Wednesday, August 10, 2005

Practice guidelines in patients with multiple diseases not just inappropriate -may be harmful-JAMA article and editorial

That single disease guidelines may be harmful in multi-disease patients is a topic I have talked about before. Dr. Mary Tinetti published an excellent article on that topic in the NEJM in 2004.
An important and hopefully influential article on this same general issue was published in the August 10, 2005 issue of JAMA by Dr. Cynthia Boyd and colleagues. Their bottom line,take home message is The use of practice guidelines as the basis for pay-for-performance initiatives that focus on single disease treatments are not suited for patients with multiple diseases may well be harmful and this particularly impacts the elderly. Current single disease guidelines as applied to multi-disease patients are not ready for prime time and because of their naive simplicity will never be.
I would put it this way : The fact that a given treatment for a given disease in a certain selected study population is demonstrated to be efficacious and safe is not sufficient reason to apply that treatment to a given patient with co-existing other diseases. It follows that a physician should not be subject to economic sanctions on the basis of adherence to single disease practice guidelines in a patient with multiple comorbidities.
The editorialist, Dr. Patrick J. O'Conner,makes recommendations for guidelines that clearly imply guidelines as they currently exist are not adequate. He says, " Strategies to address the limitations of current CPG's (clinical practice guidelines) need to be developed and implemented,including providing recommendations based on level of evidence for particular patient groups and considering the potential economic and personal burden on the patient and caregiver as well as potential interactions with comorbid conditions".
Representatives of organized medicine who will meet with and negotiate with representatives of big insurance and Medicare have a very strong argument to make. As Dr. Dr. Boyd et. al. said:
the guidelines are not designed for quality assessment,they are recommendations based on varying levels of evidence by committees largely dominated by specialty groups for the management of single diseases, their application could lead to " perverse" economic incentives to emphasize the wrong aspects of care and the guidelines assume that clinical judgment and patient preferences will be incorporated into clinical decisions and yet when these guidelines are applied for quality grading no allowance is made for clinical judgement or patient preference. To apply single disease guidelines to patients with multiple diseases should not be negotiable.
The arguments of Dr. Boyd et al and Dr. O'Conner are cogent, important and should be acted on by resisting on whatever fronts present themselves any pay-for-performance schemes which ignore the complexity of human illnesses and desires and circumstance and judge clinical quality by adherence to simplistic single disease management rules and guidelines which themselves may be limited by the often flawed evidence underlying them.
As much as I agree with the arguments of the two articles, I am troubled by the assumption that both authors seem to make, namely that pay-for-performance is inevitable. I am reminded of the flurry of articles in the early years of the "gate-keeping" fallacy that it will occur, it is occurring and you doctors out there better get on the bandwagon or be left out. There was no shortage of players in medical academia who-for whatever motivations and some may have been well intended-who were complicit with the insurance industry. Pay-for performance may be one of those things that we would be better off being left out.

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