Improving the quality of care for patients

The front-page article of June 26 titled, “Study: U.S. doctors miss steps in treating illnesses,” caught my attention, and hopefully the attention of most Bangor Daily News readers. Having practiced internal medicine in Bangor for more than 25 years, I am keenly aware of the problems facing the American pubic regarding their health care.

The Associated Press article is a review of an original study titled, “The Quality of Health Care Delivered to Adults in the United States,” by E.A. McGlynn and others published in the June 26 issue of the New England Journal of Medicine. Having perceived in the newspaper review a negative tone toward doctors, I went to the original article for clarity. As stated, participating patients received only 54.9 percent of recommended care. Also, there was little difference in the percent whether one looks at preventative care, care for acute conditions, or care for chronic diseases. The conclusion in the NEJM is: “The deficits we have identified in the adherence to recommended processes for basic care pose serious threats to the health of the American public.” Unfortunately, neither the BDN article nor the original article in the NEJM looks farther than the American doctor for an explanation of bad behavior. I prefer to look farther.

It is necessary to improve the quality of care for our patients, and the present condition is more than serious, it is a near disaster. Doctors do need to know the practice guidelines that apply to their patients. Carrying out those guidelines is of utmost importance. One might wonder where the doctor, or system, fails. Here are a couple of examples from my own practice.

I have numerous patients with coronary disease or angina. These patients should be on an aspirin a day and most of them take one. They should also have a low-density cholesterol (LDL) level under 100. This often requires lifelong medication as well as lifestyle changes. Many patients are reluctant to start medication for this problem, and a large part of my time is spent on counseling, educating and otherwise trying to convince patients of the merits of the guidelines. There are many reasons why my patients won’t take the needed pills, from expense to anticipated side effects.

The conclusion reached in the NEJM article is simply that the doctor did not follow appropriate guidelines. My experience is that patients often choose not to follow suggestions that are based on the guidelines. A similar example would be adequately treating a patient for high blood pressure, or having a diabetic start an ACE inhibitor for the purpose of kidney protection if protein is found in the urine. Trying to convince patients to take more medication is a major part of my daily work. I understand the concerns about the cost of these drugs, but there is no mention of cost of medication in the NEJM article as a reason that doctors are not practicing quality medicine.

In the area of preventative care, quality issues are numerous. But are the doctors ignoring guidelines? We are supposed to be screening for colon cancer with hemoccult slides in all patients over age 50. The number of hemoccult slides I give away in my practice far exceeds the number of slides returned to the lab for analysis. Also, patients over age 65 should get flu vaccines each fall. However, reimbursement no longer covers the cost. In my practice, we may not be able to afford to have our usual flu vaccine clinics this fall.

In order to improve outpatient care, several changes must take place. The article in the NEJM does not elaborate, but Dr. E.P. Steinberg, in his editorial comment in the same issue of the NEJM, mentioned four. These include measuring and publicly reporting quality data, making greater use of informational technology, increased public education regarding the care they should receive, and investments in improving the compliance of health care providers.

We are beginning to see developments in the area of collecting and reporting data. Computerization is in its infancy in outpatient practices, and speaking from experience using a computerized office record in my office, this is an expensive undertaking. Increasing public awareness in looking at and interpreting data will require a huge investment in time and resources. Investments in improving compliance will require insurers to completely change the way medical care is compensated in the United States.

Primary care providers are under enormous strain to provide the best possible care. The demands for better quality of care come at a time when providers have to spend less time with patients due to dropping reimbursements and increasing overhead costs. Insurers, especially Medicare and Medicaid, are paying less for primary care and have never reimbursed well for preventative care.

Now, more than ever before, patients must become active participants in their own care, must understand the guidelines for their own conditions, must follow guidelines and instructions, and help their providers practice effective and efficient medicine.

All of the participants in the health care system can do better, including patients. Though the prognosis for recovery in American health care is poor, it is not a lost cause. For patients and primary health providers, the present quality issues are real. Doctors and patients must work together to improve quality, but will not succeed until there are system changes. These changes need to occur very soon, especially in the area of reimbursement for office computer technology and the outpatient delivery of care that focuses on patient information and counseling.

Allan D. Currie, M.D, is a doctor at Norumbega Internal Medicine in Bangor and is chief of Medical Service at Eastern Maine Medical Center.