Quality of health care: Do we practice what we preach?
A recent study published in the New England Journal of Medicine attempted to evaluate the quality of care provided to patients by comparing medical records from hospitals with the standard "evidence-based" best practice relative to the patient's particular medical problem.
Records from nearly 20,000 patients were reviewed. The results of the study revealed a large gap between what has been proven to work to improve patient condition, and what is actually recommended or done. (See Suggested Reading, p. 33.)
Some examplesI wondered how this study would turn out in veterinary medicine.Let's consider some examples. It's long been considered standard of care to place patients in congestive heart failure (CHF) on combination therapy with diuretics and ACE inhibitors. How many CHF patients are on Lasix monotherapy? We have known for some time that hypertension is common in our patients with chronic renal failure (CRF), and that this elevated blood pressure carries silent, but detrimental consequences. Do you routinely measure blood pressure in your newly diagnosed CRF patients prior to diuresis? Are you checking anti-convulsant blood levels and chemistry panels every six months in all your seizure patients?
Most endocrinologists advise that we routinely recheck our diabetic patients every three to four months to monitor body weight and clinical history. Do you send out reminders for your diabetic rechecks? Oncologists consider a combination chemotherapy protocol for lymphoma that includes Doxorubicin (Adriamycin) as most likely to provide a long lasting remission. Do you use this drug in all your dogs with lymphoma, or advise referral to someone who does?
It is well known that dogs and cats with advanced forms of inflammatory bowel disease (IBD) benefit from adjuvant immunosuppressive therapy in addition to steroids. Do you routinely advise GI biopsies in patients you suspect have IBD? Or, do you offer therapeutic trials with prednisone or injectable steroids?
Technological advancesI believe the most significant changes our profession has witnessed in the last 20 years relate to advances in technology. The advent of advanced diagnostic imaging (ultrasound, CT, MRI) has drastically altered the way we manage our patients, and has clearly improved our detection of cancer in companion animals.
Our use of computerized medical management systems has vastly improved our ability to invoice more thoroughly, manage our practices, and track statistics that before were simply too cumbersome to monitor.
In addition, the widespread availability of point-of-care (in-house) lab testing has clearly transformed our ability to render immediate diagnoses and institute rapid therapy. Remember the days when our clients waited until the following day for the patient's results regardless of their condition? Yet, despite these technological advances, in many aspects of practice we seem not to have made progress at all.
Wasting valuable timeWe still spend considerably more time than we would like haggling with our clients over estimates for patient care, and justifying the financial value of the services we are capable of providing.
Each of us individually bemoans this side of our daily life, yet we have done very little to improve this problem by educating our clients about the rising costs of veterinary care, or options for financial coverage including credit and insurance.
We were slow to embrace pain management, and have been equally slow to recognize the disadvantages of leaving our patients unattended overnight in the dark, and the corollary advantages to patient care of overnight observation when this is available. We justify our sedentary ways with statements that suggest your clients won't pay for these (narcotics, 24-hour care) but, the real problem is an attitude of "that's the way I've always done it".
This reminds me of Dana Carvey's "grumpy old man" skit on Saturday Night Live. (Remember it?"In my day, we didn't need buses and cars we walked through 10 ft. of snow to get to school, in our bare feet...and we liked it.")
Improving the quality of care our patients receive will require a paradigm shift in our collective attitudes. More particular suggestions include:
Most of us presently use our computer reminder systems principally to encourage compliance with vaccinations.
It still amazes me how often my clients will ask me in fear, "Is it OK if Mugsy is a week late for his shots, cause he's getting over pancreatitis?" We've certainly trained our clients of the necessity of seeing us for vaccines. If we could translate this motivation into sending reminders to our clients with pets with chronic illness (diabetes, CRF, CHF, geriatric work-ups), we would improve patient care, find disease earlier and improve our bottom lines as a side effect.
Take the cue from the recent American Animal Hospital Association study on compliance. We are doing a poor job on things we don't even bother to monitor. We have a huge window of opportunity to do better.
It amazes me how often your clients seem clueless regarding the most important aspects of their pet's medical illness. I see clients continuing to give their diabetic pet insulin in the face of anorexia, or clients with an epileptic pet that watch their pet seizure for more than 24 hours prior to seeking help.
Does your practice routinely provide handouts for your clients with diabetic and epileptic pets? Perhaps if you did, my emergency hospital would see fewer cases of insulin-induced hypoglycemia and comatose epileptics. If in addition to sending out medical reminders, we could take time to train our clients about the importance of periodic rechecks, we'd certainly improve patient care.
Let's face it; none of us would greet the prospect of a colleague reviewing our records with cheer. Yet, many of us are solo practitioners with no opportunity (or desire) for peer review. Our records are likely an accurate reflection of the way we practice. Fortunately, AAHA has recently shifted its emphasis for accreditation from the physical plant to reviewing medical records. This is a laudable change, and should be encouraged even if you have no desire to be an AAHA-accredited practice. Perhaps we could institute a system for license renewal whereby sample records from your practice are reviewed by an anonymous colleague that is not in your locality.
I suspect you know that your patient should have the type of care I have outlined as standard, but you may assume that your client is either not interested in providing that level of care, or you fear that suggesting this may strain your relationship with your client. Thus, the steroid trial for IBD is more appealing to you and your client than GI biopsies.
In human medicine, financial disincentives, such as insurance and managed care, often discourage quality care and follow-up. We have no such excuse. It is to the benefit of our patient and our pocketbooks to take our care to the next level.
It's pretty clear that the quality of health care delivered in both human and veterinary medicine is considerably lower than it should be. We can and should take action to see that we do "practice what we preach."