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D. Brad Wright

D. Brad Wright

Posted: December 9, 2009 01:40 PM

Continuous Quality Improvement in Health Care?

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In the United States, we love competition. It tends to drive efficiency: our goods get better and cheaper at the same time. But there are exceptions, and health care is one of them. Sure, we continue to see new technologies and brilliant innovations introduced that promise to prevent, treat, or cure illness, but things aren't getting cheaper. In fact, prices are going up faster in health care than they are in any other sector of the economy. People like to claim that this is because of the high cost of research and development that drives medical innovation, but technology in all other areas from automobiles to big screen TVs refute this view. As they've gotten bigger and better, they've also begun to cost less.

As Harold Pollack points out, the problem in health care is one of perverse incentives that encourages overutilization by rewarding providers on the basis of quantity supplied and removing the conditions that would make consumers place limits on the quantity of care they demand. All of this is further confounded by the fact that we lack information on what care works and what care doesn't. In an excellent story in the New York Times Magazine, David Leonhardt makes the case that change can happen--that health care can become more efficient--and he cites the work of Dr. Brent James to prove it.

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James is a surgeon by training with a passion for improving health care quality. His approach is one familiar to most in the quality control division of other sectors: continuous quality improvement. How does he go about it? Basically, he and his colleagues draft care protocols for given situations and then gather data and revise the protocols based on that data. In short, it's about continuing to make steps in the right direction. It also relies heavily on electronic medical records to facilitate the process at both ends: gathering data from physicians, but also prompting them to follow the current protocol.

Leonhardt also acknowledges the work of Dr. Jerome Groopman, whose book How Doctors Think is rather anti-protocol, preferring the physician to think outside the box to successfully treat non-textbook cases. But Dr. James' protocol doesn't prevent physicians from treating patients as they see fit. Instead, it just reminds them of the protocol and gives them the option of overriding it.

I think they're both right. Doctors do need to be able to synthesize a large amount of information and handle the "tricky" patients. That's why I and so many others love to watch the brilliant--if completely fictitious--diagnosticians on House. At the same time, physicians are likely to benefit from a better understanding of what typically does or does not work given the indications. We don't have enough of that in medicine now, and it costs us thousands of lives and billions of dollars in wasted procedures every year. As my childhood report cards would say: Needs Improvement.

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