Many hospitals and hospital systems are trying to ensure that they are satisfying quality metrics to help with accreditation, and to confirm that they are satisfying their mission and providing community benefit. Superior performance in achieving clinical quality may allow an institution or system to acquire a competitive advantage. However, the definition and measurement of excellence is clearly more credible if from an independent source. In many ways participation in a disease based clinical registry will be the optimal way for institutions to know what they are really doing with respect to clinical quality. The most recent definition of what constitutes a credible registry is in the 2010 AHRQ publication on registries. AHRQ defines a registry as “an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure,” Usually registry participation is across several systems (as in the New York State, Northern New England, or national medical association registries). In some very large health care delivery systems, the registry may be developed and maintained within the system (as in the Intermountain, Kaiser, or Geisinger systems). Registries can be used to develop rankings in quality measures. In addition, they can help institutions or groups understand rare diseases/conditions, or the outcomes of various therapies or results of implants. In almost all instances, registries reflect the real world rather than the somewhat artificial constraints of experiments (clinical trials). The size of effects will usually be less marked than those seen in the initial clinical trials. Thus, participation in registries will help improve the real scientific basis of medicine (“Evidence Based Medicine”).
Most other reporting methods of institutional performance have major shortcomings.
Measures of the process of care for conditions such as Acute Myocardial Infarction, Heart Failure and Pneumonia, often called “Core measures”, actually encourage a rush to mediocrity. They generally are summaries of what one of my colleagues is fond of calling “Checking the box”. There is a place on a report form to say, “I probably thought of this”. However, checking the box does not really ensure the robustness of the intervention that allowed the box to be checked. For example, everyone knows that smoking cessation in smokers is a valuable health outcome. The box on a discharge form can be checked if the patient is given a preprinted form that says, “stop smoking”. A more difficult, but probably more effective, intervention is to sit down with the patient who is a smoker, assess the smoking habit, assess willingness to quit and then help the physician institute a comprehensive behavior modification program, either with or without some pharmacologic adjuncts. Both allow the box to be checked.
CMS, in its hospital compare website, does report outcome data, which are more rigorous than process measures. However, providers frequently complain that these data, which are often approximately a year old, are dated. Everyone that I have talked to has said to me, “Those are old numbers, we are now doing better than that.” Often on review of updated numbers they didn’t really improve.
Many other data sources do give “benchmarks” and allow one to rank oneself. One complaint is that to provide data to these is expensive and may not have a real ROI (that is, drive more paying patients to the hospital). On the other hand, participation in most registries facilitates providing CMS and other payers many of the requirements for public reporting. This physician and system benefit works for both employed physicians and your independent physicians who will feel a greater sense of affiliation (alignment) to a system or institution, because it helped them do a better job.
Rankings such as Thompson, Health Grades, USNWR and others are often fraught with difficulties. In the early 1990s, one Chicago hospital system had a high grading from a national ranking organization, and the next year was investigated by HCFA (the predecessor to CMS) for financial and clinical irregularities. Most hospitals appear on someone’s top 100 hospitals of some kind or other.
On the other hand, registry participation, with groups such as the national cardiovascular and oncology systems has been a way to ensure that hospitals or systems are working toward optimal care. While the initial Cancer Cooperative groups were and still are means of collecting large amounts of data on cancer participation they also helped move participants toward practicing to a national standard.
Participants registries have almost uniformly improved performance and have seen provider and patient satisfaction increase, which makes for a marketing (Public Relations) bonanza. Helping with registry participation is a low cost way for institutions/systems to improve alignment with physicians, and to demonstrate superior performance to payers.
For a listing of some of the premier registries and their web address, send us an e-mail. We will send our version to you.
September 4, 2011
Recent reports from the European Society of Cardiology meeting held in August 2011 have confirmed the proposition that registries are going to be more and more important as we continue trying to improve medicine