January 2006 | Back to Table of Contents

Commentary

Enhancing the Role of Internal Medicine Subspecialty Societies in Defining Quality of Care

The subspecialty organizations within internal medicine ought to be actively involved in developing and promoting evidence-based practice standards.

By Jayant A. Talwalkar, M.D., M.P.H.

Efforts to define and measure the quality of medical care in the United States continue to gain momentum. This movement intensified following the release of a 1999 Institute of Medicine (IOM) report that showed patient safety and system reliability were only adequate at best.¹ In a later report, which formally defined a gap or “chasm” in quality, the IOM acknowledged that safety, efficacy, patient-centeredness, timeliness, efficiency, and equity were required in order to provide high-quality care.² Subsequently, health insurance purchasing coalitions such as the Leapfrog Group (a consortium of Fortune 500 companies and other large private and public health care purchasers), the Buyers Health Care Action Group (a Bloomington, Minnesota, coalition of public and private employers), and the Centers for Medicare and Medicaid Services (CMS) have begun to require the reporting of quality indicators such as the use of aspirin upon diagnosis of myocardial infarction or delivery of antibiotic therapy within four hours among patients with pneumonia. This has led to a Medicare pay-for-performance program that’s being tested in hospitals and ambulatory care settings. CMS currently provides financial incentives to medical groups that meet quality benchmarks for the treatment of diabetes, congestive heart failure, coronary artery disease, and hypertension. Notably, the move toward pay for performance by CMS has generated serious discussion about quality in clinical practice among a number of medical specialty organizations eligible for this program.

Professional Societies and Quality
The practice of specialty medicine evolved out of advances in technology and medical care that started in the early 1900s. Until 1915, there was no regulatory body that could verify the self-reported credentials of physicians who claimed to be specialists. That year, the American Board of Medical Specialties was created in order to provide certification to qualified specialists through the passage of written examinations.³ Beginning in 1917, the first medical specialty board was created to distinguish ophthalmologists from optometrists. Today, 24 medical specialty boards exist, including the American Board of Internal Medicine. Within internal medicine, boards were added for subspecialties such as cardiology, gastroenterology, pulmonary medicine, nephrology, and medical oncology.

Today, specialty and subspecialty boards verify individual practitioner competence primarily through written examinations. However, it is the professional societies—membership organizations made up of board-certified physicians—that are organizing the existing knowledge for evidence-based practice in their particular specialty or subspecialty. By the late 1980s and early 1990s, a number of societies began to commission the development of clinical practice guidelines—documents to assist busy clinicians in the diagnosis and management of selected conditions. Data from the scientific literature are the foundation for the guidelines, which in effect serve to translate knowledge gleaned from research into practice. The idea is that using guidelines based on scientific evidence would greatly increase the use of effective therapies and reduce unwarranted variations in practice.

However, it is now up to these organizations not just to create guidelines but to take the lead in encouraging medical groups to implement them and demonstrate their importance in terms of improving quality and increasing value. Leaders of specialty and subspecialty societies and organizations need to understand that CMS and other insurers are no longer interested in paying for services just because they are approved treatments. They want to reward those who use treatments appropriately and not reward those who continue to underuse evidence-based therapies. Once CMS achieves its goals with diabetes, heart failure, coronary artery disease, and hypertension, it is likely to implement pay-for-performance initiatives for other less-common but serious conditions.

If the professional societies do not proactively define and improve quality themselves, then CMS could develop contracts with outside groups that will define quality of care for them. If that happens, physicians may be forced to practice medicine in a way that is not consistent with current practice. In addition, many subspecialty organizations will lose their clout in terms of being able to modify performance measures and improve care as new information becomes available.

Relying on established clinical practice guidelines may not be enough, however. Although every subspecialty society within internal medicine has developed clinical practice guidelines based on the principles of evidence-based medicine, the presentation and format of those guidelines varies among organizations. This raises questions about the reliability and validity of the processes used for their development. Few guidelines are written in a way that allows them to be easily incorporated into a physician’s daily activities. Also, the grading of health care recommendations is done using different formats, and occasionally the authors of the guidelines select evaluation systems without explicit reasoning. The credibility of physicians as champions of quality may then be questioned if, for example, multiple societies within a larger specialty develop and issue differing guidelines on the same topic. This appearance of fragmentation within the same profession will be obvious to policymakers on Capitol Hill and other stakeholders.

One subspecialty within internal medicine that has demonstrated a longstanding interest in quality of care is cardiology. The American College of Cardiology (ACC) and American Heart Association (AHA) have worked together in developing clinical practice guidelines for nearly 20 years. The initial clinical practice statement from the ACC/AHA defined the appropriate indications for use of implantable permanent pacemaker devices. Subsequently, the organizations now consider improving the quality of cardiovascular medical care to be a core mission. The ACC/AHA guideline-development process has several strengths including 1) a standing task force on practice guideline creation and revision, 2) writing committees that include broad representation from other specialties such as general internal medicine and family medicine, 3) the ability to consult with the Agency for Health Care Policy and Research’s Evidence-based Practice Centers for assistance with compiling evidence, and 4) the continuous disclosure of potential conflicts of interest by members of the task force and writing committees.⁴

A similar approach to clinical practice guideline development has been adopted by the American College of Chest Physicians.⁵ The college has developed guidelines for the diagnosis and management of lung cancer and pulmonary hypertension, weaning patients from mechanical ventilators, and the use of appropriate devices for aerosol therapy.

Another organization that has been on the forefront of evidence-based practice is the National Kidney Foundation (NKF). The NKF issued its first practice guideline in 1995 for the care of patients requiring dialysis therapy. A version of this guideline was initially created by the Renal Physicians Association. Based on widespread use of this guideline and related statements, the NKF developed a practice guideline in 1999 to improve the prevention, early detection, and treatment of all chronic renal disease as part of its Kidney Disease Outcomes Quality Initiative. Features of this document are now being incorporated in the Healthy People 2010 initiative sponsored by the U.S. Department of Health and Human Services to reduced the burden of chronic kidney disease.⁶

Improving Subspecialty Involvement in Quality Initiatives
Despite the widespread availability of practice guidelines, the actual use of these tools to improve quality of care is essentially unknown. Numerous studies have shown that passive dissemination of guidelines is not a realistic way to change medical practice, as physicians are often too busy to figure out how to implement them and because they have little time during a patient encounter to actually refer to a guideline.⁷ Unfortunately, the majority of internal medicine subspecialty societies have done little to encourage and help their members effectively use the clinical practice guidelines they develop. The following are some suggestions for getting specialty and subspecialty society members to implement guidelines and get involved in more broad-based
quality-of-care initiatives.

View quality as a core mission. The task of fully engaging members in quality improvement research requires commitment and vision from the society’s executive leadership. This happens when a group of experienced physicians with credibility and authority takes the lead in this endeavor. In the case of the ACC and AHA, an individual from each society (usually a prominent member) is chosen to chair the task force on quality on a rotating basis. A committee of distinguished and accomplished experts in cardiovascular medicine is then formed to assist the task force chair in selecting members for writing committees and to oversee practice guideline development. Most important, these organizations have established a track record of cohesion rather than fragmentation when they are required to collaborate on clinical practice guideline development. Within the American College of Chest Physicians, for example, the health and science policy committee is responsible for selecting an executive committee, which then names a chairperson and panel members to develop and write clinical practice guidelines. Panel members are often chosen for their superlative writing skills and their proven ability to work together on previous projects.⁵ By finding ways to get society leaders and prominent physicians in their fields to take on the development and implementation of practice guidelines, subspecialties can further strengthen the voice of internal medicine in the quality movement.

Define criteria to develop performance measures. The term “performance measure” describes the operational tool that is used to measure and quantify a particular action that represents high-quality medical care. Performance measures must be standardized, reliable, and meaningful. One measure that is being used by CMS is the proportion of patients who are diagnosed with heart failure and undergo testing to measure left ventricular ejection fraction. Currently, CMS requires hospitals to report adherence rates for this and other cardiovascular measures every three months. Results of individual hospitals may be compared with local and national averages to rate performance.⁸ It is anticipated that hospitals performing in the top 10 percent to 20 percent in terms of compliance will be awarded additional payments.

Tasks such as defining the target population, choosing the correct data elements to create performance measures, and determining the feasibility of the measures require extensive work. Subspecialty groups generally have not perceived identifying these parameters as important because of an overall lack of emphasis on quality. Having their members get involved is necessary if those organizations are to be viewed as leaders for measuring and improving the quality of care.

Promote guideline implementation projects and assess quality improvement. In response to concerns about the actual use of evidence-based medicine in practice, there have been recent efforts to implement guidelines and measure clinical outcomes. In 2000, the ACC and AHA supported projects to identify gaps in care for patients with cardiovascular disease. The AHA project, Get with the Guidelines, used a data-collection system at individual hospitals to monitor the use of certain processes and treatments in the care of patients with acute myocardial infarction (MI). Now used in more than 160 hospitals, Get with the Guidelines has demonstrated significant improvements in survival and in the rate of utilizing strategies to prevent a second MI. The number of deaths from acute MI in the United States that could be prevented by using Get with the Guidelines is estimated to be 80,000 per year.⁹

The ACC endeavor known as Guidelines Applied in Practice (GAP) has also focused on acute MI care at 18 hospitals in southeastern Michigan. Study groups included hospitals that met the criteria to be a GAP study site and volunteered to participate, hospitals that met the criteria but did not choose to be a GAP site, and hospitals that failed to meet the criteria. After several interventions, including the use of a hospital discharge form with explicit instructions regarding medication use and lifestyle modification, this study demonstrated significant improvements in adherence rates by 5 percent to 10 percent with acute and post-hospital medical care. For example, patients were more likely to adhere to beta-blocker, aspirin, and ACE inhibitor therapies and to quit smoking.^10,11

Additional GAP projects involving the ambulatory care of patients with heart failure and chronic stable angina are in progress or nearing completion. Although significant resources and support are needed to take on such initiatives, the concept of doing intervention studies to identify quality of care is considered necessary before widespread adoption of recommended best practices can occur.¹² Once resources are available, the professional societies can let their members know how to apply for funding through a request-for-proposals mechanism similar to that used for traditional biomedical grants.

Develop clinical leaders to promote quality measurement. In both the Get with the Guidelines and GAP projects, a critical element for success was the presence of local clinical leadership or physician champions in participating hospitals.¹³ These leaders were able to educate participants about study objectives, serve as a resource during the study, and reinforce gains in quality improvement made during the study period. The idea of requiring clinical leaders to effectively take part in quality-of-care initiatives is easily understood. What is less well-understood is how to systematically identify the individuals within professional societies who are capable of and interested in serving as leaders for these programs. Encouraging members to complete formal coursework on techniques of clinical quality improvement may be one strategy for developing potential leaders. It remains to be seen, however, whether health systems take advantage of the knowledge that these people bring back to their local practices. The training of leaders in clinical quality improvement will need to be addressed by specialty organizations and professional societies that wish to sponsor efforts in quality improvement.

Conclusion
The task of defining which performance measures and interventions comprise quality care in a medical specialty or subspecialty is currently the domain of professional societies and organizations. Yet, a number of the subspecialty societies within internal medicine have yet to become active participants in ensuring the implementation of their clinical practice guidelines in order to improve the quality of care in their fields. If specialty societies and organizations do not take the lead, their members may have to live with guidelines and quality initiatives imposed by regulatory bodies or payers and not by the physicians who understand what is best for patients. MM

Jayant Talwalkar is an assistant professor of medicine at Mayo Clinic College of Medicine.

References
1. Kohn LT, Corrigan JM, Donaldson MS(eds). To Err is Human: Building a Safer Health System. Washington, D.C.: National Academies Press; 2000.
2. Institute of Medicine (ed). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academies Press; 2001.
3. American Board of Medical Specialties Web site. Available at: www.abms.org. Accessed Sept. 1, 2005.
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5. American College of Chest Physicians Web site. Available at: www.chestnet.org. Accessed Sept. 1, 2005.
6. U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. Washington, DC; 2000.
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