PAD in Focus

Variation is the Enemy of Quality in CLI Treatment

Critical limb ischemia presents tremendous challenges that cannot be neglected or ignored. It is associated with incredibly high rates of morbidity and mortality. Clearly, the medical system is not adequately addressing the needs of these patients. I suggest that some of the flaws in the way we care for patients with CLI are emblematic of larger flaws in the U.S. health care system, and that an emphasis on consistency and team-based care may lead to improvements for these patients and our system.

There is a lack of team-based health care in our system, and this is especially detrimental for the care of patients with CLI. We are in a field in which we typically compete with others who should be on our team. Upcoming reforms in health care, especially pertaining to compensation, are likely to force us to offer more team-based care in the future. This makes for an opportunity for early adopters.

Christopher J. White

The Problem of Variation

Everywhere in medicine, variation is the enemy of quality. Every time we look at variation, we have a quality problem that gets better when variation is reduced. This is not to suggest that we need to be 99% protocol-driven. But certainly two-thirds to three-quarters of patients can be managed on protocols, and we can document when we don’t need to use those protocols.

Contributing to the variation is that we have so many tools and devices with which to treat patients with CLI, but we rarely stop to measure their efficacy. We almost never assess how much more valuable or effective one is over the other, and how that affects cost, morbidity and mortality. We simply adopt these devices and use them however we please, which contributes to heterogeneity and variation. And after a number of years, when we try to write a document about appropriate use, there are no good data on which to base recommendations, only expert consensus.

The variation in treatment of CLI in Vascular Quality Initiative centers is startling. Some centers treat every CLI case with bypass, whereas others treat every case with endovascular interventions, and there is a wide range in between (see Figure). There is tremendous heterogeneity in how we practice care of CLI, and it is bad for our patients. We need to build a better mousetrap.

Some Practices Must Change

Now that the era of accountable care is here, and CMS holds so much power over physicians, we must improve quality and reduce waste. This means reducing variation, becoming patient-centered and doing outcomes reporting.

There are several drivers of poor performers. Some providers are focused on productivity and driven by overutilization. Thankfully, this behavior has become rare. More of a problem is providers driven by the mentality of “the patient wants it.” We are training a generation of young physicians who think that patient satisfaction means giving a patient what he or she wants, not taking the time to explain what they need. What matters is not that patients are happy, but that they are well. We have to engage patients in the decision and make sure they understand the rationale. But we get it wrong when we provide unnecessary care just because it makes the patient happy.

In addition, some doctors do not understand how appropriate use criteria works and many of us do not document adequately to allow accurate risk adjustment or coding and billing. Addressing these problems will improve the quality of patient care, and they ought to be able to be solved by education.

We also need to change our clinical practice to reduce variation. Physicians must give up some of our autonomy in exchange for better quality and safety.

New Systems and Behaviors

Providers that cling to today’s systems are going to become dinosaurs. Maintaining the current cost structures despite the need for more transparency and the falling of reimbursement levels is not tenable. The organizations that consider these challenges as opportunities, that master the value agenda, will get ahead and become the winners.

How does this fit into the context of CLI patient care? We need to merge practices among cardiologists, vascular surgeons, wound care specialists and interventional radiologists to encourage team-based care. We need to implement an inclusive vascular services model that takes advantage of the strengths of all the subspecialties that treat these patients; that is, we need to offer true multidisciplinary care. We need to develop a system to review cases for quality assurance, and publicly report our outcomes, so that we are transparent about our results. Finally, we need to talk to our primary care doctors who carry the burden of seeing these patients on a day-in and day-out basis. We need to include them in the decisions we make. We need to get their input on some of the chronic illness issues that are so prevalent in patients with CLI.

Endovascular specialists also need to understand that we must tackle the problem of CLI before revascularization comes into play. The best treatment of this disease is not found in the cath lab, it is found in getting patients to take high-intensity statins, to quit smoking and to get their BP and HbA1c levels under control. Particularly in patients with peripheral artery disease and the subset at risk for CLI, we need to treat them aggressively with medical therapy, and then apply revascularization as best we can.

Disclosure: White reports no relevant financial disclosures.

Critical limb ischemia presents tremendous challenges that cannot be neglected or ignored. It is associated with incredibly high rates of morbidity and mortality. Clearly, the medical system is not adequately addressing the needs of these patients. I suggest that some of the flaws in the way we care for patients with CLI are emblematic of larger flaws in the U.S. health care system, and that an emphasis on consistency and team-based care may lead to improvements for these patients and our system.

There is a lack of team-based health care in our system, and this is especially detrimental for the care of patients with CLI. We are in a field in which we typically compete with others who should be on our team. Upcoming reforms in health care, especially pertaining to compensation, are likely to force us to offer more team-based care in the future. This makes for an opportunity for early adopters.

Christopher J. White

The Problem of Variation

Everywhere in medicine, variation is the enemy of quality. Every time we look at variation, we have a quality problem that gets better when variation is reduced. This is not to suggest that we need to be 99% protocol-driven. But certainly two-thirds to three-quarters of patients can be managed on protocols, and we can document when we don’t need to use those protocols.

Contributing to the variation is that we have so many tools and devices with which to treat patients with CLI, but we rarely stop to measure their efficacy. We almost never assess how much more valuable or effective one is over the other, and how that affects cost, morbidity and mortality. We simply adopt these devices and use them however we please, which contributes to heterogeneity and variation. And after a number of years, when we try to write a document about appropriate use, there are no good data on which to base recommendations, only expert consensus.

The variation in treatment of CLI in Vascular Quality Initiative centers is startling. Some centers treat every CLI case with bypass, whereas others treat every case with endovascular interventions, and there is a wide range in between (see Figure). There is tremendous heterogeneity in how we practice care of CLI, and it is bad for our patients. We need to build a better mousetrap.

Some Practices Must Change

Now that the era of accountable care is here, and CMS holds so much power over physicians, we must improve quality and reduce waste. This means reducing variation, becoming patient-centered and doing outcomes reporting.

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There are several drivers of poor performers. Some providers are focused on productivity and driven by overutilization. Thankfully, this behavior has become rare. More of a problem is providers driven by the mentality of “the patient wants it.” We are training a generation of young physicians who think that patient satisfaction means giving a patient what he or she wants, not taking the time to explain what they need. What matters is not that patients are happy, but that they are well. We have to engage patients in the decision and make sure they understand the rationale. But we get it wrong when we provide unnecessary care just because it makes the patient happy.

In addition, some doctors do not understand how appropriate use criteria works and many of us do not document adequately to allow accurate risk adjustment or coding and billing. Addressing these problems will improve the quality of patient care, and they ought to be able to be solved by education.

We also need to change our clinical practice to reduce variation. Physicians must give up some of our autonomy in exchange for better quality and safety.

New Systems and Behaviors

Providers that cling to today’s systems are going to become dinosaurs. Maintaining the current cost structures despite the need for more transparency and the falling of reimbursement levels is not tenable. The organizations that consider these challenges as opportunities, that master the value agenda, will get ahead and become the winners.

How does this fit into the context of CLI patient care? We need to merge practices among cardiologists, vascular surgeons, wound care specialists and interventional radiologists to encourage team-based care. We need to implement an inclusive vascular services model that takes advantage of the strengths of all the subspecialties that treat these patients; that is, we need to offer true multidisciplinary care. We need to develop a system to review cases for quality assurance, and publicly report our outcomes, so that we are transparent about our results. Finally, we need to talk to our primary care doctors who carry the burden of seeing these patients on a day-in and day-out basis. We need to include them in the decisions we make. We need to get their input on some of the chronic illness issues that are so prevalent in patients with CLI.

Endovascular specialists also need to understand that we must tackle the problem of CLI before revascularization comes into play. The best treatment of this disease is not found in the cath lab, it is found in getting patients to take high-intensity statins, to quit smoking and to get their BP and HbA1c levels under control. Particularly in patients with peripheral artery disease and the subset at risk for CLI, we need to treat them aggressively with medical therapy, and then apply revascularization as best we can.

Disclosure: White reports no relevant financial disclosures.