In this morning's keynote address, Robert Brook, M.D., an expert on quality of care issues, encouraged radiation oncologists to apply lessons learned from a range of medical specialties to ensure that all patients receive appropriate treatment. During a hard-hitting talk that called physicians to task for not being sufficiently concerned about quality control, Brook asserted that this is a real challenge for the beginning of the next century. Dr. Brook is Vice President at the Rand Corporation and Professor of Medicine and Health Services at the UCLA School of Medicine.
Too often in this country, he said, treatment for the very same diagnosis varies according to the bias (and often uneducated bias, at that) of the physician and hospital providing care. Dr. Brook urged audience members to "do something-anything-different" in their work to "facilitate a new environment in which quality is of primary importance." Too few physicians are trained in health services research, he said, and too infrequently does the medical community assess actual quality of care it is giving patients. Instead, geography is often the main determinant of what treatment patients receive; in other words, they get what their nearby hospital is in the habit of doing. There is both uncertainty about and wide variation in treatment that must be addressed through quality control measures, he said.
Applying such measures to cancer treatment, he said, is especially important because it involves such "high stakes." Cancer care makes up three to four percent of the GNP, and there are one million new cases and a half-million deaths each year. In light of such numbers, asserted Dr. Brook, three goals must be paramount as oncology enters the next century: first, providing all necessary care to everybody; second, eliminating waste and providing only what is necessary; and third, improving the mean level of quality of care and "decreasing its variation as a function of who one sees."
"Too often we do what we do from memory," said Dr. Brook, "and not according to organized systems. Science is getting better and more complex, but social systems are not keeping up. The beginning of the next century must begin with the development of systems that ensure quality control."
He also asserted that what he calls "dimensions of quality" still need to be defined more clearly for radiation therapy. These include considerations such as appropriateness (does benefit sufficiently exceed risk?), technical excellence, and whether or not the therapy puts the welfare of the patient first (i.e., is patient-centered).
Dr. Brook cited examples from oncology and other fields of specialty to support his claims. For instance, he cited a study which showed that black patients with non-small-cell lung cancer were less likely to receive surgery than whites, which in turn lowered their survival rates. While it is not clear from the data whether the physicians were at fault or that black patients were simply more likely to refuse surgery, he noted that such a difference points to a problem. A parallel situation has occurred in cardiology, with studies showing that some patients simply are not offered vascularization and therefore are more likely to die. But there is no clear reason why some patients are offered the procedure and some are not. This is why Brook feels that implementation is "haphazard" at best.
"This has nothing to do with bad doctors, bad administrators, or bad people," he said. Rather, it is more a matter of people falling through the cracks because necessary "systems" and "checklists" are not in place. "The quality of care varies enormously, and there's a large gap between the care people should receive and what they do," he said.
Furthermore, he stressed, physicians often do not know what the best approach is. "Physicians read little and treat patients without knowing the right answer," he said. Nor are they always consistent. "You can have a physician who is fanatical about making sure that patients with diabetes are referred to an ophthalmologist to have their eyes checked. But that same physician might never check the patient's feet," he added.
To suggest how technology might help to remedy the situation, Dr. Brook gave an example of a computer program that has been used to ensure the appropriate use of antibiotics. Based on a complete patient profile entered by the physician, the program can help determine whether or not certain antibiotics are appropriate, the recommended dosage, the potential for interactions with other drugs, and other key information. Lab results can be entered and the program will automatically indicate whether any changes are needed. This is just one example of a quality-control device, he noted, but it shows the possibilities for making medical practice more systematic.
On that note, he left the audience with five key questions about how they practice radiation therapy. He asked them to think about what proportion of the things they do are not necessary, and how much additional value might be gained from the amount of resources they spend. He also asked, "How many patients would benefit from your services but don't get them?" Furthermore, he urged them to think about whether they would go to their colleagues if they needed radiation therapy, and if not, why not. And finally, Dr. Brook pondered about the role of the patient, wondering aloud whether the public has a right to know about the issues he had just raised.
Surely these are not easy questions to answer, but they made for a thought-provoking start to today's sessions. Dr. Brook himself noted that his talk provided a counterpoint to the Gold Medal Award presentations that preceded it, which focused on progress and achievement. Nonetheless, he stressed that "quality control is a huge problem that we as physicians should be trying to fix."
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