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from American Medical News
Yet another study confirms that actual clinical practice often doesn't live up to recommended care.
A decade after professional organizations began pushing for implementation of clinical practice guidelines to ensure patients receive needed care, significant deviation from those guidelines is still prevalent, new data from the Michigan-based Medstat Group show. Many now think pressure will have to come from outside the medical profession before that gap can be closed.
A Medstat analysis of two years of claims data pooled by numerous employers and plans revealed serious shortfalls in basic treatment for patients with common chronic conditions. For example, only 29% of almost 16,000 patient diagnosed with diabetes received recommended annual eye exams; less than half received total cholesterol tests.
Among the 3,949 patients with heart failure included in the study, only 40% received an echocardiogram within three months of their initial diagnoses. And less than half received a chest x-ray within the first yea. Only about a quarter of the 6,404 patients with asthma whose cases were reviewed received inhaled anti-inflammatory drugs.
Similar shortfalls in recommended practice were seen for patients with otitis media, low back pain, peptic ulcer, breast cancer, hypertension and systemic heart disease said Medstar Senior Vice President Dennis J. Becker.
Countless studies show similar trends, and the Medstat data offer sobering confirmation that unexplained clinical variation is still widespread, said David B. Nash, MD an outcome expert at Thomas Jefferson University Hospital.
"What we're really learning is just how difficult it is to achieve change in behavior;" he said. "Even where we have grade A evidence, like in asthma, there's very little in the way of reportable success at decreasing variation. We're seeing pockets of improvement here and there. But there's no national effort to address this problem." In fact, in Dr. Nash's view efforts to address quality problems have been pushed to a back burner by the current managed care backlash.
At the same time, physicians and other providers often cite patients as the reason needed care are not always given. No-show rates indeed do keep many patients with chronic conditions from receiving treatment.
Yet the Medstat data also punched some holes in that excuse. For example, closer examinations of claims data of the patients with diabetes showed that most had been seen their primary care physicians frequently during the two-year period and still had not received routine blood test or eye exams.
"What we're witnessing here is lost opportunity," said David Schutt, MD, Medstat's associate medical director: "People actually are accessing the health care system, but the system's failing them."
Problems at the system, patient and provider levels have allowed the gaps between optimal and actual practice to continue, he added. Patients typically are uniformed about the care they should be receiving. Physicians and hospitals seldom step back to assess overall treatment of broader populations of patients. And the health care system currently lacks the information infrastructure to track and change clinical behavior, noted Dr. Schutt.
Major employers, however, have begun to recognize the impact that failure to receive needed care can have on their employees' quality of life and productivity. And many now are seeking data tools to track performance and demand change among plans and providers.
"Once this becomes as much of a business issues as a clinical issue, and as it is helped along by the current wave of consumerism, I believe this will get much more attention than it has over the past few years," Becker said. "That's also going to require those on the payer side to be willing to pay for the care that's recommended."
Dr. Nash agreed. "Large employers, and the employees they represent, are really the only group now with the leverage to make a difference. Demanding monetary refunds for failure to meet a target is the only way to make a business case for quality."
There are some indications indeed that some employers and plans are serious about making the necessary investment. A related report on innovative models of care, release last month by the American Accreditation Healthcare Commission, highlighted almost 100 initiatives that have helped promote adherence to guidelines. The majority were driven by business coalitions and plans.
For example, Blue Cross and Blue Shield of the Rochester Area was able to increase its eye exam rate for patients with diabetes from 42.8% to 58% between 1996 and 1998 by providing data reports and guideline information to physicians, utilizing nurse case managers and disseminating educational materials to patients. More than 80% of those with diabetes employed by Black & Decker Corp. receive annual eye exams now that it's enlisted outside care coordinators to educate patients and contact primary care physicians to verify that patients receive needed tests.
Year long care plans for patients with congestive heart failure are developed in conjunction with patients' primary care physicians through a program devised by Evanston (III.) Northwestern Healthcare. The initiative helped the physician -hospital organization cut 30-day readmission rates for CHF from 19% to 2.7%.
In the report, Caren Heller, MD, acknowledge that gaps exist between The use of clinical interventions demonstrated to be effective and current practice. She noted that successful efforts to enhance "evidence-based practice" universally use guidelines that physicians or multidisciplinary teams have customized for local use, tools to integrate guidelines into daily practice and information systems to provide reminders and feedback on best practices. "Physicians are critical to implementing evidence-based clinical practice to improve quality and manage costs," she wrote. "However; they need support to achieve this goal systematically."
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