Time for Quality in Quality Studies
Where is the separation between the Church of Research and the State of Research?
A Rough Guide to Spotting Bad Science is being used to outline the many problems with current research in areas such as in quality and in primary care.
The institutions and individuals involved in research are limited to a select few. Only certain types of carefully screened individuals have access to the data or the research funding. Not surprisingly the data is processed in carefully screened ways.
Journals, editors, and their publicists help lead the charge to obtain or disseminate results that they would like to see. Researcher careers and academic careers are promoted or ended based on findings rather than the quality of their work. This helps shape rigid thinking, failure of problem solving, and status quo rather than progress.
The priority placed upon innovation may actually distract the nation from solutions that have worked. Innovation is catchy but is often developed by those most distant from care delivery. This is a constant problem in primary care.
There has been widespread rapid promotion of desired results. Minimal attention is given to studies that are critical. Studies have also indicated that journalists have made matters worse with incorrect or exaggerated headlines or articles. Jumping on the bandwagon or creating controversy are just two of the means to the ends of selling advertising or gaining more attention. Unfortunately what is popular is often not correct.
Misinterpreted Results/Speculative Language
Authors, reviewers, and editors often fail to be critical about the language used to describe results – especially if it fits what they believe or what they advocate. This is compounded by vague definitions of what is being studied or measured – especially cost of care, quality, or access.
Misinterpretations abound in health care. Cost, quality, and access have always been the three most important areas in health care delivery. Cost and quality actually cannot exist without access, but the experts ignore these basics just as they ignore the workforce to address access, cost, and quality. New Triple Aims, Quadruple Aims, and various interpretations have become popular.
Access to care has been equated with insurance access. Apparently it will take some time for those who still believe in flawed regression equations to understand that there is a vast difference between research equations and the reality of the process of health care.
Primary care and mental health are paid too little by insurance plans to pay for the team members to deliver access to care. Government plans are the worse and contribute the most to access barriers. Too little paid equals too little access and situations are worsened where basic services dominate and are paid less.
Correlation and Causation
These flawed regression equation studies date back to quality studies such as To Err Is Human - the IOM study which has led to the great medical error distraction. Other studies correlate insurance access with care outcomes - conveniently skipping the contributions of patients, workforce, and other situations and relationships. The focus upon error and the focus upon insurance access has effectively prevented investments in areas that could matter.
Correlation is not causation. Numerous patient factors and situations contribute to errors. Quality is about 60 - 70% patient situations, relationships, and determinants. This study led the charge to focus attention upon the 10 - 20% of outcomes that could be addressed by clinical interventions.
exhibited serious errors. Packing equations to get the desired results is common plus failure to include variables that would explain the results – insuring that the findings are significant or are exaggerated.
Process - Pediatric and primary care associations have invested much time and effort in the Primary Care Medical Home. Foundations have supported much of the research.
Headlines - Journals have rushed to publish the findings.
A realistic interpretation of Primary Care Medical Home is mixed results and too early to tell. (References Schwenk, Abrams, Jackson and Williams References)
Misinterpreted Results/Speculative Language - Studies have been far too brief and definitions are vague as are measures.
New associations promoting primary care have been formed and prosper based on their promotions. Research careers prosper or suffer based on the findings.
In the meantime, primary care is not better and may actually be worse off. New distractions prevent primary care practices from receiving the funding to deliver more primary care, primary care where needed, and primary care that reaches out into patient populations and communities.
Even worse, accelerating costs of delivery can shrink dollars remaining for care. Primary care medical home costs $105,000 per primary care physician per year. These are dollars spent on consultants, certifications, and other non-delivery costs. Certifications do not reflect levels of performance. Quality focus requires over $40,000 per year per physician and is increasing. Each year quality reporting requires 785 hours a year from physicians. It is quite clear that encounters per primary care physician can only shrink as will access.
This article does a critical review of Primary Care Medical Home, indicates the problems with studies and measures, and proposes ways to actually measure value - something not measured well so far.
A Rough Guide to Spotting Bad Science
Pressures Mount for ACA Changes
The Real Kerfuffle - How much chaos can family physicians stand?
Declines in Health Care Delivery Despite Increases in Health Spending - If We Keep Accelerating Non-Delivery Costs, We Can Continue to Remain Behind Health Care Demand
Primary care can be recovered and should be recovered.