While [health-care quality] metrics are essential and valuable, the rigid application of these without significant built-in flexibility can have unintended consequences.
—Chandrakanth Are, MBBS, MBA, FRCS, FACS
A very pleasant 68-year-old woman was referred to my clinic with biopsy-proven liver metastasis from primary colon cancer. She was initially diagnosed with colon cancer, which was resected, and she then received chemotherapy. A suspicious liver lesion was biopsied in the adjuvant setting, which confirmed the presence of metastatic disease. After she completed the chemotherapy, she was referred to my clinic.
Staging workup revealed disease isolated to the liver that was resectable with a good future liver remnant. She noted a history of smoking for about 50 years. Cardiopulmonary performance status assessments were completed, and she was considered fit for the proposed surgery.
The patient was always accompanied by her daughter, who is a nurse by profession. The patient’s husband had recently passed away, and she now relies on her daughter, who lives close by. The patient led an active lifestyle and was independent in her activities of daily living.
After going over the prognosis and various treatment options, along with their risks/benefits and other pros/cons, the patient and her daughter wanted to proceed with operative intervention. It was explained to the patient and her daughter that although hepatic resections are safe procedures, her smoking history could likely increase her mortality and morbidity. Nevertheless, the patient and her daughter opted to proceed with resection.
The patient underwent an uneventful right hepatectomy. Her postoperative period was marked by pulmonary problems that were not unexpected given her long-term smoking history. Although these problems were reversible and easily treatable, after a few days the patient and her daughter wanted to withdraw all active interventions. After several discussions, their wishes were respected, and the patient was transitioned to comfort care measures. She passed away peacefully, surrounded by her family members.
Delivering effective, safe, and compassionate care has always been the guiding principle for physicians. Several factors in recent times have placed a renewed emphasis on delivering high-quality patient care. The two reports published by the Institute of Medicine in 1999 (To Err is Human: Building a Safer Health System) and 2001 (Crossing the Quality Chasm: A New Health System for the 21st Century) have been instrumental in zeroing in on the quality of health-care delivery in the United States.
As a result of these reports, pressures from the elected officials, obligations to the public, and a need to improve patient care, a fundamental redesign of health-care delivery got underway. Quality was perched right at the top of this redesign pyramid. Many new measures and metrics were created by various agencies such as the Center for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality. Some of these measures and metrics included the Surgical Care Improvement Project, Patient Safety Indicators, Hospital Acquired Conditions, and Hospital Consumer Assessment of Healthcare Providers and Systems.
Clear-cut metrics such as mortality, morbidity, length of stay, and readmissions are closely monitored, and hospitals and providers fall somewhere along this quality spectrum based on their performance. Performance on these quality metrics has been incorporated into the reimbursement paradigm. These quality metrics have now become part and parcel of a physician’s daily practice.
Any and every attempt to improve the quality of patient care should be embraced openly. Our primary constituents are our patients, and anything we can do to improve their care and quality of life should be welcome. The various agencies should be given credit for their efforts in developing objective metrics to assess the quality of health-care delivery for nearly 300 million people. Similarly, the providers and hospitals should be applauded for their efforts in incorporating these new practices and measurement tools into their practice, which is not easy, considering the significant variations in health-care delivery in the United States.
Limitations of Metrics
Objective metrics play a key role in assessing performance in any field, and health care is no different in that aspect. While objective metrics enable assessment and measurement, subjective variations need to be borne in mind. This is where the health-care field is unique. Subjective variations are so enormous in health care that sometimes no amount of objective or statistical adjustment can justify the occurrence of some events.
There are situations where despite the satisfaction of all quality metrics, the outcome is either unacceptable or undesirable. For example, even with the use of appropriate pharmacologic/mechanical methods of prophylaxis and ambulation, a patient may still develop deep venous thrombosis. In other cases, despite the failure to fulfill quality metrics, patients may have a satisfactory outcome. These are patients who do not develop any clinical evidence of deep venous thrombosis even without prophylaxis.
In our patient with liver metastases, we satisfied all the required quality metrics. She received appropriate preoperative assessment of her performance status, and correct investigations were performed to assess her liver function. Her operative procedure was uneventful with minimal blood loss and acceptable operative time. She received appropriate postoperative care between the ward and intensive care unit. Her pulmonary problems were addressed appropriately until the family wanted us to withhold care.
We held several discussions with the patient and family members and respected their wishes. The family members were very grateful for the compassionate care the patient received and for our abiding by their wishes. The family was completely at peace with the decision they made, as this is what the patient had wanted.
It appears that we did everything appropriately. But for that person sitting by a computer remotely and assessing our quality of care objectively, this mortality will be seen in a negative light. This can negatively influence the Physician Performance Feedback Report and also the hospital mortality statistics when compared to others. Mortality is a “yes” or “no” metric, with little to explain it subjectively in such situations. Anyone who has ever laid a hand on a patient is fully aware that these types of situations are not uncommon.
Need for Flexibility
As we continue on this quality journey, everyone involved in the improvement of health-care quality needs to be constantly aware of the considerable influence of subjective variations. As the spokespersons for our patients, we need to strongly advocate and embrace measures and metrics that improve the quality of patient care. While metrics are essential and valuable, the rigid application of these without significant built-in flexibility can have unintended consequences.
Prolonging the life of our patient may have led to her survival, which would make us look good on an objective scale. But try telling this to the families of patients burdened by the emotional and psychological weight of making the decision to withdraw care. Try explaining this to a patient who has lost all the will to live. That would not qualify as compassionate care, which, as we all know, is not associated with a measurable metric.
The patient’s daughter noted that her parents were married for 49 years and had never spent a Christmas apart. The patient’s husband had passed away a few months earlier, and the family had to make the decision to withdraw care for the patient in December. As the patient passed away a few days before Christmas, in peace and comfort, surrounded by her family, the daughter commented that her parents had spent 49 Christmases together, and now they would spend the 50th together as well.
Try capturing that aspect of medicine and finding a quality metric for it. ■
Dr. Are is Associate Professor of Surgical Oncology, Vice Chair of Education, and Residency Program Director in General Surgery at University of Nebraska Medical Center, Omaha.
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO. Some details have been changed to protect patient privacy.