Abstract
Controversy exists surrounding how to best define and assess quality in the health care setting. Clinical practice guidelines (CPGs) have been developed to improve the quality of medical care by highlighting key clinical recommendations based on recent evidence. However, data linking CPGs to improvements in outcomes in otolaryngology are lacking. Numerous barriers contribute to difficulties in translating CPGs to improvements in quality. Future initiatives are needed to improve CPG adherence and define the impact of CPG recommendations on the quality of otolaryngologic care provided to our patients.
Defining Quality
In recent years, quality has become a topic of intense focus in medicine. Medical quality is defined as “the degree to which health care systems, services, and supplies for individuals and populations increase the likelihood for positive health outcomes and are consistent with current professional knowledge.” 1 Despite advances in science and technology, the health care delivery system fails to consistently provide quality medical care to patients. This point was highlighted in the 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century, where the authors identified 70 publications in peer-reviewed journals that documented serious quality shortcomings. 2
Numerous controversies exist regarding quality in medicine. For example, what is the best way to assess quality in health care? What outcomes are important when defining quality? These questions are particularly relevant as the Merit Based Incentive Program (MIPS) of the Affordable Care Act ramps up over the next several years. The paradigm for reimbursement for medicine is shifting to be based on quality. In the upcoming years, physicians participating in the Medicare program will begin reporting on quality measures or face financial penalties.
Recently, numerous national medical organizations have made the development of clinical practice guidelines (CPGs) a priority. CPGs aim to improve the quality of medical care by translating medical evidence into practical clinical recommendations. According to the American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) Clinical Practice Guideline Development Manual, CPGs promote quality by reducing health care variations, improving diagnostic accuracy, advocating for effective therapy, and discouraging ineffective interventions. 3 Indeed, the very process by which CPGs are developed is “quality driven” using current best evidence to formulate key action statements. 3
Do CPGs Improve Quality?
It is essential that we as otolaryngologists be engaged in defining quality for our specialty. According to the Centers for Medicare & Medicaid Services (CMS), quality measures are tools that measure health care processes, outcomes, and patient perceptions that are associated with the ability to provide high-quality health care. Quality measures are aimed at promoting effective, safe, efficient, patient-centered, equitable, and timely care. One common source for the identification of quality measures is CPGs. Other medical specialties have used CPGs as a source for quality measures. For example, the National Kidney Foundation–Dialysis Outcomes Quality Initiative (NKF-DOQI) CPG outlined a list of evidence-based recommendations regarding the provision of high-quality dialysis care. 4 In 1998, CMS partnered with a health care quality improvement organization to assess the feasibility of translating NKF-DOQI CPG recommendations into clinical performance measures that could be used to assess the quality of dialysis services. By involving a range of stakeholders in the renal community, a set of 16 performance measures were identified from the NKF-DOQI CPG and pilot tested over 9 months. The AAO-HNSF has recently undertaken a similar process to identify CPG statements that can be used for quality reporting for our specialty.
While CPGs are excellent resources for the development of performance measures, there are limited data that CPGs actually improve patient outcomes. In a recent cardiology study, adherence to the European Society of Cardiology CPG was associated with improved outcomes in patients with heart failure. Patients with heart failure who were treated beta-blockers according to the recommendations outlined in the European Society of Cardiology CPG demonstrated a significant survival benefit. 5 A search of the otolaryngology literature failed to identify any publications that demonstrated definitive improvements in health care quality following the development of CPGs. A recent large database review 6 compared outcomes in children undergoing tonsillectomy before and after the publication of the AAO-HNSF Tonsillectomy in Children CPG. 7 The authors described an increase in the administration of dexamethasone and a reduction in antibiotic usage in children undergoing adenotonsillectomy. 6 However, there was actually an increase in hospital revisits for tonsillectomy-related complications (primarily related to poor pain control) following CPG publication. Thus, the authors concluded that while the Tonsillectomy in Children CPG was associated with improvements in perioperative care processes, there was not a significant benefit in terms of outcomes.
Numerous barriers contribute to the difficulty in translating CPGs into improvements in health care quality in otolaryngology. First, CPGs are primarily focused on quantitative data with less inclusion of qualitative measures. This represents a shortcoming of CPGs as patient-related outcomes such as satisfaction are typically qualitative in nature. Adherence to CPGs also remains a challenge. A gap often exists between CPG recommendations and implementation in clinical practice.8,9 For example, a study by Darrat et al 9 showed poor adherence among otolaryngologists to the AAO-HNSF CPG on Adult Sinusitis.
Future Initiatives
Ultimately, the goal of CPG development is to improve the quality of care our patients receive. Clinical registries can be used to help bridge the gap between CPGs and the provision of quality health care. Such registries enable clinicians to report on quality measures and receive feedback regarding their performance compared with benchmark data. Other specialty societies such as the American College of Cardiology and the American Academy of Ophthalmology have had success in using large clinical registries to track quality. These registries provide timely feedback to clinicians and allow for rapid-cycle improvement for identified quality measures. Future studies are needed to assess whether such processes lead to improvements in health care quality.
Conclusion
While CPGs are developed with the intent to improve quality, there is little evidence that they are associated with enhanced outcomes. Future research is needed to clarify the impact of CPGs on quality in otolaryngology.
Author Contributions
Disclosures
Footnotes
Acknowledgements
This manuscript is being submitted as part of the AAO-HNSF G-I-N Scholars Program. The commentary was inspired by topics discussed at the G-I-N annual meeting in the fall of 2016.
No sponsorships or competing interests have been disclosed for this article.