Philip van der Wees: Patient preferences to distinguish between good and bad practice variation

Philip van der Wees“Keeping good practice variation and reducing bad practice variation is a main driver for quality improvement in healthcare.” With this key message, Albert Mulley, professor at the Dartmouth Center for Health Care Delivery Science in the United States, summarized his keynote presentation at the fourth conference of the Scientific Institute for Quality of Healthcare at Radboud University Medical Center. His message revealed an essential dilemma, in assessing the quality of patient centered healthcare at the individual patient level, versus quality assessment at the healthcare system level.

Gert Westert, head of the Scientific Institute for Quality of Healthcare, concluded in his talk that valid and reliable measures of patient centered care exist, but few of these measure all the aspects that matter to patients. He also concluded that the research evidence for the effects of patient centered care on outcomes of care is mixed, and that further investment in this type of research is needed.

Inger Ekman, from the University of Gothenburg in Sweden, further elaborated on the concept of person centered care. She showed remarkable and promising results from local studies, which showed that person centered care reduced the length of stay for inpatient care.

Patient centered care requires shared decision making at the individual patient level, which means taking the preferences of the patient into account. Patient preferences lead to diverse clinical decisions, depending on the clinical and personal context of the patient. Mulley phrased a lack of recognition of context by clinicians as “the silent epidemic of preference misdiagnosis.” Clinicians think that they know what is best for their patients, but oftentimes forget to incorporate patient preferences and to discuss alternative options with them. Therefore, good practice variation is related to clinical and personal differences, and is crucial to high quality healthcare.

Bad practice variation can be caused by professional uncertainty or ignorance. With the establishment of evidence based medicine, clinicians should incorporate the available evidence into their clinical decision making. Evidence based guidelines provide recommendations for clinicians in making their day to day decisions. Strong recommendations are typically based on high quality evidence and should be followed in most clinical situations. Weak recommendations may represent low quality evidence for a certain treatment, or for which alternative treatment options are available. Weak recommendations are therefore more sensitive to patient preferences. Therefore, bad practice variation is related to a lack of adherence to existing evidence.

A crucial component in evaluating and stimulating the quality of healthcare is to learn from practice variation. At the individual level, peer assessment on specific patients is useful to distinguish between good and bad practice variation. If clinicians discuss their clinical decisions in a safe environment with their colleagues, it is likely that they will learn from the feedback of their peers. Feedback should include aspects of the process and outcome of care—all in relation to the available evidence and the patient’s preferences—and by continually feeding back data in this way, clinicians can feel supported in such a learning environment.

When measuring the performance of healthcare providers by comparing outcomes of groups of patients, detailed information about individual patient preferences is usually not available. It will therefore be more difficult to distinguish between good and bad practice variation at the group level.

Although the “average variation” in performance between provider organizations can be calculated, it is important to evaluate the underlying mechanisms that lead to variation. Case mix correction for patient characteristics is an accepted approach to understanding some of the variation in practice, but this does not include patient preferences in patient centered care. It is therefore crucial to integrate the use of outcomes in clinical practice at the individual level, and for performance measurement at the group level. However, the measurement of outcomes to support patient-provider decisions, and the use of performance measures to evaluate healthcare providers, operate in two separate spheres [1].

The key messages of Al Mulley and Inger Ekman initiated further discussions in the unique setting of the conference, with participation and presentations from both patients and clinicians under the theme: “Nothing about me without me.” Emma Schell, a patient with a progressive neuromuscular disease, was interviewed on stage by Dr Myrra Vernooij-Dassen. She emphasized the need for shared decision making in patient centered care, and clinicians confirmed the importance of patient-provider partnership.

Policymakers and purchasers of care recognized the importance of integrating the use of outcomes in clinical practice and for performance measurement. The fruitful discussion chaired by Dr Jan Kremer contributed to establishing a shared vision between patients, clinical professionals, and purchasers to stimulate patient centered care and to incorporate patient preferences in evaluating the quality of healthcare. The quality of the clinical decision making process is crucial and essential for patients. Clinicians may see this as a process measure and therefore subordinate to clinical outcome, but patients feel that process is an important aspect of their health outcome.

[1] Van der Wees PJ, Nijhuis-van der Sanden MWG, Ayanian JZ, Black, Westert GP, and Schneider EC. Integrating the Use of Patient-Reported Outcomes for Both Clinical Practice and Performance Measurement: Views of Experts from Three Countries. The Milbank Quarterly, 2014 [forthcoming].

Philip van der Wees is senior researcher at the Scientific Institute for Quality of Healthcare (IQ healthcare), of Radboud University Medical Center, the Netherlands. He is also affiliated with Celsus, the academy for sustainable healthcare. His research projects are aimed at quality, implementation, and evaluation of healthcare.

Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests:

• Employed by Radboud University Medical Center, Nijmegen, the Netherlands (2013-present).
• Harkness Fellow of the Commonwealth Fund, Harvard Medical School, Boston, MA 2011-13.
• Employed by the RAND Corporation, Boston, MA (2012-13).
• Chair of Guidelines International Network (G-I-N) (2010-12).
• Project grant by the Royal Dutch Society for Physical Therapy (KNGF) to evaluate patient reported outcomes for quality improvement and transparency of care.