Looking for Quality under the Lamppost

Concepts such as clinical complexity, multimorbidity, severity of illness, and disease burden seek to characterize the subset of patients whose severity and/or number of illnesses disproportionately affect their lives. We see many such patients in our clinics and in our hospitals. As the numbers of these patients grow, with escalating health care costs and utilization, it is increasingly urgent to answer the following questions: Are these clinically complex patients receiving quality care? Are they satisfied with their experience with the health care system? How can we best measure these important domains and ensure that quality measures adequately are directing providers and health systems to prioritize attention and resources to the most important areas for these patients? These issues, while important for all patients, are especially critical for clinically complex patients. The paper by Werner and Chang both adds to our understanding of these issues as well as highlights some of the technical problems in attempting to answer questions of quality of care and patient satisfaction 1 . Werner and Chang build on recent work on the impact of performance measurement on clinically complex patients in two important ways. Several recent papers have documented that clinically complex patients are more likely than less complex patients to receive recommended care 2,3 , but in prior research frequency of medical visits was either not assessed or, in at least one study 3 , did not affect the independent relationship between multimorbidity and quality of care. In contrast, Werner and Change found that higher quality of care was mediated by increased frequency of medical visits. In multivariate analyses controlling for visit frequency, higher clinical complexity was associated with lower odds of receiving recommended processes of care more often than expected. Second, they found that satisfaction with care was higher among clinically complex patients with high measured performance of recommended processes of care. This finding suggests that compliance with performance measures was not crowding out other aspects of care valued by these patients. This is an important finding, since as they note, if a patient has needs that lie outside of the measured conditions, performance measures may ‘crowd out’ unmeasured care by creating incentives for physicians to attend to measured medical problems over unmeasured ones. This line of research, however, raises a number of technical issues particularly germane to complex patients and highlights many of the clinical management issues facing such patients and their physicians. We will address a number of the technical issues and then suggest an approach to such patients that we believe will ultimately prove to be of increased value to both the patient and their physicians. The first technical question is the mechanisms by which increased medical visits influence both quality of care and patient satisfaction. As the authors hypothesize, does seeing a single physician frequently give that doctor more opportunities to successfully address all the many competing demands of clinical complexity and still meet performance measures? It is also possible that this observed effect is mediated by seeing multiple physicians, each of whom has a different area of clinical emphasis and potential to ‘catch’ omissions of other doctors. Another possibility is the role of clinical systems beyond the actions of individual physicians. The Veterans Affairs (VA) health system studied in this paper is in the forefront of developing systems to monitor chronic conditions and ensure, through electronic health record alerts, mandatory intake nurse check lists, and other methods that patients with those conditions receive the necessary screening, treatment, and follow-up. Maybe this is a success of more frequent interaction with the infrastructure we are trying to institute under the Advanced Medical Home concept– and not just increased interactions with the physician. As with all good research the results often trigger many more important questions.