To the Editor:
Few articles, if any, have caused me more anguish than “Improving Chronic Disease Care in the Real World: A Step-by-Step Approach” [October 1999].
The real positives of this article are contained in the last two pages, where “how-to” recommendations are made for instituting changes in the practice habits of physicians. The real negatives of the article are contained in “Step 3: Aim for something.”
In this step, the quality improvement team of Family Care Network defines its measures and goals for diabetes care: 60 percent of patient charts should have a documented self-management plan, 80 percent of charts should have a diabetic flowchart system, 90 percent of patients should have two or more HbA1c measures within a year, etc.
Very few, if any, professional organizations would accept goals with percentages like these. Why should physicians? Can you imagine pilots setting their goals for improvement at the end of the year at 60, 70, 80 or 90 percent? Is it no wonder that managed care and other organizations looking over the shoulders of physicians are complaining?
In my opinion, setting physicians' goals so low is not acceptable in a profession that was once regarded so highly. When one seeks mediocrity one will probably succeed; only when one seeks perfection can excellence be obtained.
Dr. Hall's question regarding health care goals is an important one. It emphasizes the distinction between idealistic goals (e.g., 100 percent of patients meet targets) and realistic, attainable goals. Most studies demonstrate that, in the United States, the care of patients with diabetes meets the American Diabetes Association's recommended goals less than 35 percent of the time. To improve these outcomes significantly, the entire system of care must be redesigned. The current system is designed to achieve the results it produces. “Trying harder” will not produce better results.
The goals mentioned in the article are not arbitrary. They are set by the Institute for Healthcare Improvement and cannot be accomplished without a significant breakthrough in care redesign. If Family Care Network, or any other medical group, can meet these goals, it will be on the leading edge of diabetes care.