What to do with those bad Health Scorecards?

As many people reading this site already know, The Commonwealth Fund has released their National Scorecard U.S. Health System Performance for 2008 . The summary of their report is:

Across 37 core indicators of performance, the U.S. achieves an overall score of 65 out of a possible 100 when comparing national averages with U.S. and international performance benchmarks. Overall, performance did not improve from 2006 to 2008. Access to health care significantly declined, while health system efficiency remained low.

The methodology may not be perfect (see Maggie Mahar’s HealthBeat Blog), however, this report is still one of many describing the unacceptable level of quality associated with our healthcare system.

I do not quibble with the methodology of any of these studies. We are attempting to measure data that were not pre-ordained to be tracked as quality measures. However, I do (in general) advise caution when trying to suggest improvements based on results from studies such as these.

When reform is based on hitting specific metrics, the metrics then define the mission statement.

For example, the metrics for “Effective Care” in the Commonwealth Fund’s Scorecard include “Chronic Diseases under control,” which is defined as lower blood sugar levels and at least borderline normal blood pressure. These are important measures of disease control, to be sure. However, I am not convinced there is good evidence to say that patients with diabetes and hypertension live happier, healthier lives if this is the only metric that is met.

It’s not difficult to imagine that if we optimized our system around easily available (rather than thoughtful) metrics, we may find that hitting these metrics does not increase the quality of life.

Several medications for hypertension result have complications such as fatigue and impotence. Would we also track the resultant depression associated with loss of ability associated with over-medication? Tighter control of blood sugar by higher doses of diabetic medications may lead to increased hypoglycemic events. Would we track ER visits, ambulance calls, and the attendant anxiety of finding a loved one unconscious in the living room?

I believe that if we are to go forward, we need to develop thoughtful and global measures. Then we need to measure them. Then we may see the type of change we seek.

As this is an interest of mine, I will be writing more on this in future postings.