A (Not So) Perfectly Designed System: The Paradox of Medical Stewardship and Quality Measurement.

Abstract

“Every system is perfectly designed to get the results it gets.”1 Health care quality measurement has become important for evaluating hospitals, practices, and individual clinicians. Unfortunately, our current quality measurement system is designed to reward those who do more even when doing more may not benefit, and may even harm, patients. Today, medical care is scrutinized through the lens of quality improvement and measurement, with patient experience being a key component of health care assessment. With medical overuse being described as a serious and extensive quality problem in US health care,2 the current system will need to be redesigned for clinicians to effectively minimize unnecessary testing and treatments and, in short, champion medical stewardship. Despite efforts of campaigns and the dissemination of evidence-based guidelines to reduce the wasteful and unsustainable use of medical resources, pediatric patients continue to receive low-value care.3 Here, we propose that 2 of the main vehicles for quality measurement do not currently align well with the intent of medical stewardship: quality measures and patient satisfaction scores. Present-day measures tend to favor assessments of underuse rather than overuse. As an example, >75% of the currently used quality process measures in pediatrics are used to target the underuse of health care services, such as documenting hydration status in gastroenteritis, obtaining a blood culture in patients with community-acquired pneumonia, and performing hearing testing for patients …