Medical Care Quality

MEDICAL CARE QUALITY

I. Nature of the problem

A. Suboptimal quality

II. What is quality?

A. Bundle of characteristics

B. Value of characteristics

C. Subjective and objective value

III. Medical care quality measurement

A. Three categories of characteristics

1. Structural characteristics

2. Process characteristics

3. Outcome characteristics

IV. Medical care quality evidence

A. Evidence before 1999

B. Evidence 1999 and after

1. Institute of Medicine Report: To Error Is Human (1999)

2. Starfield study (2000)

3. Institute of Medicine Report: Crossing the Quality Chasm (2001)

4. McGlynn et al. study (2003)

5. James study (2013)

6. Makary et al. study (2016)

7. Urban Institute study (2009)

8 Commonwealth study (2014)

V. Three types of quality problems

A. Overuse

B. Underuse

C. Misuse

VI. Reasons for overuse, underuse, misuse

A. Lack of scientific evidence

1. Reasons for lack of scientific evidence

a. Cost

b. Not required

c. Little financial incentive

2. Scientific evidence of effectiveness

a. Drugs

b. Medical devices

c. Medical and surgical procedures

B. Inadequate use of existing scientific evidence

1. Evidence-based medicine

a. Two types of evidence-based medicine

1. Evidence-based guidelines

2. Evidence-based individual decision making

2. Reasons why doctors don’t use evidence-based medicine

a. Medicine is an art

d. Financial incentives

C. Inadequate use of information technology

1. Two uses for information technology

a. Electronic medical records

b. Computerized physician order entry

2. Reasons why information technology would improve quality

a. Coordination of care

b. Medication errors

c. Evidence-based medicine

d. Monitoring physician performance

3. Reasons for inadequate use of information technology

a. High cost

b. Physician resistance

c. Little financial incentive

4. Government incentives to adopt and use IT

a. Office of the National Coordinator of Health Information Tech, 2004

b. Medicare e-prescribing program, 2009

c. Health Information Technology (HITECH) Act of 2009

d. Affordable Care Act of 2010

5. Effectiveness of government incentive programs

a. Hospitals

b. Doctors

c. Problems

1. Health information exchange (HIE)

D. Payment system

1. Economic incentive to treat illness not promote wellness

a. Fee-for-service payment

2. New types of payment systems.