Chronic care measurement: A study in complexity
February 1, 2000 4 minutes read
DM and Chronic Care
Chronic care measurement: A study in complexity
It takes multidimensional measures to show ourselves, our patients, and our third-party payers how well we manage chronic conditions. "It’s not enough to measure and report how many flu immunizations we gave," cautions Mark Splaine, MD, MS, senior scientist of measurement and statistics in the department of quality education, measurement and research at the Dartmouth Hitchcock Clinic in Lebanon, NH.
"We need to incorporate the science around good care and the business perspective of good service," he says.
There are at least two ways to achieve this. "Both are right — they’re simply different," notes Splaine, who is also assistant professor of medicine and community & family medicine at Dartmouth Medical School in Hanover, NH.
Dartmouth Clinical Compass
This tool measures four "domains" of health care service and thus balances processes and outcomes.
Domain #1, Clinical
• For the frail elderly, clinicians should understand specific chronic diseases.
• A good system offers hassle-free access to specialty care for each chronic condition.
• Prevention is critical, including cancer and vision screening, and fall prevention as well as monitoring of cognitive ability.
Domain #2, Functioning of the patient
• The SF 36 or the Dartmouth COOP chart (with smiling or frowning faces to depict functional levels) are two widely tested measures of general well-being.
More specific are assessments of ability to perform activities of daily living (ADL) such as bathing, getting around the house, etc.; and instrumental activities of daily living (IADL) such as meal preparation, money management, etc.
Domain #3, Patient satisfaction against need
Wait times, both for available appointments and from arrival to provider visit, are only part of it.
• Patients’ ratings of the provider’s listening, teaching, and caring are important feedback for individual clinicians.
• The provider’s awareness of and offers to work on the patient’s problems are essential to chronic care. For example, patients might be ashamed of incontinence, or ignorant of the significance of balance problems. But providers’ questions can bring such problems to light and, sometimes, mitigate them.
Domain #4, Cost
• Direct costs are fairly easy to monitor.
• Indirect costs are more elusive, but essential to gauging the quality of elder care.
"The burden of care’ figures into this picture, and it’s tough to get a handle on it. We have to ask what’s the cost of care to the son or daughter who has a job and a family as this elderly parent loses the ability to take care of him- or herself?" Splaine points out. Do we arrange clinic appointments to deliver as much service as possible so the daughter will only have to take one morning off work?
As with all things related to chronic care, quality measurement is not straightforward. "We often make tradeoffs among the domains," Splaine says. "For example, if we treat incontinence and reduce the problems it causes for a patient and for the family caregivers, we might hit a benefit in several domains. That’s why it’s important to look at overall functioning, not merely how well we control glucose levels."
Process Metrics
A second way to organize quality measurement of chronic care is to look at the processes of clinical care or organizational practice. In fact, it’s hard to separate one from the other. "Sometimes when we look at our clinical or satisfaction measures, we realize we need to redesign our organizations to improve the clinical or satisfaction domains," Splaine notes.
Some systems present obvious directions. For instance, if the crying need is to improve clinical care, then measurement grounded in clinical improvement and outcomes might be the best choice. If the organizational dimension appears to hold the greatest — or most achievable — improvement opportunity, then go with organizational process measures.
Here are the key points in both approaches:
1. Process measures grounded in clinical care. This follows disease specific problem lines. Take depression or arthritis, for instance. One improvement opportunity to act on and measure might be the involvement of providers beyond primary care, such as psychologists, psychiatrists, or physical therapists.
2. Process measures grounded in organizational practice. Typical organizational improvement opportunities to resolve and measure might include better understanding of the burden of care for a disease group and design of an organizational response to the need. For example, appointment reminder cards for the daughter who drives her mother to the clinic. Opportunities in the ambulatory care office might involve triage of phone calls, procedures for prescription renewals, or clinic visit coordination. "We need to constantly ask ourselves how to organize our practices to change the outcomes," Splaine says. "A key difference between traditional clinical and cost measures, and what we need to measure in chronic disease management is how we’re getting at the patient’s unmet needs."
(Splaine credits a good deal of the original research on quality measurement for chronic care to Paul Batalden, MD, of the Dartmouth Medical School and to Edward Wagner, MD, MPH, of the Group Health Cooperative of Puget Sound in Seattle. Both are associated with the Institute for Healthcare Improvement’s Breakthrough Series, "Beyond Disease Management: Improving Care for People with Chronic Conditions." For contact information, see box, p. 15.)
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