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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Bridging the research chasm
Crossing Our Quality Chasms
Another Case of Pay for (Bad) Performance?
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Thomas E Kottke, Minneapolis, MN USA Medical Director for Evidence-Based Health, HealthPartners
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In their book, The Innovator's Prescription, Christensen, Grossman and Hwang write that "the inadvertent result of [the NIH review system] of sending proposals for review by the scientists with the deepest expertise in the specific topic is that it has "silotized" the structure of scientific work into ever narrower disciplines and subdisciplines. . . But if the proposal intends to push knowledge in a different direction-- crossing the boundary into a different scientific domain--the proposal tends not to be viewed as positively. This is in part because most reviewers aren't comfortable vouching for the scientific potential of something beyond the boundaries of their own domain, and in part because it doesn't deepen knowledge in the direction in which their work and reputation are building." (page 372) Until the NIH agenda is transformed to "optimizing practice through research", the agenda will be developed without attention to the intermediate needs of care delivery process improvement. Without research addressing care delivery process improvement, the inefficient agenda-setting process will persist and health care improvement will continue to evolve at an agonizingly slow pace. The book is well worth reading by anyone who has a stake in the transformation of health care despite the fact that the authors have overlooked the potential of lifestyle interventions to reduce health care expenditures--a person who isn't sick doesn't have health care costs. Competing interests: None declared |
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Joseph E Scherger, San Diego, CA Clinical Professor, University of California, San Diego
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Solberg, et al, from the NAPCRG Committee on on Advancing the Science of Family Medicine provide a tour de force article. As the only family physician on the IOM Committee on the Quality of Health Care in America that wrote Crossing the Quality Chasm, I believe the Committee would have welcomed this analysis. Why Americans do not consistently receive the best care at the time of service is complex, and this article provides insight and five excellent recommendations. I would add a sixth. The process of primary care and family medicine must change to deliver higher quality care. Two major developments, available today, must occur. First we should stop trying to provide are off the top of our heads and embrace computerized knowledge management and clinical decision support. Other HIT applications will help us raise the bar of quality. Second, we must stop trying to do complex work during episodic brief encounters. The first rule in Crossing the Quality Chasm is that care should be based on continuous healing relationships (and not on visits). When the complexity of the patient are continuously connected to the resources of the care system, much higher quality of care will be possible. Competing interests: None declared |
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Michael S. Victoroff, Denver, CO, (USA) Chief Medical Officer, Lynxcare, Inc.
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One of the headlines to take from this article seems to be, "Researchers and publishers produce the wrong products because they are paid to -- just as clinicians are." It's commonly said, but rarely responded to, "We have exactly the system that we bought." The authors seem to be telling us that what keeps the lights on in research centers, academic departments and publishing houses may be a system of poisonous incentives, (analogous to what "procedural coding" has wrought upon clinical practice). When clinicians do what we wish they didn't, and fail to do what we wish they did, it's often because they are frozen in a culture of rotten incentives. Likewise, researchers might be discouraged from investigating the things we need to know, because of the hazards of discovering things we do not wish to learn. My suggestion would be to fund less research into proving that family medicine is wonderful (and only our pathetic salaries keep us from being perfect), and fund more research into finding out what's wrong with family medicine, which I consider a failed state. Competing interests: None declared |
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