Division of General Internal Medicine, Northwestern University, 750 North Lake Shore Drive, 10th Floor, Chicago, IL 60611, USA.
Ann Intern Med. 2010 Feb 16;152(4):225-31. doi: 10.7326/0003-4819-152-4-201002160-00007.
Quality improvement programs that allow physicians to document medical reasons for deviating from guidelines preserve clinicians' judgment while enabling them to strive for high performance. However, physician misconceptions or gaming potentially limit programs.
To implement computerized decision support with mechanisms to document medical exceptions to quality measures and to perform peer review of exceptions and provide feedback when appropriate.
Observational study.
Large internal medicine practice.
Patients eligible for 1 or more quality measures.
A peer-review panel judged medical exceptions to 16 chronic disease and prevention quality measures as appropriate, inappropriate, or of uncertain appropriateness. Medical records were reviewed after feedback was given to determine whether care changed.
Physicians recorded 650 standardized medical exceptions during 7 months. The reporting tool was used without any medical reason 36 times (5.5%). Of the remaining 614 exceptions, 93.6% were medically appropriate, 3.1% were inappropriate, and 3.3% were of uncertain appropriateness. Frequencies of inappropriate exceptions were 7 (6.9%) for coronary heart disease, 0 (0%) for heart failure, 10 (10.8%) for diabetes, and 2 (0.6%) for preventive services. After physicians received direct feedback about inappropriate exceptions, 8 of 19 (42%) changed management. The peer-review process took less than 5 minutes per case, but for each change in clinical care, 65 reviews were required.
The findings could differ at other sites or if financial incentives were in place.
Physician-recorded medical exceptions were correct most of the time. Peer review of medical exceptions can identify myths and misconceptions, but the process needs to be more efficient to be sustainable.
Agency for Healthcare Research and Quality.
允许医生记录偏离指南的医疗原因的质量改进计划在保留临床医生判断的同时，使他们能够努力追求高绩效。然而，医生的误解或游戏行为可能会限制这些计划。
实施具有记录质量措施的医疗例外并对例外进行同行评审的计算机决策支持，并在适当的时候提供反馈。
观察性研究。
大型内科实践。
符合 1 项或多项质量措施标准的患者。
同行评审小组判断 16 种慢性疾病和预防质量措施的医疗例外是否合适、不合适或不确定。在提供反馈后，审查病历以确定护理是否发生变化。
医生在 7 个月内记录了 650 项标准化的医疗例外。报告工具在没有任何医疗原因的情况下被使用了 36 次（5.5%）。在其余的 614 项例外中，93.6%是医学上合适的，3.1%是不合适的，3.3%是不确定的。冠心病的不适当例外频率为 7（6.9%），心力衰竭为 0（0%），糖尿病为 10（10.8%），预防服务为 2（0.6%）。在医生收到关于不适当例外的直接反馈后，19 例中有 8 例（42%）改变了治疗方案。同行评审过程每个病例不到 5 分钟，但每次临床护理发生变化，都需要进行 65 次审查。
研究结果可能因其他地点或是否存在经济激励措施而有所不同。
医生记录的医疗例外大多数时候是正确的。对医疗例外进行同行评审可以发现一些误解和错误观念，但该过程需要更高效才能可持续。
医疗保健研究与质量署。
