Volume 87, Number 3, 2009
Commentary: Public Health and Health Care Quality Assurance—Strange Bedfellows?
Jonathan E. Fielding
Los Angeles County Department of Public Health; University of California, Los Angeles
hat is the role of governmental public health in ensuring the quality of medical care? With some notable exceptions, state and local public health departments have taken a passive role in medical care system quality assurance. Yet medical care can contribute much to improving the health of populations and at least some to reducing health disparities. The article in this issue of The Milbank Quarterly by Chamany and colleagues describes one public health agency’s novel approach to the clinical management of adult diabetics: working with health care providers.
The authors regard their work as filling a temporary gap, pointing out that most providers are not equipped to automatically remind patients to consult their doctor when laboratories report high glycosylated hemoglobin (A1C) levels. But clinical decision support systems’ broader use of electronic health records, which is now a federal priority, should, at least in theory, make it unnecessary for public health agencies to assume this role.
Quality Assurance and Public Health
The larger question is how medical care quality assurance relates to the mission of governmental public health. I believe that state and local public health agencies have largely abrogated their responsibilities to participate actively in medical quality assurance. If the mission of public health is to protect and improve both our individual and our collective health, then why aren’t public health departments regularly giving consumers comparative information on health plans and individual providers to inform their choices? What did state and local public health departments contribute to developing the Healthcare Effectiveness Data and Information Set (HEDIS) measures or to forming the National Quality Forum? How did they help improve care practices to enhance quality? Is relating health outcomes to medical care practice and health care system processes a common function of state and local public health departments?
Even when the government has joined in quality assurance for those services for which it pays, traditional public health agencies have usually been involved marginally, if at all. How many state public health officers help develop quality assurance systems for state Medicaid programs? Even at the federal level, the link between payer and public health has been weak. For example, how closely have the Center for Medicare and Medicaid Services’ quality assurance efforts been linked with the Centers for Disease Control and Prevention, the principal federal agency responsible for public health?
The prevailing assumption is that public health’s ambit was population-based challenges that the private sector did not address, such as controlling the spread of communicable diseases, identifying and working to remedy environmental exposures like lead or arsenic, or advocating illness or injury prevention policies like clean indoor air statutes or requiring seat belt use in motor vehicles. The pioneering work in New York City strongly suggests that reconsideration of this artificial dichotomy is overdue. New York City also has conducted academic detailing (educational outreach with face-to-face education) of physicians, another example of how public health can positively influence local medical care.
This program was successful in demonstrating the feasibility of collaboration between a large local health department and practicing physicians. It chose A1C as a measure because it could mandate its reporting and had a scientific consensus on the levels associated with a high risk of diabetic complications. But even though glycemic control is valuable, it is equally important for diabetics to control their blood pressure and lipids. Good diabetes care has other components as well, such as periodic foot and eye exams. Accordingly, this approach is not a substitute for systems of care such as providers’ use of the chronic care model.
New York City’s intervention is medical, very close to medical practice. It therefore would be difficult to expand this program to its logical conclusion, that is, having the health department, on behalf of practicing physicians, send information to patients, from laboratories and other sources, about individual health risks.
A Population-Based Approach
A better approach for public health is to identify, promote, and monitor health care system interventions that are uniformly associated with better outcomes, as based on systematic reviews. The Guide to Community Preventive Services recommends health care system interventions that improve the outcomes of care for diabetics. For example, the Guide’s recommendations, including disease and case management, have been shown to improve glycemic control, as has diabetes self-management education (see www.thecommunityguide.org). As chronic diseases continue to take a rising and more costly toll, the need for integrated clinical- and population-based approaches becomes critical.
Health promotion, a core aspect of the public health mission, is another important component of a comprehensive, population-oriented approach to reducing both the incidence and severity of diabetes. It should include primary prevention strategies to increase physical activity and reduce weight in both children and adults.
Engaging Public Health to Improve Quality of Medical Care
Even more important than the specific health problem addressed in Chamany and colleagues’ article is its reinforcement of the valuable role of governmental public health in medical quality assurance. However, many public health departments, even the larger ones, lack the requisite expertise and staff to be credible experts in quality assurance. Redressing this deficiency requires (1) explaining how medical quality assurance fits into the department’s mission and priorities, (2) determining what is most likely to improve outcomes, (3) gaining the support of elected state and local leaders for these actions as appropriate and necessary, and (4) providing leadership in working with health plans and providers on these issues. Ensuring the quality of care and care systems to continuously improve health outcomes is a responsibility shared by both the public and private sectors. It is time for public health to assume its rightful place in protecting health.
Reference
Chamany, S., L.D. Silver, M.T. Bassett, C.R. Driver, D.K. Berger, C.E. Neuhaus, N. Kumar, and T.R. Frieden. 2009. Tracking Diabetes: New York City’s A1C Registry. The Milbank Quarterly 87(3):547–70.
Address correspondence to: Jonathan E. Fielding, Los Angeles County Department
of Public Health, Kenneth Hahn Hall of Administration, 500 W. Temple
Street, Los Angeles, CA 90012 (email: jfielding@ph.lacounty.gov).
The Milbank Memorial Fund is an endowed operating foundation that engages in nonpartisan analysis, study, research, and communication on significant issues in health policy. In the Fund's own publications, in reports, films, or books it publishes with other organizations, and in articles it commissions for publication by other organizations, the Fund endeavors to maintain the highest standards for accuracy and fairness. Statements by individual authors, however, do not necessarily reflect opinions or factual determinations of the Fund.
©2009 Milbank Memorial Fund. All rights reserved. This publication may be redistributed electronically, digitally, or in print for noncommercial purposes only as long as it remains wholly intact, including this copyright notice and disclaimer.
Printed in the United States of America.
Online producer: Stephanie Moe-Quiggle
