Saturday, August 9, 2014

Putting Quality on the Global Health Agenda-NEJM & IOM crap

I read the article praising Institute of medicine political statements from the NEJM and wrote the following (naturally not accepted for publication). I used real definitions to define the problem, not politically motivated ones:
Placing the “mea culpa” in real terms regarding "quality healthcare".
The recent perspective on quality in healthcare continues to miss many essential realities. Quality is also defined as:”A measure of excellence or a state of being free from defects, deficiencies and significant variations.”
Rehashing the Institute in Medicine’s particular brand of definition, emphasizing: “it is safe, effective, patient-centered, efficient, timely, and equitable” simply does NOT describe modern medical care:
Safe: The very nature of healthcare (surgery, drug administration, anesthesia and procedures) is extremely dangerous, while this fact is typically minimized in expectations and when obtaining informed consent.
Effective: Typically the patient’s ability for self-healing is only promoted by treatment, typically introducing drugs and procedure related specific known dangers in the process-often as dangerous as the disease itself.
Patient centered: Increasingly emphasis decries utility of preventive care including PSA, mammograms, pelvic and even routine yearly physical exams-emphasizing cost effectiveness over patient centricity.
Efficient and timely: would require maintenance and preventive care-currently not emphasized-see above.
Equitable: you cannot purchase health, only health care. Poverty and lifestyle remains after healthcare, as a causative factor.

By failing to recognize that quality healthcare starts with having health and maintenance, whereby the patient is the primary source of health, we will never get past placing blame on physicians and health care systems for inadequate quality. Physicians cannot consistently replace that, which is already lost. The continued emphasis on “adverse outcomes” blaming heathcare systems, ignores the many patient centered causes of sickness including poverty, handguns, rampant drug, tobacco and alcohol abuse, obesity and multiple other life style choices including “extreme” and professional sports-which are not typically terminated by the patient, even after problems are treated and causality confronted. Adverse outcome continues to be defined as anything less than an optimal desired (advertised) outcome typically=restitutio ad integrum! This “failure” is not equal to malpractice, deficient or even inadequate care. Patients come to hospitals, when problems become severe and baseline health is marginal, increasing the risks from receiving care.
The example of the inability to decrease maternal mortality by financing all deliveries in hospitals is not surprising, as provision of care introduces specific risks (a la Semmelwiess or modern expected risks): I.e. failure to provide adequate pre and postpartum care, C/section rate risks are certainly as, or even more important, than delivery in a hospital vs home . We need to quite blindly accepting corporate definitions from the IOM or elsewhere and accepting all blame for complications.

As an anesthesiologist and for example, where the expectation is to provide general anesthesia (versus no anesthesia needed) for a MRI scan, in the most extremely hostile physical environment known, to merely “take a picture”, expected complications will always prevail and provide “adverse outcomes”. It is time to capture all inherent/statistical/expected risks and start tabulating adverse outcomes based in the real world.

This is the article available at:
Putting Quality on the Global Health Agenda
Kirstin W. Scott, M.Phil., and Ashish K. Jha, M.D., M.P.H.
n engl j med 371;1 july 3, 2014

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