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Most Doctors Not Pursuing Quality Improvement

As early as 1917, physician and medical reformer Ernest Codman noted that "medicine, however sophisticated it may now be, is always in an experimental stage. We are all in the business of continuous quality improvement."

Nearly a century later, the concept of continuous improvement has yet to permeate the culture of medicine, a new study concludes. The authors of "Measure, Learn, and Improve: Physicians' Involvement in Quality Improvement" (Health Affairs, May/June 2005) find that although health care purchasers, accrediting organizations, and consumer advocates are using quality improvement methods to improve care, physicians themselves are not routinely engaged in such efforts.

Drawing upon data from the Commonwealth Fund National Survey of Physicians and Quality of Care, the Fund's Anne-Marie J. Audet, M.D., Michelle M. Doty, Ph.D., Jamil Shamasdin, and Stephen C. Schoenbaum, M.D., determined that only one-third of doctors have been involved in any redesign efforts aimed at improving performance.

Part of the reason may be that many physicians lack essential data about their own practices. According to the survey, more than four-fifths of doctors find it difficult or are unable to identify which of their patients have abnormal laboratory results or are taking high-risk medications. Just a third, moreover, have access to data about the quality of their clinical performance, while seven of 10 physicians do not feel the public should have access to such data.
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The survey also revealed surprisingly low use of electronic medical records: only a quarter (27%) of doctors reported using computerized records routinely or occasionally.

Practice size matters. Physicians in large offices (with 50 or more doctors) were more likely than those in smaller practices to generate data about their patients and to have access to performance data—a likely result of their greater financial resources and an organizational culture that fosters such activities. Big practices also were more likely to engage in redesign efforts.

As the authors note, however, the majority of U.S. physicians work in solo or small-group practices—those with fewer than 10 physicians. Policymakers, they say, should therefore help small practices build the capacity to improve and design educational initiatives targeted to their needs.

Payment policies need to reward quality as well. The Fund survey found that quality is not a factor in most physicians' compensation, which is still determined primarily by productivity measures. Few doctors reported that measures of clinical care (8%), patient surveys (8%), or quality bonuses or incentive payments (4%) are major factors in their compensation.

"Unfortunately, most solo practitioners and small group practices simply don't have a quality infrastructure in place and find themselves facing significant financial barriers to adopting information technologies and systems needed for quality improvement," says Fund vice president Anne-Marie J. Audet, M.D. "We have designed tools and solutions for large physician groups and doctors practicing in hospital networks, but much remains to be done to foster adoption of quality improvement by the individual physician."

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