Intended and unintended consequences: what should we really worry about?

Despite spending nearly $2 trillion annually on health care services, American adults receive just half of recommended care for the leading causes of death and disability.1 Similar findings have been reported for older adults, with only approximately one-third of recommended care delivered for a subset of geriatric conditions such dementia, falls, and urinary incontinence.2 These empirical studies, along with reports from the Institute of Medicine,3 have contributed to agreement that there is a substantial gap between what we know works and what is being done for patients. There is, however, less agreement about how to close the gap, and grave concerns often are expressed about whether the cure will be worse than the problem we seek to solve. The article by Ganz and colleagues4 offers the most rigorous evidence to date on the question of whether interventions to improve care for select conditions will lead to significant unintended consequences. The good news from this study is that the quality of care for conditions that were not the focus of the quality improvement intervention did not deteriorate. (The other good news from the main study on which this secondary analysis is based is that it was possible to improve care by about 15 percentage points.)5 The news from this study that is bad or good depending on your perspective is that the quality of care for conditions that were not targeted for improvement did not get better. This study offers an opportunity to reflect on what we should really be worrying about or paying attention to as different approaches to improving quality are undertaken. First, we should be worried about the lack of an appropriate information infrastructure for delivering, evaluating, rewarding, or improving the delivery of health care services. For both the intervention and the evaluation, the investigators had to create new data collection tools, including telephone surveys (eg, to screen patients before a visit for the presence of dementia, falls, or urinary incontinence), structured visit forms, reminders, automatic order sets, and manual medical record abstraction (eg, to assess clinical quality of care for targeted and masked conditions). It is not possible within today's information environment to routinely monitor performance on clinically detailed measures of technical quality or patient-centered care at all levels in the health care system. Much of the information content required to assess performance is also essential for managing the delivery of excellent, evidence-based care (eg, populating the data fields required to run decision support tools). Most programs in place today to profile physicians or medical groups, reward performance, create tiered networks, or provide public reports rely primarily on administrative data. These data sets are missing key information necessary for managing patients with complex chronic conditions. Much less attention has been paid to the unintended consequences of inadequate information. You cannot manage what you cannot measure. Until we solve the information infrastructure deficit, we can expect only limited progress on closing the quality gap. Second, we should worry about the lack of standardized approaches to delivering evidence-based or guideline-adherent care. A major focus of the intervention described here was on standardizing the way patients were screened for the presence of particular problems (case-finding), making a plan for the visit (structured visit forms), and developing a treatment plan including standing orders for select elements of care. This type of