Friday, March 30, 2007

Still more cogent critcism of P4P and guidelines that ignore risk adjustment

Two important analyses are discussed in the March 30, 2007 posting on Health Care Renewal. They deal with the fantastically, overhyped goal for hemoglobin A1c which is given a thoughtful and critical once-over as is the 4 hour rush-to-give antibiotics for patients diagnosed with community acquired pneumonia (CAP).

Dr. Roy Poses references and discusses two articles regarding these topics and raises serious questions regarding the dangerously simplistic foundational premises behind P4P.

Poses says

"... developing performances measures that will truly benefit patients will require...understanding of the clinical context,statistical analysis of the available research data and careful balancing of the benefits,harms and costs."

and calls for a detailed disclosure of all conflicts of interests of those involved in the guideline development processes.

A major problem that was discussed was the typical lack of risk adjustment in the guideline movement. For example, in regard to the glycoselated hemoglobin target, the one size fits all target is mandated for patients included even though they posses clinical characteristics which excluded them from the clinical trials which demonstrated the risk reduction benefit for lowering the A1c. In this group of patients, e.g. the elderly and very elderly and those with multiple other illnesses, the risk of hypoglycemic reactions may well negate any unproved theoretical benefit in long term cardiovascular and microvascular disease reduction. But that type of decision has to be made by a thoughtful physician in consultation with the patient taking into account the individual clinical context and the patient's values and preferences, none of which necessarily have anything to do with guidelines.

The further the decision making is removed from the rapidly- becoming- marginalized physician-patient decision making unit the more likely it is that harm will result and reasoned decisions will be pre-empted by treatment mandates that ignore the individual details that embody the patient.The overarching principles -even if they may not be driven by one special interest or another- of the guideline authors and advocates need not reflect the values and preferences of the patient.

More and more reasoned, thougtful critiques of P4P appear in the medical literature but the movement shows little signs of slowing down. I hope we are not seeing another instance of " the dogs barking and the caravan moving on" but I am afraid we are.

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