Health Care Reform Is on the Way: Do We Want To Compete on Quality?
Health Care Reform Is on the Way: Do We Want To Compete on Quality?
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医疗改革在即：我们要拼质量吗？
DOI：
10.7326/0003-4819-120-1-199401010-00015
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发表时间：
1994
影响因子：
39.2
通讯作者：
R. Brook
中科院分区：
文献类型：
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作者：
R. Brook
关于医疗改革的讨论，即使是那些涉及医生的讨论，通常都集中在成本和获取途径上：应该有一个单一付款人系统吗？有管理的竞争如何省钱？病人应该支付高额的免赔额还是共同保险？牙科和精神护理会是基本福利计划的一部分吗？奇怪的是，这些谈话忽视了临床实践应该如何改变。在这一期的Annals b[1]中，Topol和Califf支持一项基本的临床变革，包括发布医生特定的表现信息。特别是，医生A的病人在控制了疾病之后，是否比医生B的病人做得更好？虽然在医生层面公开发布信息的建议并不新鲜[2-6]，但这篇文章很重要，因为它来自两家著名机构的心脏科医生，因为它是关于发布心血管手术结果的信息。到目前为止，要求公开发布医生业绩信息的呼声通常来自企业、政府或希望看到其他专业的医生发布数据的医生。这篇文章是否代表了一种范式转变？它是否代表了未来美国医疗保健系统将在医生层面上涉及质量竞争的认识？如果是这样，可能的后果是什么？让我们考虑两个不同的世界。世界1代表目前的系统，其中医生特定的性能数据没有发布，世界2代表这些数据的发布。在世界1，随着成本控制的发生，心血管手术的使用增长将放缓。因为只有关于价格的信息是可用的，所以收费低的医生会得到更多的生意。做高质量手术的医生或取得更好结果的医生并不比不做手术的医生更富有。我所说的更富裕，是指与能力较差的同事相比，他们更有可能继续经营下去，增加市场份额，或者提供更多的心血管护理。由于所有医生为了增加市场份额而偷工减料，质量可能会下降。维持我们现有的系统可能会有两个消极的结果和一个积极的结果：首先，医生的结果差异可能仍然很大。对于冠状动脉搭桥手术，这可能意味着每100名接受手术的患者中有5人额外死亡。其次，个体医生的职业生存不太可能依赖于获得更高的质量。第三，由于质量将不会是一个竞争发生的领域，医生之间在推进临床知识方面的合作可能不会减少。在世界2中，特定于医生的性能数据将由公众、医院管理人员、健康计划主管、保险公司高管和政府使用。病人可能会选择那些对病人的治疗效果好于预期的医生。在常规水平（P < 0.05）下，患者可能不太关注医师之间的差异是否有统计学意义。事实上，P值为0.1、0.2、0.3，甚至更高，仍然意味着，平均而言，患者去看质量排名靠前的医生会比去看质量排名靠后的医生更好。对患者来说，重要的是这些差异是否具有临床意义。在这方面，我们需要开发可理解和科学有效的方法，以确保我们向患者提供的数据不会产生误导。例如，病例组合调整后的分析显示，去年A医生每100名患者的死亡人数比B医生少5人，但这并不意味着未来的差异将是相同的。平均而言，它很可能小于100亿美元。向公众公布医疗质量数据将给医生带来巨大压力。能够熟练地完成一项手术的医生可能会失去在一个地区执业的能力，因为他们的水平一般。例如，如果一个城镇碰巧有五名心血管外科医生，他们的水平都高于平均水平，那么质量列表上的最后一名医生可能会失业。这样的医生可能不得不搬家。如果世界2中使用的质量测量有一定的有效性，那么它们的释放将改善并减少医生结果的差异。要使这些事件发生，质量措施不一定是完美的。例如，我们不需要知道如何完美地衡量疾病的严重程度。然而，从医生的角度来看，他或她受到不合理歧视的可能性与质量测量系统的有效性有关。如果医生的病人平均病情较重，但他们的病情水平没有被纳入严重程度的衡量标准，那么他们可能会被无理地逐出行业。此外，不良结果不是医生的唯一责任。那些不幸的医生，因为他们选择了一个提供很少支持的组织，可能同样会受到玷污，并发现很难实践。因此，尽管公众可能从世界2中受益，但一些医生可能会经历相当大的（有时是不公平的）困难。下个世纪，临床医学面临着如何进行医学实践的重大选择。公开发布关于医生水平的质量信息将极大地改变我们的实践方式。这可能比华盛顿的经济改革对这个行业产生更大的影响。如果我们要用这种方法来减少质量的差异，提高护理质量的平均水平，那么我们必须仔细检查我们所做的每一步。此外，几乎所有的结果比较的医生使用死亡率作为他们的结果测量。几乎所有有效的临床模型分析医生对病人做了什么（过程）使用死亡率作为结果变量。尽管死亡是一个重要的结果，但生活质量也是如此；医生之间的结果比较最终必须包括对生活质量影响的比较。这在死亡不常见的门诊地区尤其重要。最后，在这个注重成本的世界里，在广泛的生活质量衡量标准上进行竞争，可能导致需要在医疗保健方面花费更多而不是更少。医生被要求花更少的时间，而不是更多的时间在病人身上；然而，改善患者的性、社会、身体和精神健康当然与这样的政策不一致。关于结果数据发布的主要技术问题是：需要收集多少临床数据才能将结果比较的有效性提高到医生可以接受的错误信息的水平？一个相关的问题是：应该投入多少资金来提高公开发布信息的有效性，以确保将医生排名中的错误减少到可接受的水平？纽约州的Hannan及其同事[9,10]表明，添加临床数据会改变一些医院冠状动脉搭桥手术的死亡率排名。然而，有效性的提高可能不足以保证收集临床数据的费用。我们需要一份分析报告，说明在可接受的效度水平上为公众提供关于医生和医院的数据的成本，并描述成本如何随不同的效度水平而变化。这些信息可能会导致公众和医生之间的妥协，即公众是否愿意花钱购买有效的数据系统，以及医生是否接受足够准确的数据，以确定哪些医生提供了更高质量的护理。我们能两全其美吗？
Conversations about health care reform, even those involving physicians, usually focus on cost and access: Should there be a single-payer system? How will managed competition save money? Should patients pay a large deductible or have co-insurance? Will dental and mental care be part of the basic benefit plan? It is strange that these conversations ignore how clinical practice should be altered. In this issue of Annals [1], Topol and Califf endorse a fundamental clinical change involving the release of physician-specific information about performance. In particular, do the patients of physician A do better, after controlling for sickness, than those of physician B? Although proposals for public release of information at a physician-specific level are not new [2-6], this article is important because it comes from physicians in cardiology departments of two prestigious institutions and because it is about releasing information on the outcome of cardiovascular procedures. Until now, calls for public release of information about physician performance have usually emanated from business, government, or physicians who would like to see physicians in other specialties release their data. Does this article represent a paradigm shift? Does it represent the realization that the future U.S. health care system will involve competition about quality at a physician-specific level? If so, what are the likely consequences? Let us consider two different worlds. World 1 represents the present system in which physician-specific performance data are not released, and world 2 represents the release of such data. In world 1, as cost containment occurs, the growth in the use of cardiovascular procedures will slow down. Because only information about price is available, physicians who charge less receive more business. Physicians who do procedures with higher quality of care or who achieve better outcomes will not be better off than those who do not. By better off, I mean having a greater likelihood of staying in business, increasing their market share, or providing more cardiovascular care than their less competent colleagues. Quality may go down as all physicians cut corners to increase their market share. Maintenance of our present system is likely to have two negative results and one positive result: First, variations in outcome by physicians are likely to remain large. For coronary artery bypass surgery, this might mean 5 additional deaths per 100 patients who received surgery [7]. Second, the professional survival of an individual physician is unlikely to depend on achieving higher quality. Third, because quality will not be an area in which competition occurs, cooperation among physicians to advance clinical knowledge will probably not decrease. In world 2, physician-specific performance data would be used by the public, hospital administrators, directors of health plans, insurance company executives, and the government. Patients would probably select those physicians who obtain better than expected outcomes for their patients. Patients may not pay much attention to whether differences among physicians are statistically significant at the conventional level of P < 0.05. In fact, a P value of 0.1, 0.2, 0.3, or even higher, still implies that, on average, the patient would be better off going to the higher doctor on the quality list than the next lower one on the list. What is important to the patient is whether these differences are clinically significant. In this regard, we need to develop understandable and scientifically valid ways to make sure that the data we present to patients are not misleading. For example, case-mix adjusted analyses that show that last year Dr. A had 5 fewer deaths per 100 patients than did Dr. B do not mean that the difference will be the same in the future. On average, it most likely would be smaller [8]. Release of data on quality to the public would put enormous pressure on physicians. Physicians who can do a procedure competently might lose their ability to practice in a region because they are average. For instance, if a town happened to have five cardiovascular surgeons, all of whom were above average, then the last physician on the quality list might be out of work. Such a physician might have to move. If the measures of quality used in world 2 had some validity, then their release would improve and reduce variation in outcomes by physicians. For these events to occur, the quality measures need not be perfect. We do not need to know, for example, how to measure severity of illness perfectly. However, from a physician's viewpoint, the likelihood that he or she will be unjustifiably discriminated against is related to the validity of the quality measurement system. Physicians whose patients were sicker on average but whose levels of sickness were not incorporated into the severity measure might be unjustifiably forced out of business. In addition, poor outcomes are not the sole responsibility of the physician. Physicians who are unlucky because they selected an organization that provides little support might be similarly tarnished and find it difficult to practice. Thus, although the public is likely to benefit from world 2, some physicians might undergo considerable (and sometimes unjust) hardship. Clinical medicine is facing a major choice about how medicine will be practiced in the next century. Public release of information about quality at the physician level will dramatically change the way we practice. It may have a greater effect on the profession than economic reforms from Washington. If we are going to use this method to decrease variations in quality and to improve mean levels of quality of care, then we must examine carefully each step we make. In addition, virtually all outcome comparisons of physicians use mortality as their outcome measure. Almost all valid clinical models that analyze what physicians do to patients (process) have used mortality as the outcome variable. Even though death is an important outcome, so is quality of life; outcome comparisons among physicians must eventually include comparisons on quality-of-life effects as well. This is especially important in the ambulatory area where death is an infrequent outcome. Finally, in this cost-conscious world, competing on broad measures of quality of life may result in the need to expend more rather than less on medical care. Physicians are being asked to spend less time, not more, with patients; however, improving a patient's sexual, social, physical, and mental well-being is certainly not consistent with such a policy. The major technical question about the release of outcome data is: How much clinical data needs to be collected to increase the validity of the outcome comparisons to a level that the amount of misinformation is acceptable to physicians? A related question is: How much money should be invested to improve the validity of the publicly released information in order to make sure that mistakes in ranking physicians are decreased to an acceptable level? Hannan and colleagues [9, 10] in New York State have shown that adding clinical data changes the mortality rankings of some hospitals for coronary artery bypass surgery. However, the increase in validity may not be sufficient to warrant the expense of collecting the clinical data. We need an analysis describing the cost of producing data for the public about physicians and hospitals at an acceptable level of validity and describing how the cost varies by different levels of validity. This information might lead to a compromise between the public and physicians about the public's willingness to spend money on a valid data system and the physician's acceptance of the data as accurate enough to identify which physicians were producing higher quality of care. Can we have the best of both worlds?