sive increase in heart transplantations, competition for donor hearts is going to intensify. He predicted this will mean a more exacting patient-selection process, and thus a more major role for psychiatrists serving on hearttransplant teams. Phipps, a member of the transplant team at Montreal's Royal Victoria Hospital, said absolute contraindications would be chronic psychosis, mental retardation, evidence of irreversible brain damage, or a history of recent drug and/or alcohol abuse.
"Moreover, those patients who show poor compliance with medical treatment or those with unrealistic expectations are considered poor candidates for surgery", he said. "Patients treated pharmacologically for depression are often rejected because of the risk of recurrence of the mood disturbance, necessitating treatment with agents having adverse cardiac effects." Phipps said there are also relative contraindications to transplantation and there is more difficulty dealing with them in the
screening process. "These may include personality disorders, a lesser degree of drug or alcohol dependence, or social isolation", he said. "Personality disorders characterized by a history of aggressive acting or antisocial behaviour will be closely watched due to a possible continuation in the postoperative period and the possibility of poor compliance. "These relative contraindications are not final in themselves but may become more important when accompanied by other relative contraindications."m
Fear must not slow development of standards of care, MDs told Ann Silversides W ith quality assurance in be used constructively or destruchealth care moving to a tively, but if we do not develop higher spot on the polit- them there will be more inapproical agenda, many physicians are priate care and more variations in worried about the consequences. the rates at which procedures are Although none is against measures performed." that will improve quality of care, The conference, which atmany are worried about the mo- tracted about 500 people, was the tives behind them. And with rea- last of three national health care son. As they look for ways to put symposia requested by Canada's the brakes on rising health care premiers at their 1988 premiers' costs, politicians are beginning to conference. discuss issues such as surplus surDoctors, who have been gery and inappropriate proce- trained to be agents for patients, dures. feel like double agents when poBut this fear of government licymakers ask them to be agents must not stop doctors from draw- for society, said Dr. John Eisening up standards of care, a US berg, professor of internal mediphysician told the International cine at the University of PennsylConference on Quality Assurance vania. But Eisenberg, a member and Effectiveness in Health Care, of the Health and Public Policy held in Toronto in November. Committee of the American Col"The fact is we desperately need lege of Physicians, said volume standards and guidelines", said controls are inevitable and for Dr. Robert Brook, deputy director physicians the practical response of the health program at the Rand "is to reduce services of little or Corporation and chief of geriat- no benefit". rics and professor of public health Brook thinks appropriate care at the University of California. occurs when "the expected health "We cannot know if they will benefits of the procedure exceed its expected negative consequence Ann Silversides is a freelance writer living by a sufficiently wide margin that in Toronto. the procedure is worth doing". He 60
CAN MED ASSOC J 1990; 142 (1)
said that when a group of doctors applied that standard to three procedures performed under Medicare, a health insurance program for elderly Americans, they concluded that from 33% to 65% of the procedures - endoscopy, coronary angiography and carotid endarterectomy - were inappropriate or of no proven medical benefit. Among other things, quality assurance involves attempts to reduce inappropriate care. The definition put forward by a conference organizer, Jonathan Lomas of McMaster University, was: "The measurement of health care activity and the outcomes of that activity in order to identify whether the expected objectives of the activity are being achieved, and when this is not the case to respond with effective action to reduce the deviations from objectives." Many speakers stressed that pursuit of quality assurance should not involve a punitive approach. Dr. Donald Berwick, vicepresident for quality of care measurement at the Harvard Community Health Plan in Massachu-
-1
setts, said that when he was creating his quality assurance plan he had frightened and discouraged health care providers by misusing information. For instance, he asked primary care physicians to critique the service, care and communication provided by specialists, and then told specialists the results. This offended the specialists, although they phoned Berwick individually after that meeting to review the reports. "The chiefs of specialties were frightened when numbers looked like grades", Berwick said. 4.6.. When we measure, we report to them what they usually already know. Of course we anger them." As many speakers observed, information about wide international and intranational variations in surgical rates has been available for years. Indeed, enough research had already been done that "the data could have supported a conference like this 10 years ago", said Robert Evans, a professor of economics at the University of British Columbia. "Concern with quality assurance is not rising to prominence because of the research", he observed. "Rather, it is changes in the payment system and other pressures that are driving the concern for quality assurance." Some variations in the rates at which medical procedures are performed are remarkable. Canada, for instance, has a cholecystectomy rate that is five times the rate in England and Wales, noted Klim McPherson of the Department of Community Medicine at Oxford University, England. Similarly, the hysterectomy rate in Canada is almost five times the rate in Norway and Japan. These statistics indicate there are some "fairly massive implied uncertainties in medicine", McPherson said, but until recently it has "remained virtually untouched. Yet the implications for costs are gigantic and for quality of care enormous". He acknowledged that the sta-
tistics reflect, in part, cultural differences: "For example, in Britain most people want to avoid surgery at all costs, while in the United States surgery is seen as a panacea." But he argued that these cultural differences are closely tied to dominant clinical attitudes - the things people are told by doctors - and to spending limits. The conference also heard of variations within countries. Lomas, an associate professor of clinical epidemiology, said that in the Ministry of Health's five administrative regions in southern Ontario fetal distress is diagnosed three times as often in one region as in another. As well, 50% more cesarean sections because of breech presentation and 66% more coronary artery bypass operations are done in one region than in another one. Similarly, Dr. John Wennberg, director of the Centre for the Evaluative Clinical Sciences at Dartmouth Medical School, Hanover, New Hampshire, found significant differences in per capita surgical and medical expense rates in Boston and New Haven, Conn. For instance, if Boston had the same rates as New Haven, the city could close 500 hospital beds. The differences in rates would be "tolerable only if there is more illness in Boston", Wennberg argued, but the variations do not correlate to illness, but to the number of hospital beds, number of doctors, and prevailing medical theory. Brook said rates at which surgery is performed within the United States can vary by up to 300%. "Studies show that doctors take on the characteristics of the hospital practice in the local area", he said. "We don't have a national practice of medicine in the United States. It is very parochial." Like other speakers, Brook stressed that standards and guidelines for care must be drawn up by the medical profession. They must be in the public domain and "the
body that maintains standards has to have a public board". He thinks the many local groups, including in-hospital ones, that are drawing up standards south of the border have been "a gross waste of time. About 98% of the people supposedly doing it are ignorant of how to do quality assurance. Up to now [these] have been a big waste of money". Instead, said Brook, there should be consortia of academic institutions to develop and foster standards, perhaps international ones. In Wennberg's view, what is needed is "an international effort to establish a new branch of science". In the Canadian context, Evans thinks the creation of standards should be left to provincial disciplinary bodies, since these colleges are directly responsible to the public. If the task is left to medical associations, he warned, there is potential for "conflict of interest between the interests of the providers and of the public". (Dr. Martin Barkin, Ontario's deputy minister of health, referred to the "nice and healthy tug of war" between the College of Physicians and Surgeons of Ontario and the Ontario Medical Association over this issue.) Evans said government must create an environment in which there is a "sort of transmission belt" to ensure that research findings lead to changes in behaviour. Perhaps taking her cue from this, Ontario Health Minister Elinor Caplan announced that she is establishing a committee to find ways to lower the cesarean section rate in Ontario from 20.2% of deliveries to 15% within 2 years. After a national consensus conference, Canadian doctors in 1986 accepted voluntary guidelines for reducing the relatively high rate of this procedure. But according to studies published recently in CMAJ and the New England Journal ofMedicine, 3 years later no significant reduction has taken place.CAN MED ASSOC J 1990; 142 (1)
61
"Moreover, those patients who show poor compliance with medical treatment or those with unrealistic expectations are considered poor candidates for surgery", he said. "Patients treated pharmacologically for depression are often rejected because of the risk of recurrence of the mood disturbance, necessitating treatment with agents having adverse cardiac effects." Phipps said there are also relative contraindications to transplantation and there is more difficulty dealing with them in the
screening process. "These may include personality disorders, a lesser degree of drug or alcohol dependence, or social isolation", he said. "Personality disorders characterized by a history of aggressive acting or antisocial behaviour will be closely watched due to a possible continuation in the postoperative period and the possibility of poor compliance. "These relative contraindications are not final in themselves but may become more important when accompanied by other relative contraindications."m
Fear must not slow development of standards of care, MDs told Ann Silversides W ith quality assurance in be used constructively or destruchealth care moving to a tively, but if we do not develop higher spot on the polit- them there will be more inapproical agenda, many physicians are priate care and more variations in worried about the consequences. the rates at which procedures are Although none is against measures performed." that will improve quality of care, The conference, which atmany are worried about the mo- tracted about 500 people, was the tives behind them. And with rea- last of three national health care son. As they look for ways to put symposia requested by Canada's the brakes on rising health care premiers at their 1988 premiers' costs, politicians are beginning to conference. discuss issues such as surplus surDoctors, who have been gery and inappropriate proce- trained to be agents for patients, dures. feel like double agents when poBut this fear of government licymakers ask them to be agents must not stop doctors from draw- for society, said Dr. John Eisening up standards of care, a US berg, professor of internal mediphysician told the International cine at the University of PennsylConference on Quality Assurance vania. But Eisenberg, a member and Effectiveness in Health Care, of the Health and Public Policy held in Toronto in November. Committee of the American Col"The fact is we desperately need lege of Physicians, said volume standards and guidelines", said controls are inevitable and for Dr. Robert Brook, deputy director physicians the practical response of the health program at the Rand "is to reduce services of little or Corporation and chief of geriat- no benefit". rics and professor of public health Brook thinks appropriate care at the University of California. occurs when "the expected health "We cannot know if they will benefits of the procedure exceed its expected negative consequence Ann Silversides is a freelance writer living by a sufficiently wide margin that in Toronto. the procedure is worth doing". He 60
CAN MED ASSOC J 1990; 142 (1)
said that when a group of doctors applied that standard to three procedures performed under Medicare, a health insurance program for elderly Americans, they concluded that from 33% to 65% of the procedures - endoscopy, coronary angiography and carotid endarterectomy - were inappropriate or of no proven medical benefit. Among other things, quality assurance involves attempts to reduce inappropriate care. The definition put forward by a conference organizer, Jonathan Lomas of McMaster University, was: "The measurement of health care activity and the outcomes of that activity in order to identify whether the expected objectives of the activity are being achieved, and when this is not the case to respond with effective action to reduce the deviations from objectives." Many speakers stressed that pursuit of quality assurance should not involve a punitive approach. Dr. Donald Berwick, vicepresident for quality of care measurement at the Harvard Community Health Plan in Massachu-
-1
setts, said that when he was creating his quality assurance plan he had frightened and discouraged health care providers by misusing information. For instance, he asked primary care physicians to critique the service, care and communication provided by specialists, and then told specialists the results. This offended the specialists, although they phoned Berwick individually after that meeting to review the reports. "The chiefs of specialties were frightened when numbers looked like grades", Berwick said. 4.6.. When we measure, we report to them what they usually already know. Of course we anger them." As many speakers observed, information about wide international and intranational variations in surgical rates has been available for years. Indeed, enough research had already been done that "the data could have supported a conference like this 10 years ago", said Robert Evans, a professor of economics at the University of British Columbia. "Concern with quality assurance is not rising to prominence because of the research", he observed. "Rather, it is changes in the payment system and other pressures that are driving the concern for quality assurance." Some variations in the rates at which medical procedures are performed are remarkable. Canada, for instance, has a cholecystectomy rate that is five times the rate in England and Wales, noted Klim McPherson of the Department of Community Medicine at Oxford University, England. Similarly, the hysterectomy rate in Canada is almost five times the rate in Norway and Japan. These statistics indicate there are some "fairly massive implied uncertainties in medicine", McPherson said, but until recently it has "remained virtually untouched. Yet the implications for costs are gigantic and for quality of care enormous". He acknowledged that the sta-
tistics reflect, in part, cultural differences: "For example, in Britain most people want to avoid surgery at all costs, while in the United States surgery is seen as a panacea." But he argued that these cultural differences are closely tied to dominant clinical attitudes - the things people are told by doctors - and to spending limits. The conference also heard of variations within countries. Lomas, an associate professor of clinical epidemiology, said that in the Ministry of Health's five administrative regions in southern Ontario fetal distress is diagnosed three times as often in one region as in another. As well, 50% more cesarean sections because of breech presentation and 66% more coronary artery bypass operations are done in one region than in another one. Similarly, Dr. John Wennberg, director of the Centre for the Evaluative Clinical Sciences at Dartmouth Medical School, Hanover, New Hampshire, found significant differences in per capita surgical and medical expense rates in Boston and New Haven, Conn. For instance, if Boston had the same rates as New Haven, the city could close 500 hospital beds. The differences in rates would be "tolerable only if there is more illness in Boston", Wennberg argued, but the variations do not correlate to illness, but to the number of hospital beds, number of doctors, and prevailing medical theory. Brook said rates at which surgery is performed within the United States can vary by up to 300%. "Studies show that doctors take on the characteristics of the hospital practice in the local area", he said. "We don't have a national practice of medicine in the United States. It is very parochial." Like other speakers, Brook stressed that standards and guidelines for care must be drawn up by the medical profession. They must be in the public domain and "the
body that maintains standards has to have a public board". He thinks the many local groups, including in-hospital ones, that are drawing up standards south of the border have been "a gross waste of time. About 98% of the people supposedly doing it are ignorant of how to do quality assurance. Up to now [these] have been a big waste of money". Instead, said Brook, there should be consortia of academic institutions to develop and foster standards, perhaps international ones. In Wennberg's view, what is needed is "an international effort to establish a new branch of science". In the Canadian context, Evans thinks the creation of standards should be left to provincial disciplinary bodies, since these colleges are directly responsible to the public. If the task is left to medical associations, he warned, there is potential for "conflict of interest between the interests of the providers and of the public". (Dr. Martin Barkin, Ontario's deputy minister of health, referred to the "nice and healthy tug of war" between the College of Physicians and Surgeons of Ontario and the Ontario Medical Association over this issue.) Evans said government must create an environment in which there is a "sort of transmission belt" to ensure that research findings lead to changes in behaviour. Perhaps taking her cue from this, Ontario Health Minister Elinor Caplan announced that she is establishing a committee to find ways to lower the cesarean section rate in Ontario from 20.2% of deliveries to 15% within 2 years. After a national consensus conference, Canadian doctors in 1986 accepted voluntary guidelines for reducing the relatively high rate of this procedure. But according to studies published recently in CMAJ and the New England Journal ofMedicine, 3 years later no significant reduction has taken place.CAN MED ASSOC J 1990; 142 (1)
61
