Metric Myopia — Trading Away Our Clinical Judgment

Excerpt – The perception that practice variation signals quality deficiencies remains foundational to the pursuit of “high value” care. But if value is defined as quality divided by cost, measuring value faces all the same problems as measuring quality — flawed risk adjustment, metric gaming, omission of the many aspects of quality that defy measurement. So why do we continue to embrace these flawed constructs, particularly when it’s not clear that the current regulatory approach serves patients or clinicians? [president of the Commonwealth Fund David] Blumenthal offers international context: “The French, the Brits, the Swedes — they don’t torture their clinicians the way we do with these administrative encumbrances.” But U.S. health care costs, including physicians’ salaries, are much higher than those in other countries. [..] With the public increasingly concerned about runaway costs, quality or value becomes a way to prove our worth — so essentially, “U.S. physicians have traded income for autonomy.” [..]

Where does the health system’s work end and society’s begin? We can give a patient with recurrent asthma exacerbations state-of-the-art therapy, ensure she’s received appropriate vaccinations, and update her asthma action plan — while knowing we can’t meaningfully change her illness trajectory because she’ll be discharged to the same polluted environment that triggers her asthma. If better outcomes cannot be achieved without addressing factors beyond our traditional reach, should health care systems be responsible for fixing these factors?

Social determinants of health have long been recognized, but now some alternative payment models give us financial incentives to address them. If a health system is reimbursed for achieving certain outcomes in a population that includes a substantial proportion of unhoused people, for example, then investing in housing — which could shorten lengths of hospital stays, reduce readmissions and ED visits, and help hospitals qualify for tax exemptions for charitable care — may financially benefit the health system. Yet even if these investments improve outcomes, when this approach is considered within a larger economic and social context, it may not offer a net benefit to the people most in need. As Suhas Gondi and colleagues have noted, hospital prices, by increasing insurance premiums and reducing wages, may contribute more to homelessness than any investment in housing offsets. Though health systems could lower prices, the appearance of fulfilling a critical social need may absolve them of addressing the greater economic toll their pricing exacts. The mission-fulfillment box gets checked, but the root ills driving inequities remain. [..]

Is it in society’s best interest for health systems to execute large-scale social interventions? Atheendar Venkataramani, an economist and internist at the University of Pennsylvania, explains that since the ACA was passed, “We have been operating under the assumption that health systems are best positioned to solve social and public health problems.” [..]

Venkataramani suggests that effective policy requires a broader social lens. Trials comparing the effects on patient outcomes of health system–funded housing versus no housing may ask the wrong question, he notes. What we should be comparing are the benefits of “a dollar spent by the hospital versus one spent by [the Department of] Housing and Urban Development.” Emphasizing the health benefits of social policies ranging from the child tax credit to minimum-wage increases, Venkataramani argues that health systems should focus their limited resources on their forte: taking care of patients.

[..] in highlighting the impulse to offer simple solutions to complex problems, this belief helps clarify, on the level of human cognition, where the quality movement has gone astray. In Thinking Fast and Slow, Daniel Kahneman offers a unifying conceptual framework for the mental shortcuts he describes. “When faced with a difficult question,” he writes, “we often answer an easier one instead, often without noticing the substitution.” We are particularly prone to these cognitive distortions when facing complex questions with no obvious answers — such as how to measure and improve the quality of medical care. A metric is to our health care system what a heuristic is to our minds: the path of least resistance, tricking us into thinking we’re solving a problem that we may instead be exacerbating. [..]

First, the epidemiology of quality must extend beyond measurement; even the most concrete outcomes, such as death, may not capture the quality of care delivered. And second, insofar as we limit physician autonomy with incentives focused on discrete measures, we risk compromising physicians’ judgment and critical capacity to weigh trade-offs within the entire scope of a patient’s clinical scenario. These risks were borne out during the public-reporting era: revascularization rates among patients with acute myocardial infarction and cardiogenic shock decreased, with some suggestion of worse outcomes in public-reporting states, probably because higher-risk patients were turned away. Today, [interventional cardiologist at Brigham and Women’s Hospital Brian] Bergmark told me, vestiges of that psychology linger. Indeed, he suggested that by fostering risk aversion, quality measures have distracted from our duty to save lives. [..]

To Robert Yeh, an interventional cardiologist at Beth Israel Deaconess Medical Center who has documented unintended consequences of performance metrics in cardiology, public reporting clarified where QI has gone astray. It backfired, Yeh believes, because it failed to consider how clinicians are trained to think. Emphasizing, for instance, that not intervening in patients with ST-segment elevation myocardial infarction and shock is almost uniformly fatal, Yeh noted that clinicians are trained to weigh alternatives: What risks are posed by intervening versus not intervening? By looking only at outcomes among patients who received an intervention, public reporting misframed the question and was thus disconnected from the exigencies of clinical decision making.

With “every clinical encounter,” Yeh recalled, “it became clear that my goals for providing the best patient care and my goals for looking good were completely misaligned; they moved in opposite directions.” This disharmony echoes throughout medicine. “Clinicians are just trying to fulfill their documentation requirements,” Yeh remarked, “so they can move on to the work they actually have to do to take care of patients.”

Full article, L Rosenbaum, New England Journal of Medicine, 2022.4.20 [This is the second article in the journal’s series: Medicine and Society – The Quality Movement. Rosenbaum’s initial article summarized here.]