shared accountability improve performance measures?

Ira Nash, MD
Physician
December 27, 2014
Share
Tweet
Share

There are plenty of good reasons why thoughtful physicians are often unhappy with the current approach to measuring the quality of care they provide. Some, of course, object to the whole notion of quality measurement, but I believe they are in a shrinking minority clinging to an anachronistic mental model in which each physician defines for himself what constitutes high quality care. I have addressed this previously. But even those, who like me, believe it is essential (and possible) to measure quality, can point to legitimate shortcomings in the way it is done.

Among these shortcomings is the imperfect process by which individual physicians’ results are adjusted to account for differences in the patients they care for. In the simplest case, when the quality of care is judged by looking at patient outcomes, this risk-adjustment is meant to reflect the fact that clinical outcomes reflect both the baseline characteristics of the patients being treated and the treatment they get.

For example, if one were to use in-hospital mortality rates to assess the quality of care for acute myocardial infarction, it would be essential to know how sick the patients, on average, were on presentation. A 50-year-old man with a small inferior wall MI is likely to live even in the absence of good care (or any care for that matter), whereas a 90-year-old woman with cardiogenic shock from an anterior wall MI is likely to die even with state-of-the-art care. Any attempt to assess the quality of care for a population of MI patients must take this into consideration.

There is a more subtle way in which patient characteristics play into quality measurement schemes, even when the measurements are about processes of care instead of patient outcomes. In this construct, providers are assessed by how often patients eligible for some service or intervention actually get it.

Did the patients with diabetes get fundoscopic exams? Did the women in their 50s get mammograms? Are the patients with coronary heart disease all on aspirin? Here it is easy to prospectively define exclusion criteria, which are meant to mimic reasonable clinical decision-making, and shield the provider from a grade that really reflects unmeasured differences in patient populations.

For example, it would not be reasonable (or be indicative of high quality care!) to give aspirin to a patient with an aspirin allergy, so patients with aspirin allergy are excluded from the denominator, and the provider is not judged harshly for a failure to prescribe it. So far, so good. This gets a whole lot trickier, however, when trying to figure out how to handle instances where care is recommended, but not done. What happens if the patient is advised that she should have that mammogram, but doesn’t get it?

Assuming for a moment that it is possible to accurately distinguish between a failure (on the part of the physician) to recommend and a failure (on the part of the patient) to adhere to the physician’s recommendation, who is responsible for the latter? On the one hand, it seems pretty straightforward: The right care was recommended, and the patient failed to take good advice, so this can’t possibly be used to judge the care the doctor provided, right? Well, maybe so, but maybe the patient didn’t take the recommended course of action because the doctor failed to explain it in a way the patient understood, or because the patient couldn’t access the recommended service, or because the patient experienced a side-effect that the physician did not elicit. In these instances, accountability is shared by patients and their physicians.

This idea of shared accountability was recently addressed by a joint committee of the American College of Cardiology and the American Heart Association. These organizations have been collaborating for years to produce clinical practice guidelines. The guidelines, in turn, have been used as the basis for a wide range of performance measures, which have been used to assess the quality of cardiovascular care. The published statement is a thoughtful consideration of how to balance the interdependent responsibilities of clinicians, patients and systems of care. The salient figure from the paper is reproduced below, but I urge you to read the whole thing. Once you do, let me know what you think.

sharedaccountability

Ira Nash is a cardiologist who blogs at Auscultation.

Prev

From medical student to patient, in a matter of minutes

December 26, 2014 Kevin 3
…
Next

Is reactive scheduling for hospitalists a good idea?

December 27, 2014 Kevin 3
…

Tagged as: Cardiology

Post navigation

< Previous Post
From medical student to patient, in a matter of minutes
Next Post >
Is reactive scheduling for hospitalists a good idea?

ADVERTISEMENT

More by Ira Nash, MD

  • Let’s stop trying to change what doctors do

    Ira Nash, MD
  • Keeping up with the rapid developments in mobile health technology

    Ira Nash, MD
  • Not all doctors are physicians

    Ira Nash, MD

More in Physician

  • Why hiring physician intrapreneurs is the future of health care leadership

    Arlen Meyers, MD, MBA
  • Love, birds, and fries: a story of innocence and connection

    Dr. Damane Zehra
  • The overlooked power of billing in primary care

    Jerina Gani, MD, MPH
  • Why pain doctors face unfair scrutiny and harsh penalties in California

    Kayvan Haddadan, MD
  • Why physicians need a place to fall apart

    Annia Raja, PhD
  • The joy of teaching medicine through life’s toughest challenges

    John F. McGeehan, MD
  • Most Popular

  • Past Week

    • Why transgender health care needs urgent reform and inclusive practices

      Angela Rodriguez, MD | Conditions
    • New student loan caps could shut low-income students out of medicine

      Tom Phan, MD | Physician
    • Why pain doctors face unfair scrutiny and harsh penalties in California

      Kayvan Haddadan, MD | Physician
    • Love, birds, and fries: a story of innocence and connection

      Dr. Damane Zehra | Physician
    • What street medicine taught me about healing

      Alina Kang | Education
    • The silent cost of choosing personalization over privacy in health care

      Dr. Giriraj Tosh Purohit | Tech
  • Past 6 Months

    • Why transgender health care needs urgent reform and inclusive practices

      Angela Rodriguez, MD | Conditions
    • Why primary care doctors are drowning in debt despite saving lives

      John Wei, MD | Physician
    • Confessions of a lipidologist in recovery: the infection we’ve ignored for 40 years

      Larry Kaskel, MD | Conditions
    • A physician employment agreement term that often tricks physicians

      Dennis Hursh, Esq | Finance
    • Why taxing remittances harms families and global health care

      Dalia Saha, MD | Finance
    • mRNA post vaccination syndrome: Is it real?

      Harry Oken, MD | Conditions
  • Recent Posts

    • Why hiring physician intrapreneurs is the future of health care leadership

      Arlen Meyers, MD, MBA | Physician
    • How the One Big Beautiful Bill could reshape your medical career

      Kara Pepper, MD | Policy
    • A new telehealth model for adolescent obesity [PODCAST]

      The Podcast by KevinMD | Podcast
    • Love, birds, and fries: a story of innocence and connection

      Dr. Damane Zehra | Physician
    • Why the future of cancer prevention starts from within

      Raphael E. Cuomo, PhD | Conditions
    • A new approach to South Asian heart health [PODCAST]

      The Podcast by KevinMD | Podcast

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 18 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Why transgender health care needs urgent reform and inclusive practices

      Angela Rodriguez, MD | Conditions
    • New student loan caps could shut low-income students out of medicine

      Tom Phan, MD | Physician
    • Why pain doctors face unfair scrutiny and harsh penalties in California

      Kayvan Haddadan, MD | Physician
    • Love, birds, and fries: a story of innocence and connection

      Dr. Damane Zehra | Physician
    • What street medicine taught me about healing

      Alina Kang | Education
    • The silent cost of choosing personalization over privacy in health care

      Dr. Giriraj Tosh Purohit | Tech
  • Past 6 Months

    • Why transgender health care needs urgent reform and inclusive practices

      Angela Rodriguez, MD | Conditions
    • Why primary care doctors are drowning in debt despite saving lives

      John Wei, MD | Physician
    • Confessions of a lipidologist in recovery: the infection we’ve ignored for 40 years

      Larry Kaskel, MD | Conditions
    • A physician employment agreement term that often tricks physicians

      Dennis Hursh, Esq | Finance
    • Why taxing remittances harms families and global health care

      Dalia Saha, MD | Finance
    • mRNA post vaccination syndrome: Is it real?

      Harry Oken, MD | Conditions
  • Recent Posts

    • Why hiring physician intrapreneurs is the future of health care leadership

      Arlen Meyers, MD, MBA | Physician
    • How the One Big Beautiful Bill could reshape your medical career

      Kara Pepper, MD | Policy
    • A new telehealth model for adolescent obesity [PODCAST]

      The Podcast by KevinMD | Podcast
    • Love, birds, and fries: a story of innocence and connection

      Dr. Damane Zehra | Physician
    • Why the future of cancer prevention starts from within

      Raphael E. Cuomo, PhD | Conditions
    • A new approach to South Asian heart health [PODCAST]

      The Podcast by KevinMD | Podcast

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Can shared accountability improve performance measures?
18 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...