Tuesday, February 9, 2010

Accountability and measurement in health care: Does it matter?

Health care and public health lacks a culture of accountability. In particular, we need to foster a culture that seeks out meaningful measures of success, monitoring and reporting of outcomes, and constant quality improvement as part of its everyday practice. Without measurement we have no idea if what we are doing is working, meaningful or the right thing.

Following the Haiti earthquake, I’ve been pondering two aspects of disaster response: Charitable giving and direct medical response. Specifically:

  1. Does giving without accountability equal giving for the benefit of the donor, and not the recipient?
  2. Are doctors who provide services in Haiti (or Havana, Honolulu or Honduras for that matter) without measuring their outcomes in fact serving their own interests more than their patients’?

First, charitable giving. For the individual who writes a check to the Red Cross or Partners in Health, there is the presumption of knowledge. They likely chose an entity based on information indicating that the majority of their dollars will be well-spent providing meaningful services to a certain population. They may even do research to make sure the charity is worthy, based on the percentage of money that reaches recipients, and other measures. The same may not always be true for larger donors: While they require annual reports about the use of their funding, they are not always linked to meaningful measures that assess the value of service provided. Is a nutrition program being evaluated by how much food it distributes, or by how it impacts the underlying nutritional status of a population? The former is easy to assess but has little meaning. The later is challenging, but has meaning for the population being served.

What about doctors? Medical history is full of well-intentioned practices that later turned out to be harmful. Think about blood-letting, using arsenic and mercury as medicine, or more recently the use of hormone replacement for post-menopausal women. Applying the scientific method is the only way to know how treatments and practices work, even crude methods that can be used in a battlefield or post-disaster environment. And assuming that what worked in one scenario will work elsewhere is not good enough. The context in which medicine is practiced impacts the outcomes of that practice, and will change as the context changes. So when docs practice medicine without an eye towards measuring results, they may be providing salve for their own professional and spiritual needs, but not the needs of their patients.

In health care cost-effectiveness sounds cold, a business metric better applied to manufactured goods. But consider that “cost” means resources, including the patient’s time and energy. When patients spend their time seeking a service, there is a commensurate opportunity cost to those other services they are NOT seeking. So the patient may be “paying” in more ways than one.

Accountability requires measurement. We must measure to know whether we are succeeding or failing. Not to try to know may be the greatest failing of all.

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