Tips from gaining health

Is the pursuit of evidence-based medicine evidence based?  That was the head-cramping question the  Disease Management Care Blog grappled with when it read this just published Health Affairs article, Tool Used To Assess How Well Community Health Centers Function As Medical Homes May Be Flawed.

Readers will recall that the National Committee for Quality Assurance (NCQA) is a Washington DC-based not-for-profit that champions the use of performance measures to assess the quality of health care.  Provider organizations go through an assessment process based on the measures and, if they pass muster, are "recognized" by the NCQA.  The performance measures are based on peer-reviewed medical evidence, vetted by expert panels and then opened for public comment before they are finalized and used.

The DMCB knows this because it has served on two of the NCQA panels.

 While its most visible activity has been the ranking of health insurers, the NCQA has been offering a soup of recognition, accreditation and certification programs for other types of provider organizations including the disease management vendors (for example) and, more recently, medical homes.  More on that group of providers later.

Once you earn it, the NCQA quality badge is more than just a festively colored addition to your letterhead and collaterals. Given the past evidence that purchasers also pay some attention to it, the DMCB recalled being unsurprised when the number of disease management vendors sporting the newly established NCQA accreditation logo multiplied faster than the number of vixens at a Kennedy White House pool party.  They reasonably believed that it would help them gain credibility and give them a leg-up against their competition.

But even if the NCQA performance measures are based on the scientific quality as well as consensus and drive competition based on quality, the question remains: if an organization achieves NCQA recognition, does that really mean that patients are better off for it?

Enter Robin Clarke and colleagues who wanted to know if that was true for medical homes and their patients with diabetes. They adapted the 2008 version of the NCQAs medical home evaluation survey tool to 40 Los Angeles community primary care health centers. The medical director or executive team at each center had to complete the tool which was scored in the usual manner.  The score - and the corresponding level of recognition - was then compared to the centers clinical diabetes care measures based on the National Quality Foundations (NQF) quality measures. These measures were collected on samples of patients based on reviews of the medical records.

Only 30 of the centers completed the tool. They were made up of 88 LA clinics that were taking care of more than 600,000 mostly low income patients. The vast majority of the patient population was Medicaid.

The NCQA survey tool is based on a combination of "must pass" criteria combined with a 100 point scale.  The average score among the centers in this study was a respectable 67. Eight would have received the highest Level 3 Recognition (more than 75 points), three would have been Level 2 (between 50 and 75) and the remainder were Level 1. The percent of patients who had a measure of HbA1c, LDL, or blood pressure in the past twelve months was 84%, 70%, and 90%, respectively. Approximately 60% of patients had kidney disease screening and 35% had a diabetes eye examination.

However, when the authors used multiple methods to look for a statistical association between higher scores or Levels and higher quality percentages on the NQF measures, none was found.

To their credit, the authors point out that 1) theirs was a faux and unaudited NCQA process, 2) that a Level 1 accreditation, while no better than a 2 or a 3,  may be better than a "zero," 3) that persons with conditions other than diabetes may still benefit from this kind of process and 4) that they didnt use the 2011 edition of the tool.  The DMCB adds that this was in a community health setting involving mostly patients with Medicaid insurance. Its possible that patients in other settings, socioeconomic classes or with other types of insurance could benefit.

Despite the limitations, the DMCB thinks this is an important study that puts the NCQA into perspective and tells us what it may and what it may not be doing. Hopefully this kind of study will be done in other settings involving other provider types, including the disease management community.  In the meantime, the NCQA would be well served to continue to examine the links between its prsitine interpretations of the science and the real-world benefits for patients. 

In other words, its time for us to better understand the link between pursuing outcomes and actually achieving them.

The Disease Management Care Blog recently received a curious email from the Patient Centered Primary Care Collaborative.  As readers may recall, this is the Washington DC-based coalition that advocates on behalf of the Patient Centered Medical Home(PCMH). 

The content of that rather defensive communication can be found here.

What provoked this? The premier internal medicine specialty journal, the Annals of Internal Medicine, published a comprehensive review of the peer-reviewed literature on the PCMH, and its authors skeptically concluded:

The PCMH holds promise for improving the experiences of patients and staff and potentially for improving care processes, but current evidence is insufficient to determine effects on clinical and most economic outcomes

Ouch. No "economic outcomes" means that there is no proof that the PCMH saves money.

Unlike the PCPCC membership, regular DMCB readers arent surprised.  For example, the DMCB pointed out months ago that the U.S. governments Agency for Healthcare Research and Quality ("AHRQ") had concluded the same thing.  Countless other DMCB posts on the medical home have pointed out that there were problems with the published PCMH literature (for example, here and here).

Thanks to a past Congressional Budget Office report, the DMCB feels the PCPCC pain. It also knows that a) finding statistically significant cost savings in health insurance data bases are notoriously difficult, b) successful medical home initiatives that are outside the academisphere are the least likely to be reported it in the peer-reviewed literature, c) "savings" isnt the only measure of patient value and d) journals like the Annals of Internal Medicine are being sidelined by innovators who are more astute judges of what works for their patients.

Whats changed for the medical home and the PCPCC after this unpleasant dust-up?  Ultimately nothing. Pairing nurses and physicians in team-based care, whether its done remote telephonic "disease management" style or in the clinic "medical home" style is ultimately a good idea with obvious face validity. The Annals problem is that we dont have pristine scientific methodologies that can identify, capture and measure the benefit.

The good news is that the science is getting better. Until it catches up, the population health and disease management service providers will remain in business and the medical home will continue to have a bright future.

There are many different medical procedures that can provide doctors with advanced diagnostic information and surgical capabilities that were not present just a few decades ago. The equipment that is used for some of these techniques can emit radiation or relies on the transmission of radiation in order to view the inside of the body without requiring exploratory surgery. Doctors and patients must sometimes wear radiation protection gear such as leaded glasses and thyroid shields in order to stop harmful levels of energy from accruing in the body while working with patients.

Standard X-Rays

X-Rays are a type of electromagnetic energy that can pass through certain substances but that are partially blocked by denser areas of matter. Patients who receive an x-ray have this type of radiation showered through a particular area. An imaging film is placed under the limb or area that is be being imaged. The result is that dense areas inside of the body such as bone, parts of internal organs or tumors create gaps in the film while less dense areas appear dark because the x-rays change the color of the film. Standard x-rays are used extensively because they are very fast, inexpensive and highly accurate for diagnosing basic problems, such as a broken bone or a fracture.

Fluoroscopy

One of the more advanced diagnostic uses for x-rays is known as fluoroscopy. This is a procedure that can give doctors the ability to actually see the internal functioning of the body in real time. This type of imaging is performed by passing x-rays through the body that are then captured by a digital sensor or a fluorescent screen. The procedure is commonly performed to examine potential problems in the gastrointestinal tract, to assist in certain types of surgeries and to view the functioning of the veins and arteries during an angiogram. Most doctors must wear leaded glasses and x-ray aprons because of the duration of radiation exposure that occurs in order to capture enough data for a diagnosis.

Laser Procedures

Lasers are used extensively in cosmetic procedures and are becoming more common in fields such as dentistry. Lasers give surgeons the ability to accurately remove layers of skin or tissue, to create clean and sanitary incisions and to cauterize tissue as needed. Some types of lasers that are used medically do emit very high amounts of radiation that need to be avoided. Often this is a concern when working with delicate handheld instruments because of the proximity of the device to the body. Leaded glasses are very important for people who are working with lasers because the energy can be particularly devastating to the structures of the eye.

Article Jeremy P Stanfords

Article Source : Common Medical Procedures That Require Radiation Protection