Changing Physician Practice Behavior

A diagnostic approach

Too many advocates of quality improvement champion their method as the only way to improve care. Hospitals, practices, and health systems often seize on a particular approach for improving quality, perhaps because it is easier to organize programs around a single theme. But there are no “magic bullets.”³¹ Seasoned clinicians know this; they understand that proper treatment begins with a good diagnosis. The first step is to “find the lesion,” to determine precisely why the guideline is not followed. Knowing whether the barriers involve knowledge, attitude, ability, or reinforcement is the starting point for designing a targeted solution. The alternative is quality improvement by reflex. No physician can improve everything at once, and this is especially true for primary care physicians because of the spectrum of diseases for which they care. Their special need to set priorities makes a rational diagnostic approach to quality improvement essential.

Seeking outcomes that matter

The study by McBride and colleagues reminds us that the utility of outcomes research often depends on the outcome measures. An effect on surrogate or intermediate end points, such as better use of medical records, does not prove beneficial for patients unless data suggest that a change in such measures improves health.³² Smoking illustrates the ideal surrogate measure because of the strong evidence linking it to disease. Too many researchers rely on less-validated surrogate measures, either because more distal health outcomes are hard to quantify or because statistical power concerns demand too large or lengthy a study. Using surrogates is easier, but it has yielded a profusion of outcome studies that fail to tell us whether patients benefit in ways that matter. It would be better to do fewer studies and conserve the resources for a definitive investigation that gives patient-centered outcomes the attention they deserve.