Improving Medical Care: What the Evidence Shows
Improving Medical Care: What the Evidence Shows
Abstract & Commentary
Synopsis: The most effective methods to improve health care are interactive education of physicians, computerized decision supports, and use of multiple strategies at once. Notably, TQM and CQI lack good evidence of effectiveness.
Source: Grol R. JAMA. 2001;286:2578-2585.
Health care providers are continuously called upon to ensure quality and to improve the care of their patients. This intelligent article applies an evidence-based medicine analysis to explore the effectiveness of the most popular approaches used to assure optimal care and to improve care. These approaches include evidence-based medicine and clinical practice guidelines, professional development, assessment and accountability, patient empowerment, and total quality management.
Grol searched for systematic reviews and individual studies on improving quality of care. Thirty-six systematic reviews were analyzed (see Table).
| Table: Effect of the Different Strategies to Improve Patient Care | |||
| Strategy | Number of Reviews |
Number of Studies |
Conclusions |
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| Educational materials, mailed information | 9 | 3-37 | Limited effects |
| CME | 4 | 3-17 | Limited effects |
| Interactive educational meetings | 4 | 2-6 | Few studies, mostly effective |
| Educational outreach visits | 8 | 2-8 | Particularly affects prescribing and prevention |
| Feedback on performance | 7 | 16-37 | Mixed effects, effect on test ordering |
| Reminders | 5 | 5-68 | Mostly effective |
| Use of computer systems | 4 | 7-21 | Computerized decision support, mostly effective |
| Total quality management (TQM) and continuous quality improvement (CQI) | 1 | 55 | Limited effects, weak study designs |
| Patient-oriented interventions | 7 | 2-34 | Mixed effects, reminding patients mostly effective in prevention |
| Combined, multifaceted interventions | 16 | 2-39 | Mostly (very) effective |
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Despite the tremendous emphasis on quality during the last 10 years, the evaluation of the methods used to improve care is mixed and often lacking. Most articles focus on one specific approach or method for quality improvement. Only a limited number of approaches have been well studied—classic didactic continuing medical education (CME)—which has demonstrated little power to change physician behavior. Also well studied and with evidence of modest effectiveness are audit and feedback and automated reminder systems.
Although evidence-based medicine and clinical practice guidelines are aimed at enhancing health care, their effectiveness is hampered by a large array of low quality guidelines, and only a 5-10% change in physician behavior when guidelines are implemented. Professional development efforts via self-directed study and interactive small group sessions have in small studies shown considerable effectiveness.
Grol’s review of using external assessment of physician performance with "report card" reporting to patients or payors as a quality improvement strategy revealed little evidence of improved quality while patient empowerment through shared information and decision making with patients is only starting to be studied. Computerized decision support and reminder systems have mostly been effective when studied.
Grol also found that despite wide acceptance, systems level interventions such as total quality management (TQM) and continuous quality improvement (CQI) are almost entirely supported by anecdotal reports.
Grol proposes further rigorous study of effectiveness, costs, and feasibility of quality improvement interventions. He points to early evidence that combined structural-, physician-, and patient-oriented interventions are most likely to succeed. He also advises that physicians occupy leadership positions in these efforts, build connections to other players, and keep abreast of this field.
Comment by Mark Potter, MD
Physicians have come under increasing pressure to reduce widely publicized medical errors, meet health maintenance targets, control costs, and comply with guidelines. This article and its bibliography point out that defining, measuring, and improving quality in medicine is more difficult than it may seem. Given the complexity of patient care, it is not surprising that there is no single superior approach to improving medical care. Grol suggests that integrative methods are most likely to be truly effective.
Physicians must make diligent efforts to improve clinically, but they should also actively seek to play a key role in defining quality in medical care. External forces, such as accrediting bodies, consumers, and insurance companies, have had a major effect in driving health care changes. These forces should be credited for demanding higher quality. However, physicians are still in the best position to "recognize quality care when they see it." In addition to excellence, quality also means the character or essential nature of medical care. Physicians must participate in the debate over quality lest our "quality" be reduced to an electronic report card.
Dr. Potter is Assistant Professor of Family Medicine, Loyola University Medical School, Chicago, Ill.
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