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The Clinical Excellent Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence is a biweekly podcast hosted by Drs. Adam Cifu and Matthew Sorrentino. The podcast has three formats: discussions between doctors and patients, discussions with authors of research pertinent to improving clinical care and the doctor-patient relationship and discussions with physicians about challenges in the doctor-patient relationship or in the life of a physician.
[00:00:00] Dr. Cifu: On today's episode of The Clinical Excellence Podcast, we have Dr. Lisa Vinci talking about quality measures in primary care.
[00:00:11] Dr. Vinci: I think actually physicians are a bit arrogant when they think that they sort of have control over someone's, you know, A1C, someone's blood pressure, someone's weight. I mean, these are very complex issues and there's a lot of different drivers behind them. And then we kind of oversimplify when we say like, "Oh, we'll control that blood pressure and we'll control that A1C, and we'll give you all those vaccines." And we're good doctors. I mean, that's not always what patients want. I mean, patients want a doctor who listens, who's a good diagnostician who's going support them.
[00:00:49] Dr. Cifu: We are back with another episode of The Clinical Excellence Podcast, sponsored by the Bucksbaum Institute. On this podcast, we speak to patients and doctors about all aspects of excellence in clinical medicine. I'm Adam Cifu, and today I am joined by Dr. Lisa Vinci. Lisa Vinci is an internist, professor of medicine, and a valued friend and colleague. She is the director of the Primary Care Group here at the University of Chicago, which makes her one of my many bosses. She is also the Associate Vice Chair for Wellness and Engagement for the Department of Medicine. Particularly germane to today's discussion, Lisa has co-directed the Quality Assessment and Improvement Curriculum, a required two-year longitudinal course in quality improvement for internal medicine residents. To name one more position, Lisa is also a Senior Faculty Scholar in the Bucksbaum Institute for Clinical Excellence. Lisa, thank you for joining me today.
[00:01:44] Dr. Vinci: Thank you for inviting me.
[00:01:46] Dr. Cifu: So for today's discussion, just to like, I don't know, lay some ground rules, I'm going to define quality measures as standards for measuring the performance and improvement of population health or health plans, providers of services, and other clinicians in the delivery of health care services. I got that off the internet. For internists, these kind of quality measures may be things like average A1C measurements for your patients, average blood pressure for people with hypertension, vaccination rates, rates of cancer screening, or even rates of annual Medicare wellness exams that have been completed. So, I'll go in hot. I'll begin hot here. I'm going to ask, why do you think achieving quality measures don't always mean providing excellent care? Like, do those always go together? Do they not always go together? What do you think?
[00:02:38] Dr. Vinci: I think quality measures are very basically defined and they're things that are easy to measure, right? It's easier to measure a level of diabetes control, a blood pressure, a vaccine rate, whether someone got a mammogram or not, but for the individual patient care is much more complex. I mean, for example, let me just give an example of diabetes, right? Our goal with diabetes is to get A1C to 7. 0. Okay? That's great. We know, at least on a population level, a 7. 0 improves outcomes, reduces strokes, reduces risk of kidney disease. However, for the individual patient, say, their A1C is 7. 3 and they're not meeting the measure that we would like them to meet, but their quality of life is good, they exercise, they're happy. They enjoy time with their family. They enjoy an occasional dessert. You're not technically meeting their quality, but they do have quality of care.
I think another interesting thing about the quality metrics, and this comes up a lot when I teach our residents, one of the quality metrics is getting colon cancer screening. And that was for a long time done by colonoscopy, which is a very big test, right? You have to be on a liquid diet for a day and then do this complicated prep that can be unpleasant and then come in, spend half a day getting a major procedure, have someone drive you home. Quite a burdensome test, right? And there's benefit to it but it's hard to estimate the benefit to an individual patient getting a colonoscopy. And the residents would say, "Well, I offered a colonoscopy and the patient refused." And I say like, "Well, I think 'declined' is a better term, right?" We offered them something that could be good for their health. We don't actually know in an individual person if it's going to have a big impact because that person may never get colon cancer. And, I mean, so we offer cancer screening, we offer vaccines. Patients have the right to decline those depending on the level of burden, their preferences, their beliefs. And then as long as we offer them education and can give them a good sense of the benefits, you know, sometimes people don't want every single preventative health and quality measure that Medicare or some health plan has decided that they should have.
[00:04:54] Dr. Cifu: So you made, I think, well, you made a lot of points, but two points which stuck out to me. One, you know, most of these quality measures measure something that's easy to measure, right? And we get into that problem all the time. I think much of education, right, we measure things that are super easy to measure. We then drive people to learn those things that we're going to measure when maybe that's not the most important thing for whether it be high school students, college students, or medical students to learn.
And then you also got a little bit to the fact that a lot of these quality measures, either the data behind them is weak, or maybe the data behind them is strong on a population level, but the hard part about evidence-based medicine is, you know, we treat individuals, right? But if I could just push back, I could say, well, listen, most of these things are pretty simple, right? So better, you know, average glycemic control is better. And sure, there are going to be outliers who you don't want to, you know, push as far, or who say, "Listen, my quality of life is better if I have an A1C of 8 versus 7." But overall, isn't it a good thing?
[00:06:16] Dr. Vinci: Well, I mean, you're, you're going into the gray zone here, right? You're saying like, "Well, there's some real outliers, and then there's some people right in the middle." And... But there's also... People come always along that continuum, right? Every single quality metric to achieve it requires some effort on the part of the patient. And that can be costly in terms of cost of medications. That could be costly in terms of just how they live their personal lives. I mean, every person is an individual, right? And what they value, what they are willing to do for their health, what they have the resources to do varies. I think actually physicians are a bit arrogant when they think that they sort of have control over someone's, you know, A1C, someone's blood pressure, someone's weight. I mean, these are very complex issues and there's a lot of different drivers behind them. And then we kind of oversimplify when we say like, "Oh, we'll control that blood pressure, and we'll control that A1C, and we'll give you all those vaccines." And we're good doctors. I mean, that's not always what patients want. I mean, patients want a doctor who listens, who's a good diagnostician, who's going to support them and respect them if they decide they don't want a colonoscopy.
[00:07:29] Dr. Cifu: Right, right. I love your sort of reference to, you know the unmeasured harm of achieving some of these quality measures, and it can be really subtle stuff, right? There can be opportunity costs that, boy, I'm spending so much time trying to get another couple of tenths of a percentage point to A1C that I'm not addressing the things that are most important for this patient. Or maybe what you were referring to is like, boy, it could really, you know, injure the doctor-patient relationship, maybe if taken far, and that may have costs down the line, right? Which there's like... There's no way to measure that. So we're almost measuring the things that are easy to measure and therefore sacrificing effort, attention to things that are difficult.
[00:08:19] Dr. Vinci: Yeah, we actually did some focus groups with our patients in our primary care practice, all African American and all who had hypertension. And they universally said what was missing, because we asked like, you know, what sort of resources, what support do you need to achieve better blood pressure control? And they, you know, pretty frequently said, "We want a doctor that listens. We want a doctor who takes into account our preferences, our needs, our lifestyle. We don't want more medicines given to us. We want actually more opportunities and support for lifestyle change," which is much harder to support someone through lifestyle change than it is to just give them another pill. I will say to the residents, our challenges in managing hypertension are not that we don't know which combination of pills to pick out. We're all very good at picking out pills, but helping a person sort of get motivated and achieve behavioral change to get to control of chronic illnesses is much more challenging than prescribing more meds.
[00:09:24] Dr. Cifu: So my next question, you know, I kind of know what you're going to say but I want to hear how you answer it because it's... You sort of alluded to it in your last comment, but do you think that people can... And people, I mean, doctors, you know, can achieve a good level of quality by these measures, right? Hit all of the goalposts for quality measure achievement and still provide poor care to patients.
[00:09:54] Dr. Vinci: I mean, absolutely. If you really push your patients hard to take more meds and to do all these measures, even... You know, do all that, do all those the cancer screening measures and all the vaccines, you can push them too hard so they feel almost bullied or coerced into doing things. And they're, you know, patients are very anxious to keep their doctor happy, especially their primary care doctor, if they have an ongoing relationship, which is actually kind of something we all leverage, right? We get people to do things we think are really important by sort of leveraging that continuity relationship. And it can go too far to the point where the patient feels like they're just doing these things for you, to keep you happy. It's not really that something they see as valuable.
[00:10:38] Dr. Cifu: Yeah. So this is maybe a little bit of, you know, therapy for me, myself.
[00:10:44] Dr. Vinci: Anytime.
[00:10:46] Dr. Cifu: As long as you don't charge me for it, you know, I'm having you on the podcast. You have to do therapy.
[00:10:51] Dr. Vinci: Send me a MyChart message. I'll charge you.
[00:10:53] Dr. Cifu: So, you know, I'm certainly aware of the data from many of the things that we take care of all the time, right? What's the benefit of a little bit better blood pressure control? What's the benefit of a little bit better glycemic control? You know, what's another 10 points in people's LDL bias, right? And what's shocking about medicine is that often the benefits of those things, certainly on a population level, are very small. On an individual patient, they're probably small, but they're also unknown, right? But sometimes when I negotiate with a patient, let's say, about, "Listen, your blood pressure is a little bit high, you know, you're not really at goal. I'm thinking about pushing up your medications," and they push back on me. And I think about, "Oh God, it's really not clear how much this is going to benefit them." And I'm like, "Okay, you know, spend another three months trying to exercise more and cut down on salt." I wonder how much of that is good informed medicine and how much of that is clinical inertia. And so when we complain about these measures, which we often do, I sometimes wonder, are we, I don't know, are we just taking the easy way out?
[00:12:20] Dr. Vinci: Right. No, I think we all struggle with that, right? Primary care visits are very complex. I mean, the patient often comes with concerns and complaints. And then you move on to chronic disease management and prevention and vaccines and cancer screening and then like how much weight and effort to put in each of those. It's a constant sort of balance and battle between an... Not a battle, but attention between an individual, right? And I just, I hate that term clinical inertia. Every time I've actually gone through... Like hypertension is one of the big areas I work on and I've actually gone through charts. I'm an old believer in chart review, right? Like you can't get everything out of a data analytics at Epic. And I will go through the charts of patients who saw their doctor and walked out of the clinic office without anything being done about their blood pressure. No new medication, no follow-up visit within a couple weeks. And to say like, well, that's clinical inertia, right? Like, why do these people not do anything? And I basically found three categories. One is that the patient didn't want anything done. The doctor offered medicine, tried to convince the patient to take it. The patient was like, "Nope, I want to keep working on my preventative health or on my lifestyle modification."
The second big category was just the patient was overwhelmingly complex. Like a mildly elevated blood pressure was only one of ten major problems. And the problems... Like, you know, having a blood pressure of 142 and the goal is less than 140 really is not relevant. That doesn't meet the quality metric, but it has no clinical relevance to that individual. So that was one. They had other overwhelmingly large problems that they wanted to focus on or the doctor needed to focus on because there was, you know, a threat of something more serious.
And then the last one, honestly, was the most fascinating and one of our most difficult is that people are checking their blood pressure at home now and they're checking their blood sugars at home with their continuous glucose monitors. And they're saying like, "Look, you wanted me to measure this stuff at home. I am measuring at home and it looks really good at home." So this one measure in the office is really, actually, we don't put trust in it and it's not really relevant, but actually it is the measure that goes into our data that now we get our little reports on and occasionally get paid based on.
[00:14:47] Dr. Cifu: I like... You're referencing, again, I think, some of the harm of this, and it is one of the things that I'm so aware of in visits where, you know, somebody is a little bit high, let's talk about blood pressure, you know, and, you know, there's the question, "Do I bring this person back?" Right? Do they need to come back to have their blood pressure rechecked to see if they're actually under better control than I think they are? And you very quickly, either because the patient expresses it or by their actions, recognize the hardship that that causes for a lot of people, right? Even if they're not paying for the visit, you know, they're paying for the cost of getting here, they're paying for parking, they're paying for time out, even if they're not working, you know, in the sort of commercial sphere, you know, maybe they're doing home care for, you know, their grandchildren or something. And I have worried that sometimes what happens is, I say, "Oh God, I got to see you back in a couple of weeks for this." I make the appointment in a couple of weeks. They don't come back in a couple of weeks because they just can't, you know, and then they don't have an appointment sort of in the future, right? And then what would have been a good three-month follow-up for that person ends up being, you know, a nine-month follow-up because they kind of get lost in the system.
[00:16:07] Dr. Vinci: Yeah. And not just lost. They feel bad. Like you wanted them to come back. They didn't come in or show up for your appointment. They really don't want to come back now because they feel like they're in trouble. When we did our focus groups, actually the average cost of transportation, either taking the bus or taking the parking, was 8 dollars per visit. And to some of these complex patients who are here three or four times a month, like it's a significant cost burden. The two biggest reasons people did not come to visits were transportation and childcare.
[00:16:41] Dr. Cifu: So, to finish up, let's sort of, I don't know, let's come up with the perfect plan going forward.
[00:16:48] Dr. Vinci: Oh, I have it.
[00:16:49] Dr. Cifu: Okay. Then I wouldn't even ask a question. Let me hear it. What is it?
[00:16:53] Dr. Vinci: So, the perfect plan coming forward, and there's actually emerging data on this, is that people need more primary care, they need more frequent visits, both virtual remote, and in person. And they also need access to their primary care doctor over MyChart and telephone calls, right? If you can... This is going to sound crazy, and this is just a study, you know, from some students that the optimal frequency of primary care visits is once a month for complex elderly patients. And seeing your own primary care doctor periodically, the same person, doesn't have to be a doctor. It could be a nurse practitioner. It's just that seeing the same person over and over allows you to build rapport. Trust allows you to work on chronic diseases over time, makes the visits less packed and intense. So there's more time for listening, communication. The big challenge, of course, is there aren't enough primary care doctors, primary care providers at this point to provide that kind of care.
[00:18:03] Dr. Cifu: And you think, and I know you're hypothesizing, you know, it sounds like you think that if that was provided, that it would actually lead to more personalized care where the people are achieving you know, whatever sort of measures are appropriate for them, because you'd be able to say, "Look, this is actually what the person can get to. I've gotten them as far as they can go, and we're holding the line there."
[00:18:33] Dr. Vinci: I think it would actually lead to better absolute achievement of the measures, right? So now instead of a hurried visit where you're trying to, you know, convince someone of a colonoscopy in the last two minutes of the visit, you may actually have opportunities to talk to them more about it, to allay their fears, to talk them through a prep, to reschedule it if it was missed and they hadn't scheduled it because a lot of people say they'll do a colonoscopy and then actually don't follow through with it. Or now there are other and easier options for colon cancer screening.
So I think it would just give docs and patients more time to consider the benefits, tailor medicine to the individual. Take some of the kind of high stakes pressure off, you know, meeting the... You mentioned annual wellness visits. I mean, the annual wellness visits are...
[00:19:23] Dr. Cifu: We don't even need to talk about it.
[00:19:25] Dr. Vinci: We don't need to talk about it. I mean, whether they bring benefit over regular primary care visits is unclear. Probably, in patients that never come in, they're helpful because it gets them in.
[00:19:37] Dr. Cifu: So let me... I was going to say, don't let me put words in your mouth. I know you would never let me do that.
But so it sounds like maybe you're less negative about these quality measures, but you almost feel like what's happened is that the quality measures have been put in before the entire, like, primary care industry, you know, is equipped to achieve them. And therefore, they're actually probably causing more harm than good.
[00:20:10] Dr. Vinci: Absolutely. I agree we have not built the infrastructure, the staffing, the nursing support, the ease of access to a primary care doctor or provider that we need to optimally achieve quality. That said, I mean, our pursual of these quality metrics has made a massive difference, right? We are getting people vaccinated. We have driven down the... We have increased the rates of hypertension control. I mean, hypertension in our local community on the South side is the biggest driver of death and disability. We are improving diabetes rates... Diabetes control, even as rates are going up. So that's a big... So there's many, many benefits to having quality metrics, to measuring them at the population level, at the health system level but I think the kind of implementation at the doctor-patient relationship level can be very complex and it's thought of as simple, but it's quite complex. And to optimize it is to basically give doctors more time and support to do it well, and to gain alignment with the patient and have the time to better understand the patient's values.
[00:21:20] Dr. Cifu: So what I'm hearing is that, you know, the way we should be using these polymetrics are to say, "Oh, they're not being achieved, that doesn't mean that the doctor's lazy, should have salary docked, you know, their practice should make less money." It should be, "Huh, you know, this is probably telling us that, you know, we'll assume that most doctors are trying to do a good job, but that this practice is kind of not equipped to take care of the probably overwhelming numbers of patients that they're taking care of." And the response to like, "Ah, there's poor hypertension care in this group," should be, "How can we improve the systems these doctors work under, the number of doctors, the number of, you know, support staff, the number of nurse practitioners who can actually, you know, work to get these numbers under control over time."
[00:22:16] Dr. Vinci: Absolutely. You said exactly what I'm trying to communicate.
[00:22:20] Dr. Cifu: What you scream about constantly, right?
Well, Lisa, thank you very much for talking. I love when conversations that begin in the clinics spill out onto the podcast.
So thanks for joining us for this episode of The Clinical Excellence Podcast. We are sponsored by the Bucksbaum Institute for Clinical Excellence at the University of Chicago. Please feel free to reach out to us with your thoughts and ideas via the Bucksbaum Institute webpage or on Twitter, X.
The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.