What is Quality Healthcare?

Regardless of the recent political arguments, healthcare in the United States is more accessible at a higher level of quality than anywhere else in the world.  It is not a perfect system by any standard. But on any given night, a homeless person in a city in the United States with acute appendicitis may access the system and receive the exact same care, the exact same surgeon and the exact same operation as the mayor.  That seems fair, and humane, and the care that God would want for His children.

So the big distraction in healthcare is not the way in which the system itself is set up but in how the system is financed.  Some think the government should just take care of all of the cost and we can just pay for it with higher taxes.  Others think it would be cheaper if all the waste was taken out and so more “vertical integration” and oversight are introduced.  Still others feel that the current system works well for the majority and should be left alone lest a great system for most is lost in favor of and substandard system for all.  All valid approaches.

But the point is that finance is a distraction from the actual activity of healing.

Financing the system is not the primary activity.  It is a necessary activity in support of and subordinate to the primary activity of healing.  Recently, this point has become confused.  In the corporate and regulatory sense, the word quality has been substituted for cost control.  And while it can be argued that cost effective care is a part of quality care, the clinical definition of quality has been dominated by the economic definition.  Simply put, what is cheaper is more important than what is best and the science for this follows the need for cost control rather than leading or determining what is clinically best.

Take for example the prophylaxis of thromboembolic disease, i.e. the prevention of deep vein thrombosis and pulmonary embolus.  There is little debate among the pharmacokinetics and scientific community that low molecular weight heparin is a better drug than aqueous heparin from the standpoint of efficacy, bioavailability, and safety. 

So why are healthcare institutions going back to aqueous heparin for prophylaxis?  Because of cost.  Is there any data to support it?  Yes.  Several studies have touted the cost effectiveness and the efficacy of a return to aqueous heparin.  Typically it is a small sample size (denominator) which when coupled with a low incidence of the disease (numerator) always yields a clinically equivalent outcome.  And this is great… unless you are the one.

So what is quality in healthcare?  Who gets to define it?  Is it a clinical definition or a financial one or is it based on actuaries?  Obviously, it includes all of the above.  But for those of us who care for one patient at a time, does the current definition of “quality” meet the clinical standard of excellence in healing.  Healing is a clinical concept, which combines the subjective components of standard of care, clinical outcome, and patient experience.

It is important to separate this ideal of healing from the important supporting activity of what we can afford.  What we are striving for at the bedside is a different question than how to pay for it.  Currently, we are confused about that point.