Sunday, June 7, 2009

Quality Assurance--- A combination of clinical excellence and cost effectiveness

Every hospital has QA (quality assurance) committees. There's one for general surgery, radiology, trauma, internal medicine. Every department has a cadre of doctors assigned to do chart reviews, flag those cases with complications, and then meet once a week/month to discuss the case in question with the physicians involved. It's a way to keep track of the errors that inevitably occur in medicine, monitor their frequency, and identify ways of reducing their occurence in the future. You can argue about how well QA committee's work, but it certainly provides a mechanism for ensuring personal accountability to your peers. There's nothing worse than getting a letter from the QA chairman telling you that you need to present Patient X the following Tuesday. No one expects perfection in medicine (right?), and most of these meetings are more educational rather than punitive, but it's still a powerful negative feedback mechanism. You don't want to look bad. You want to be better.

I had an idea the other night. Why don't we also have Cost Effectiveness (CE) committees? Isn't this the logical progression, given the reform-minded environment we currently practice in?

Here's what I mean. How about if we start flagging those charts that stand out for the inordinate amount of cost incurred during the hospitalization. Most of the time, I think you'll find that everything done was entirely justified. But what if we start to identify certain physicians who tend to overutilize resources? The gastroenterologist who seemingly performs more inpatient endoscopies as a percentage of his total number of consults, compared with his peers. The general surgeon who tends to order more HIDA scans and MRCP's than his colleagues. The radiologist who consistently recommends a breast MRI after a large proportion of her mammogram interpretations. The internist who seems to always get 4 or 5 specialist consults, ordering many of them even before seeing the patient himself. What we'd be looking for are trends, not one time transgressions. Peer pressure is a powerful force. Who knows, maybe physicians called to explain their choices before the committee will be prompted to re-evaluate the way they practice medicine in the future.

Listen, change is coming. It would be far better for physicians to proactively implement reform mechanisms (like a CE committee) than to passively wait for mandates from Washington.


HMS said...

Great post, Doc.

Bianca Castafiore? said...

Yes! Excellent idea.

MedZag said...

The only trip up I see is that superfluous tests are often frolicking hand in hand with defensive tests. Now if said cost effectiveness committee also offered an additional blanket of protection in malpractice, now that would be something. If the committee could review a case and stand behind the physician, saying the with the pre-test probability, cost/need of the test didn't warrant the extra expenditure, and as a result the prosecuting attorney could not bring that forth as evidence in court. Could you imagine, being able to step back and think "do I really need to order this?" and then not having to worry about liability if you decide to NOT order the test? Now that would be something.

Joseph Sucher, MD FACS said...

It would have to have much more infrastructure than the current QA panels. To have a true understanding of cost effectiveness you must measure it against outcomes. At the very least you would need 30 day outcomes. Additionally, you would have to have a clinical database of patient diagnoses and co-morbidities that has been validated (in other words, the tendency of the system would be to use administrative data as a surrogate to real clinical information). Fortunately for general surgeons this clinical database has been created (albeit not perfected). The NSQIP (national surgical quality improvement program) could be linked with cost data to implement your proactive thoughtful idea. Its worth exploring.