What Does Quality Mean, Anyway?

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If the quality and safety of your medical care fell short in some way, would you have any idea? Do you know where and when you should be on guard, what hospitals and clinics are doing to treat and protect patients better, and what steps do and don't work? All of that and more will be within the scope of this blog.

My interest is more than professional. In 1983, on a spur-of-the-moment impulse, I had my coronary bypass surgery photographed (OK, so I'm weird). A couple of days after the operation, the surgeon went through those amazing images with me at my bedside, explaining what he had done and why. The pictures burned the message into my brain that at any point in the operation and for long hours afterwards, my life was quite literally in the hands of others.

So quality and safety are not abstractions for me. They are real. And I've learned that improvements can look easier than they turn out to be. I'll give you an example. For a federal program called Hospital Compare intended to give consumers yardsticks to see how hospitals measure up, U.S. hospitals report, among other things, how faithfully pneumonia patients are put on antibiotics within four hours of arriving at the ER. That's seems sensible–you want to attack pneumonia aggressively. It's a killer, especially of older patients.

But think about that four-hour stipulation. A patient could have been at home for days before deciding to come in, a point made earlier this month in the Journal of the American Medical Association. How does starting the clock when patients get to the ER make sense? The four-hour limit, moreover, may be pushing doctors to give antibiotics before they can verify that a patient has pneumonia and if so, what kind, so they can fit the drug to the bug. Unnecessary use of these superdrugs contributes to the rise in resistant superbugs.

And get this: Hospitals with good Hospital Compare numbers could get a bump in their Medicare reimbursements. "[A]ttempts to improve quality may inadvertently cause harm, waste scarce resources, or affect some patients unfairly," note the authors of a paper soon to appear in the Annals of Internal Medicine. As a case in point, it cites the pneumonia rule, one that seemed so simple and logical. But medicine is full of surprises.