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AMBULATORY CARE REVIEW: A NEGLECTED PRIORITY* MILDRED A. 1\IOREHEAD, M4.D., M.P.H. Director, Evaluation Unit Professor, I)epartment of Community Health Albert Einstein College of lMedicine Bronx, N.Y.

T HERE have been and will continue to be debates about the effectiveness of review of the quality of care received by the inhospital patient. These discussions deal with methods and costs and their impact on the care of patients. Further, since the advent of the Professional Standards Review Organizations (PSROs), there will be struggles over the control of these activities-struggles between medical societies and struggles at the local level between different categories of providers, at the state level between public agencies, and at the federal level between the major funding agencies, i.e., M\edicare and Medicaid. Little attention is being given to the audit and review of ambulatory care, an area which, if priorities were reordered, in the long run would have far more influence on the health of patients, the welfare of society, and the organization of health services. Assessment of the capability to provide for the early detection of disease, to provide counselling and maintenance care in order to halt the progression of disease and prevent complications, and to maintain adequate support services for incapacitated patients on an ambulatory basis would lead to improvements which not only would accord a higher quality of life to the individual, but wvould reduce the use of expensive hospital beds. The problem of control of costs lies beneath the surface of most mandated quality reviews, including the PSRO, and would be affected by emphasis on the ambulatory patient. In a study that we conducted at the request of the Hawaii state legislature' which was interested in lowering the cost of the Medicaid program but was hesitant to affect quality (a study whose commission is unique among state and govern*Presented in a panel, A Discussion of Methods, as part of the 1975 Annual Health Conference of the New York Academy of Medicine, The Professional Responsibility for the Quality of Health (Care, held April 21 and 25, 1975.

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mental agencies concerned with the control of cost), it was our conclusion that the inpatient care provided to recipients of Medicaid was on a par with that of the better voluntary hospitals in New York City, yet the almost total absence of resources for ambulatory care led to an extremely high rate of repeated admissions. Examples include the patient with diabetes or congestive heart failure who is hospitalized two or three times a year because his illness has gone out of control and the alcoholic who is debilitated by concurrent disease and unprovided with support services on an ambulatory basis. Such patients were readmitted far too often to receive good care. The admissions might have been avoided had a higher level of ambulatory services been available during the interim periods. In addition to methodological problems and a shortsighted view that containment of costs will come first from approaching the most expensive component of health care, the hospital bed, there are reasons why the review of ambulatory care is not being discussed as an immediate reality. The vast amount of current ambulatory care continues to be provided on a fee-for-service basis within the solo practitioner's office, and the logistics as well as the politics of gaining entry to these offices is a subject that only the bravest of politicians or medical care administrators have broached. Within institutional settings access does not appear to be an obstacle, but there are other deterrents. Hospital outpatient departments in most instances have been and still are under the control of physicians whose primary interest is the inpatient. A low priority has been given not only to the review of ambulatory care but to even the provision of ambulatory services. While there are isolated instances of researchers working on methodology and special studies in such settings, to my knowledge only the New York City Health and Hospitals Corporation has undertaken the task of developing an ongoing systematic review of ambulatory records. This has been a long, sometimes painful process, without a great deal of cooperation or enthusiasm on the part of the participants. It is freqently said that it is more difficult to obtain a true picture of the quality of care given to the ambulatory patient than to the one who is hospitalized. I do not concur. Hospitalization represents a finite period of time during which the care provided may be more visible and patient compliance maximized; yet, the circumstances that lead Vol. 52, No. 1, January 1976

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to the hospitalization and the services provided after discharge are of equal or greater importance in providing adequate care. Care before and after hospitalization is rarely reviewed and even more rarely tied in with the review of the hospital episode. Reviews focused on ambulatory care in most settings can provide a picture of activities over prolonged periods, in which measures taken both to detect disease in its early stages and to prevent or ameliorate complications can l)e seen in a continuum. It is being said increasingly that ambulatory care cannot be reviewed because of the poor state of ambulatory records. The American Academy of Pediatrics is about to conclude a long, extensive study of the ambulatory care provided in the offices of volunlteer pediatricians2 who developed the criteria and permitted their records to be audited. Similar to the studies of the American College of Internal Medicine,3 the results have fallen so far below expectations that, rather than state that the criteria were unrealistic or that the care provided perhaps was not at the proper level, the rather self-serving conclusion was reached that a review of ambulatory pediatric care cannot be undertaken now because the records-in the opinion of those providing the care-do not adequately represent the services which they provide. I do not believe that this type of reasoning will long continue to satisfy a public which increasingly is becoming concerned with the accountability of the medical profession. This is not to say that there are no difficulties in reviews of ambulatory care over and above debates on methodology. Access to records has been alluded to: for many groups the use of multiple providers of care makes it difficult, if not impossible, to obtain a complete picture of medical care without expensive, time-consuming interviews with patients and providers. In addition, much time is required to identify specific diseases since most physicians and institutions do not have reporting or coding systems to aid in this identification. Debates over methodology are similar to the differences of opinion that deal with inpatient reviews. Presently, the question of whether to use the process approach or measurements of outcome is receiving much attention. Studying the process of care has been the traditional method of examining what is done to and for the patient in relation to accepted norms of practice. It is said that we do not know whether many of the procedures which we utilize actually have an appreciable effect on the patient. This is perfectly true. Yet, in the foreseeable Bull. N. Y. Acad. Med.

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future we cannot expect to have evidence to categorically state which clinically accepted procedures have a positive or negative effect on the outcome for patients. Should we not perform funduscopic examinations on diabetic or hypertensive patients because we cannot prove that this procedure affects outcome? Should we not treat urinary-tract infections because some studies show that the level of favorable results is high without treatment?4 Should we perform unnecessary hysterectoImies because the risk to the patient is lowv and the satisfaction of the patient and the provider of care with the outcome are generally high (although for quite different reasons)? These arguments may be logical but they contain a high degree of sophistry; it is unlikely that physicians or patients could or should be convinced by such reasoning. Studies of outcome are based on the reasonable hypothesis that the end product of medical care should be a favorable outcome for the patient: Did the patient's hypertension come under control? Did the child's anemia respond to therapy? These questions are excellent examples of the use of the outcome approach, and those who state that this approach supplies the only questions worthy of examination for these conditions have a convincing argument.5 However, there are limits to the types of conditions in which such simple questions can be asked-particularly in chronic disease, for which outcomes would have to be measured over a period of years. This point in time at which the outcome is measured too often is based on expediency for the study rather than on relevance to the patient's health. If a patient was discharged alive from the hospital is this sufficient information for the inference of a favorable outconme? I think not, even when anticipated levels of function and levels of health status are taken into account.6 The debate continues: Should we use implicit review, which is dependent in large measure on the judgement of the interviewer? This generally is a more flexible approach, which allows concurrent diseases and circumstances to be evaluated; yet it is criticized because of difficulties of reproducibility, subjectivity (in uncontrolled studies),7 and the expense of physician manpower. Is the explicit review preferable? Established criteria, which generally are determined by consensus among those to be reviewed, have the advantage of lacking subjectivity and thus can be employed as screening tools by nonphysician personnel. There is an ever-present danger, however, of creating either excessively detailed "laundry lists" of criteria that would unnecessarily escalate costs Vol. 52, No. 1, January 1976

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or such brief criteria that they would give an oversimplistic picture. There are other current approaches that are attractive in concept, although they have had insufficient field testing to determine their usefulness and applicability. The carefully planned principles which were suggested by David Kessner8 for the use of what are called tracers range from acquiring knowledge of the epidemiology of the condition under study to defined techniques for medical management. The approach is designed to select conditions for study from which the adequacy of total performance be projected. For studying an individual disease entity this methodology has many attractive features. Whether it will be shown that the examination of limited conditions can be projected to evaluate the operation of an entire setting is problematic. There is also a danger that an overemphasis on a few conditions will lead again to a fragmentation of services and concentration on specific disease entities. Already, we are seeing in the neighborhood health centers-one of whose founding principles was the provision of comprehensive, integrated health care-examples of this, such as the establishment of special clinic sessions for the hypertensive or the diabetic patient, and separate screening programs for sickle cell disease. Part of this fragmentation is motivated by what I consider to be misguided funding policies. However, interest and concern resulting from the findings of audits relating to specific diseases is also a factor. The tracer approach has practical difficulties of time and expense. We have recently undertaken to identify tracer conditions in neighborhood health centers on a systematic random basis. To avoid the problem created by the use of one or two conditions, we selected 23 conditions to be identified. A systematic review of the medical records in six health centers indicated that these conditions were suspected by the provider, complained of by the patient, or met preestablished criteria in an average of 39% of the patients (in an estimated population of 35,000 people). There was a considerable variation in both the prevalence of these conditions and the accomplishment of basic screening procedures in different groups; the causes for this have yet to be explored. We have had to abandon this interesting approach for the moment because of the large amount of time required to identify these conditions-to say nothing of the time needed for abstraction and analysis of the material. We found, for example, that it required an average of 88 hours per facility for the identification of cases alone, exclusive of abstraction. Bull. N. Y. Acad. Med.

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Other approaches are now being developed. The University of California at Los Angeles is working on criteria mapping,9 an algorithmic approach that uses sequential criteria. Modifications of what is called the critical incident approach, sponsored by the American College of Surgeons and the American Surgical Association, are being used. Another group on the wvest coast is working on what they call the staging concept,10 which is based on the hypothesis that the seriousness of the patient's condition at one point in the process of treatment can be interpreted and evaluated as the outcome of the patient's previous treatment. I agree with Dr. Avedis Donabedian's effort to be a peacemaker among the proponents of various approaches to assessment and support all of them wholeheartedly. All of the various approaches should continue to be used, selected on the basis of objectives and resources, since they all have utility and each can serve different purposes in the same or comparable settings. It is important, however, no matter which approach is used, to have background data on the setting that is being examined in order to place the results of studies of quality in perspective. Our studies of neighborhood health centers, of which the I69th site visit was just completed, have convinced most of us involved that, while the tools to examine performance can vary, the most effective evaluation is achieved by a multidisciplinary approach which examines all aspects of an operational setting, from fiscal management to support services and patient-flow patterns." Only when such a broadly based assessment is undertaken can the findings on the quality of health care be placed in proper perspective. Another dilemma to be faced in choosing the tools to measure care relates to the current level of care in a given setting. From the standpoint of public policy we must ask what level of care we wish to detect and at what level the greatest gains to society can be obtained by the methods employed. If the performance of medicine follows a normal curve, we could hypothesize that the greatest public gain would come from identifying and improving the lowest quartile of medical practice and that efforts to distinguish good from superior practice need not be accorded priority. Yet, in part because of the lack of information about existing levels of practice, studies undertaken by teaching institutions and specialty groups tend to set extensive optimal standards against which to measure performance. The pediatric study, for example, conVol. 52, No. 1, January 1976

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tained several hundred items to measure compliance, all of which were considered equal. One item was the presence in the infant record of a third trimester serological testing of the mother for syphilis. In our review of several thousand records of pregnant ws omen across the country we found this test to be present in the mother's record in only approximately 20% of the cases. To use the presence of this item in the infant's record as an index of pediatric perfornmance-given equal weight to, for example, a tuberculin test-seenes totally unrealistic. When we have no detailed knowledge of the level of care in a given setting it is advisable to start wvith the simplest tools: Are blood pressures taken? Are the hemoglobins of infants recorded? I)oes the recently delivered woman return for postpartum care? Where the answers to the questions are no, in many cases action then can be taken to improve the response or at least to identify the causes for their absence. An example where obvious deficiencies would be difficult to change comes from a study of city hospital outpatient departments. Here the baseline studies in the general medical and pediatric clinics, for example, are about on a par with the random samples of similar patients seen in neighborhood health centers. In both settings only al)out 60% of what was expected for adult patients and 5o% for infants was accomplished. Yet in the city hospitals only a minor portion of patient visits (14% for the adult and 35% for children) occur in the general outpatient clinics; most care is provided in emergency roonms or screening clinics where such procedures are far less likely to be done. W\hether the resources and commitment to provide basic xvork-ups to all patients are available and, even more important, wvhether we could identify those patients who need such ongoing care seems doubtful. At the next level of review come assessments directed toward specific disease entities and their management or outcome. Again, we must decide what medical level of sophistication will bring about the greatest gains in medical care. Using the \Williamson techniques of prognosticating outcomes and then following patients through interviews to learn whether the predictions were accurate is time-consuming, but it is claimed to be an educational process for the physicians involved. A simpler approach can be taken by studying a condition such as hypertension or anemia from medical records. Over a period of time was the blood pressure brought under control or did the anemia respond to therapy? Even the accumulation of material for such studies can Bull. N. Y. Acad. Med.

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provide valuable insights into patterns of care. We have completed a review of the records of 400 patients with hypertension in neighborhood health centers and hospital outpatient departments. The levels of control reached by both groups were similar: only about 40%. Perhaps of equal importance, however, was that the expert committee which drew up the guidelines for the review specified that patients should remain under care for at least three months to allow for the control of hypertension. When this criterion was applied to the cases abstracted it was found that 3o% of the patients had not been seen over this length of time. What can we estimate will be the findings of such reviews and what are the measures that can be undertaken to correct the deficiencies? Our experience has served only to reinforce the obvious: there are problems at the level of the provider of care, the patient, and the organization of the facility. As far as the provider of care is concerned, I would estimate that the rascal or exploiter of the funds of both patients and the public represents a small portion, perhaps 3 to 4% of medical practitioners. (Five percent was estimated by Dr. Lowell E. Bellin in the studies which he conducted among providers of care through Medicaid,12 although his estimate at this conference was 0o%.) Incompetence caused by both ignorance and carelessness-which are frequently difficult to separate-appears to result in approximately 30% of ambulatory care being less than adequate. There are instances in which the patient contributes to the inadequacy of his care by failing to comply with therapeutic regimes, breaking appointments, or using multiple providers-with the result that no one assumes over-all responsibility for his care. The social, educational, and economic barriers between the provider of care and the patient are, in many instances, of such magnitude that efforts in the education of patients, follow-up, or even home visits by community residents who can more readily communicate with the patient are to no avail. This area merits far greater attention than it is receiving in most settings. I must caution, however, that increasing emphasis placed on health education for the patient, although clearly desirable, should not provide the rationale for the provider to relinquish his responsibility or reduce his efforts in active follow-up on the assumption that the responsibility now rests with the "educated" patient. There are a multitude of reasons why a facility may provide inadequate care, of which I shall stress only two which in our experience are the most common and which lend themselves most readily to correcVol. 52, No. 1, January 1976

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tion. The first is the absence of written guidelines for basic assessments by age group or for the most commonly seen diseases or the failure, when these guidelines do exist, to have all members assigned roles according to their capabilities in seeing that these policies are implemented. The second serious problem results from a lack of follow-up or notice of positive findings or recommendations in laboratory, x-ray, or consultant reports. I started my career in medical auditing many years ago in the Amazon Valley of Brazil by examining positive laboratory findings which were diagnosed six months earlier in a number of community health centers. I was appalled to find that although the vast majority of these patients returned for care, only their presenting problems were treated, while the additional abnormal conditions were ignored. It is equally discouraging to find, many years later and in far more sophisticated settings, that this is still a major cause of unsatisfactory medical care. Sophisticated auditing techniques, debates over methodology, complaints about the state of medicine or of medical records are all academic exercises compared with what could be accomplished by correcting such an obvious and basic defect in the provision of health care. It is important to continue research into methodologies so that we can assess care, to examine the effectiveness and impact of our various tools, and to give equal emphasis to the care of the ambulatory patient. However, what is most important is to ensure the commitment for such studies and to begin to see a systematic, periodic review of the character and results of the care provided in every medical setting. REFER EN CES in

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1. Greenleigh Associates, Inc.: A Report to the Governor and the Leqislature

Medicinie. San Francisco, Amer. Soc.

of the State of Hawaii. Audit of the Medical Assistance Program of the State of Hawaii. Honolulu, Hawaii, Legislative Auditor, State Capital, 1970. 2. Thompson, H. C. and Osborne, C. E.: Development of criteria for quality assurance of ambulatory child health care. Med. Care 12:807-27, 1974. Office records in the evaluation of quality of care. Med. Care. In press. 3. Hare, R. and Barnoon, S.: Medical Care A ppraisal and Quality A ssurance

Intern. Med., 1973. 4. Assecler, A. WV., Susman, M., et al.: 'The clinical significance of asynIptomatic l)acteria in the non-pregnant woani. J. Infect. Dis. 120:17-21, 1969. 5. Moser, M. and Goldman, A.: Hypertensive Vascular D)isease: Diagnosis and Treatment. Philadelphia, Lippincott, 1967. 6. Rossner, It. nnd Watts, V. C.: 'The measurement of hospital output. Int. .1. Epidem. 1:361-68, 1972. 7. Richardson, F. M.: Peer review of

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AMNIBULATORY CARE, REVIEW medical care. Med. Care 1:29-39, 1972. 8. Kessner, 1). M., Kak, C. E., and Singer, J.: Assessing health (quality-'lhe case for tracers. New Eiqj. J. Med. .?8S:189-94, 1973. 9. (ireenfield, S. and Lewvis, (C.: Personal (colmmunications. 10. Gonnelita, J. S.; Louis, I). t., and McCord, J. J.: An Appro(lch to the As-

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Outcomne of A-Imbulatory

(Care. Joint Meeting, Operations Res. Soc. of A-nmerica and the Inst. of Man-

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agement Sciences. San Juan, Puerto Rico, October 1(6, 1974. 11. Morehead, M. A., et al.: A, mbulatory Health Care Aervice.s Review la uail. Bronx, New York, Evaluation Unit, Albert Einstein College of Medicine, 1973. 12. Bellin, L. and Kavaler, F.: Medicaid p)ractitioner abuses and excuses vs. counter-strategy of the New York City Health D)epartmnent. A mer. J. Public Health 61:2201-10, 1971.

Ambulatory care review: a neglected priority.

6o AMBULATORY CARE REVIEW: A NEGLECTED PRIORITY* MILDRED A. 1\IOREHEAD, M4.D., M.P.H. Director, Evaluation Unit Professor, I)epartment of Community H...
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