Sunday, May 22, 2016

Measuring Physician Quality - Bully or Just Plain Bull

Patients are amazing creatures.   The current breed is hyperinformed on medical information and has an ever expanding reservoir of physician data to trove through.  I’m not just referring to physician reviews on Angie’s list.  Soon, the public will be encouraged to review our success and failure rates with respect to medical treatments, how much cash the drug companies grease us with, all disciplinary actions, comparison with peers, complication rates, medical malpractice entanglements and how much Medicare reimbursement we have received.

There will be published quality benchmarks on physicians so that the public can see how their physicians scored on these various quality measurements.  I have opined throughout this blog that I feel that these measurements are tantamount to taurine excrement.   Sadly, reimbursement will be tied to these results with physicians who don’t rate high enough having some of their income confiscated.  Physicians who don’t make the grade may game the system to achieve higher grades, which has nothing to do with true medical quality.  Is that what our patients want and deserve?

Source of Taurine Excrement

I was poised to begin a colonoscopy on an informed woman who asked me what my ADR was.  I will presume that readers are not aware of what this means.  Most physicians are likely also ignorant of what these letters stand for.  In fact, I’ll bet a decent percentage of gastroenterologists are clueless here as well.  The ADR refers to the Adenoma Detection Rate, which is one of the silly statistics that ‘experts’ feel separate skilled colonoscopists from pretenders.  Adenomas are polyps which are precursors to colon cancer and are the target lesion for screening colonoscopies.  When you consent to undergo a colonic delight at age 50, your gastroenterologist is seeking out adenomas, removing them before they can morph into a cancerous condition.

‘Experts’ advise that competent gastroenterologists should have an ADR of 25% in males and 15% in females who are undergoing screening colonoscopies.  Lower rates, they claim, suggest sloppy or rushed examinations.   Now, some colonoscopists are removing every pimple they find to make sure they will surpass these thresholds.  Does this sound like good medicine?

Remember, colon polyps are surrogate markers.   The true objective of colonoscopy is to prevent cancer, not finding small benign polyps.  A patient should be more interested to know if their gastroenterologist prevents colon cancer, which is not that easy to measure.   In contrast, measuring the ADR is simple, so it is used as a substitute for colon cancer prevention because it is so easy to do.   Similarly, the statin drug companies boast about their cholesterol lowering properties, which is easy to measure.  Cholesterol levels are also surrogate markers for what we should really care about – heart attacks and strokes – events that can’t be studied and measured as easily as simple blood test results.  A surrogate marker ‘benefit’ may not lead to the desired medical outcome, despite claims that it will.

My nurse assured the inquisitive woman on the gurney that my ADR was above threshold.   Am I a high quality gastroenterologist?   I must be.  I’ve got ADR mojo.    Let’s give a shout out to the government and the insurance companies for adopting the ADR standard.  Can we agree that it’s Another Dumb Regulation?


  1. I agree that our focus on surrogate markers is often foolish, but the challenge is for us to come up with ways to measure quality. As the potion of the GDP consumed by health care approaches 20% (1 in 5 dollars spent), we are sinking a ridiculous amount of money into activities which appear to have no clear measure of quality or value.

    The challenge is for you and your GI colleagues to come up with some way of determining who does the best work. Take a hypothetical case where I am a gastroenterologist who puts people under but does not even look. How could the quality of my work be shown objectively to have worse outcomes than someone who was meticulous in terms of their exam? If there is no way to show a difference, why are we bothering to do the exam in the first place?

    You are not unique in GI. While the particulars may be different in different specialties, the similarities are there, especially for those doing screening exams to avoid low frequency events.

  2. @MC, thanks for your thoughtful comment. While I am not certain how gastro MD's, or other specialists can offer a rubric that truly measures quality, the current system fails. Look at the nat'l controversy and tension over measuring teachers' quality? Not easy to do! The current systems for measuring medical quality are poorly veiled systems to cut cost, in my view. Additionally, they were designed and implemented without meaningful input from physicians and medical professions. If the agenda of the committee is to cut costs, guess what the final product will look like?

  3. I prefer my own silent "protest."
    Whenever I get a Press Gainey form to fill out for a physician, I try to give h/her all perfect scores.
    Yes, they get the best possible scores from me because I think that this is all ridiculous.
    I know for a fact that none of my doctors are perfect, but I don't care.

    That being said, this has been going on for a long time in other jobs, so why do physicians think they should be exempt?