Viewpoint
Improvement also Applies to Quality Improvement
At the MMA, we are hearing concerns about the usefulness and validity of some of the measures and methodology used by MN Community Measurement. To be clear, the MMA and I support the use of measurement to improve quality. You cannot improve what you do not measure. That being said, the process of measurement needs to be continuously improved just like other processes in medical practice. Specifically, we are hearing about measures related to asthma and depression treatment. My own experience with these measures illustrates how flawed methodology can result in scores that do not reflect the actual quality of care being given.
The asthma measure, which assesses how providers care for patients with asthma, requires that a written action plan be given to the patient and placed in his or her chart. However, the data supplied by our colleagues with expertise in allergy care increasingly show that an action plan is only useful for high-risk asthma patients, not the majority. This may be a requirement that Community Measurement needs to alter to reflect the best standard of care.
Community Measurement also bases its measure on the five-question Asthma Control Test (ACT). The problem for me is that I have a high percentage of athletes in my practice, and a fair number of them have exercise-induced bronchospasm (EIB). Here’s why that’s a problem: Patients with EIB who exercise vigorously and often (five to seven days a week) may feel short of breath as often as once a day and use albuterol before exercising five to seven times a week. As a result, patients with EIB often have ACT scores that indicate their asthma is not controlled. They also receive an action plan, which may be of no value to them. Most of us would agree that people who exercise daily and use albuterol before exercising and then exercise to the point of being short of breath are not poorly controlled. Rather, they are athletes who are receiving the care they need in order to pursue their sport. But my scores are low because of that.
The factors that can affect my score on the depression measure are even more complicated. Community Measurement bases its depression measure on the PHQ-9 test and views depression as an isolated, acute illness rather than a chronic or episodic disease. A patient with a score greater than 9 during an index period is considered depressed. These patients are followed over time and monitored for remission (a PHQ-9 score less than 5 after six months). I recently reviewed my charts and found that during the past 18 months, I had a total of 214 patients coded for visits for depression. Of those, 126 (59 percent) were in remission. However, according to Community Measurement, I had far fewer depressed patients and a much lower remission rate.
The primary reason for the discrepancy is that Community Measurement doesn’t count all the patients I’ve helped to achieve and maintain remission over time, nor does it count those patients I’ve helped before they met the strict definition of depression. Because I have been seeing many of my patients for many years and can take only a limited number of new ones, I don’t have many new patients with depression. Also, our clinic treats depression as a chronic, rather than acute, condition, and we aggressively screen for it (using the PHQ-2) and treat it early. The result is that even though I effectively manage my depressed patients, I am left with a concentrated population of chronically depressed patients who are receiving optimal care but who do not achieve remission. And I am also left with an unrepresentatively low Community Measurement score for depression care.
Although the MMA supports MN Community Measurement, we feel it needs to dialogue with physicians regarding these and other issues so that measures better reflect the care that physicians are providing to their patients.