Published 10/1/2018

Patient Safety Committee Discusses Using Overutilization as a Quality Measure

Patients’ misconceptions are another topic worth tackling

When orthopaedic surgeons think of quality and safety, things like medication errors, wrong-site surgery, and hospital-acquired infection often come to mind. To be safe and improve quality, we adopt computerized order entry, utilize the World Health Organization checklist, and wash our hands going into and out of every patient’s room. And we measure our performance.

When it comes so-called shared decision making, most of us think, “I do that well.” But do we really? Patients’ expressed preferences are often based on misconceptions rather than true values. Physicians may not realize how much their own biases affect the diagnostic and therapeutic options they offer. To ensure that patient choices reflect patients’ own values rather than misconceptions or physician biases and incentives, the shared decision making process is sometimes framed as a more compelling quality and safety issue: misdiagnosis.

Examples of misdiagnosis of patient preferences include prescribing antibiotics for a viral upper respiratory infection or sinusitis or ordering an MRI for low back pain. Patients often request such treatments, sometimes vehemently, even when the therapies are at odds with their core values. Moving past patients’ expressed preferences to those more consistent with their values depends on highly effective communication strategies. Yet patients rate the communication effectiveness of orthopaedic surgeons lowest among all specialists.

Recently, members of the AAOS Patient Safety Committee (PSC)—David C. Ring, MD, PhD, PSC chair; Michael R. Marks, MD, MBA; Dwight W. Burney III, MD; Ramon L. Jimenez, MD; Alan M. Reznik, MD, MBA; Michael S. Pinzur, MD; and Nina R. Lightdale-Miric, MD—met to discuss another strategy to limit misdiagnosis of patient preferences that may be compelling: using overutilization (low-value care) as a quality measure.

What follows is a compilation of their discussion.

Dr. Ring: The first article of a new JAMA professionalism series proposed that overutilization of tests and treatments be considered a quality event that should be reviewed by hospital quality committees and at morbidity and mortality conferences. What do you think of the idea of overutilization as a quality measure?

Dr. Pinzur: This is evident in the statistic that orthopaedic surgeons who own an MRI machine are seven times more likely to order the test than those who don’t. I see two issues. First, defensive medicine: “We better do everything so we don’t miss anything,” which inadvertently finds unhelpful things that people find difficult to ignore. Second, greed: Low-value tests and treatments are lucrative. It can be hard to draw the line between the two.

Dr. Ring: My impression is that the most pressing issue is a patient feeling like, “My only hope is for you to find this problem and fix it.” I don’t want to disappoint people or make them angry. I don’t want them to lose hope. I want their primary-care doctor to refer more patients to me. I don’t want a bad review. I’ve found it easier to make these topics compelling if we leave aside the judgment and cynicism and say, “I’m right there with you. Those are tough days in the office.”

Dr. Burney: Another compelling paradigm is the amount of Medicare funds that are spent in the last year of a patient’s life. We need to improve our communications with patients about how they prefer to close their lives.

Dr. Ring: In some cases, patients haven’t thought about values and preferences or discussed them with family members. What if we take that end-of-life scenario and transfer it to all of medicine? For example, when patients are considering whether and when to have total knee replacement or an MRI of an aching back or shoulder, we need to explore their values and check that their preferences are consistent with their values. Patients find it difficult to understand how a test could be harmful, misleading, or low value. They are, therefore, at risk of choosing a test that is not consistent with their values. We need strategies and tools that help people better understand probability, uncertainty, and risk. These concepts are difficult to understand and can be counterintuitive.

Dr. Jimenez: Many patients request an MRI. But when they understand that it is most frequently used to plan surgery, they say, “Surgery? Oh, I don’t want surgery.”

Dr. Ring: For about 20 years now, AAOS has bolstered effective surgeon-patient communication via the Communication Skills Mentoring Program. Surgeons think, “Wow. I’d love to help patients correct misconceptions and make choices consistent with their values, but I just don’t know how to begin to talk to a patient about it. They get mad at me if I don’t do this or that. I have to order the test, or I’ll get sued.”

Dr. Jimenez described one technique. Start with affirmation: “Yes. We can get an MRI.” Then move to a complex reflection: “MRI is one step toward surgery. You’re thinking about surgery?” This type of reflection helps people explore their values. Often, people are unaware of their values and how their preconceptions might not be in line with their values. Ineffective communication takes the form of trying to convince, whereas effective communication tactics avoid contention or argument.

Decision aids are another useful tool. These can be a video, pamphlet, or website, but I find them most useful as interactive, web-based tools, which can be balanced, dispassionate, and helpful to gently correct misconceptions. “Why don’t you go over this information, and I’ll be back in 10–15 minutes?” Then, “Are you a little unsure? Why don’t you take it home, and I’ll give you a call in a few days?” These tools and skills can save surgeons time because they avoid fruitless debates and repeat explanations.

Dr. Marks: We should always ask ourselves, “What’s the consequence of ordering that test, and is it going to have an impact?”

Dr. Ring: In a brief time during this discussion, we’ve identified several types of overutilization that could be considered quality measures. We also appreciate that tests and treatments are often obtained to avoid difficult discussions and that a key to appropriate utilization is effective communication strategies. For instance, in my specialty of hand surgery, you might be the outlier because you perform diagnostic wrist arthroscopy (expensive, low-yield diagnostic surgery), so you can justify telling the patient there is nothing wrong. What if that becomes something that you are asked to publicly justify? What if your rate of diagnostic wrist arthroscopy, relative to the average, becomes a discussion point at morbidity and mortality rounds because you may be exposing people to unnecessary risk?

Dr. Marks: People working in a Bundled Payments for Care Improvement Advanced Model are looking at rates of arthroplasty in patients who are morbidly obese or have poorly managed diabetes. That’s a type of overutilization. The priority should be on other aspects of their health, but in the past, the incentive may have been on volume rather than quality.

Dr. Ring: People in arthroplasty bundled payments are now interested in symptoms of depression and catastrophic thinking because excessive worry about the appearance of a wound may lead to antibiotics or readmission. Further, stiffness from catastrophic thinking may lead to a second anesthetic for knee manipulation. This example illustrates how utilization as a quality measure has improved the quality and safety of care by inducing surgeons to think about patients’ mental health along with their physical health.

Dr. Lightdale-Miric: Are we going to stand as a group and define appropriate use? It may help to come to a consensus.

Dr. Ring: Overutilization is probably not the best word because it does imply some agreed-upon threshold that is evidence based. A more useful framework may be ensuring that patient preferences match their values. Substantial variation among surgeons also reflects inadequate influence of patient values.

Dr. Lightdale: Is there a role for a dashboard and transparency? For instance, “What do you think of how many times you transfused this month?”

Dr. Ring: That’s the Brent James, MD, approach, of Intermountain Health. There is good evidence that it does change practice. The American Society for Surgery of the Hand, along with AAOS, is consider proposing quality measures for new federal programs, and we did look at utilization. Using national claims data, we found that a certain percentage of patients with carpal tunnel syndrome get MRIs and probably none of them should. These examples would be nationally reported measures.

Dr. Burney: I really think you’re talking about the value of care. It doesn’t have much chance of helping the patient or meeting his or her needs and goals, which are what we probably might have identified in the beginning. We’re talking about low-value care, a term that’s in popular usage. It’s a little less emotionally laden than the term overutilization. Appropriateness is emotionally charged, too. It’s important to use a term that won’t put people on the defensive. We need more people who are willing to sit and talk about this topic.

Continue the discussion

The PSC hopes this discussion helps broaden the concept of quality and patient safety. More than omission and error, sometimes commission can do harm. Your ideas about how to make these quality and patient safety ideas more appealing and compelling are welcome.