Wednesday, November 14, 2007

More on "quality movement can be hazardous to your health"

I have mentioned before the danger of the "four-hour"pneumonia rule and the ill advised rush to quality rules about peri-operative beta blocker use and those likely only touch on the tippy top of the iceberg.

I have seen so many Journal supplements that are poorly disguised promotions for certain medications or classes of medications that when I see a supplement I cringe, but the April 2007, volume 120 Supplement of the American Journal of Medicine seems to be different( although I don't rule out the possibility that the issue is promoting something or other since a major drug company sponsored it.) I have become very cynical over the last two years.

This is on a topic near to my heart, the heterogeneity of treatment effects (HTE) which I have written about before,highly recommending a landmark article in the Millbank Quarterly,which I think is no longer available on line.

The editor of the issue is Dr. Sheldon Greenfield from UC-Irvine School of Medicine. He presents an important editorial and co-authors an article with Dr. Richard Kravitz, also from UC-Irvine, who was the lead author on the above referenced Milbank article. I believe if you go to www.amjmed.com and register you can obtain the AJM supplements for free.

The major points made by Greenfield in his editorial are:

He asserts that there are 2 evolving phenomena that "impair the ability to develop guidelines, payment rules and quality of care measures based on randomized clinical trials (RCTs)." They are:

First,there is now a broader spectrum of illness severity included in trials . That is, more patients with less severe illness who will be less likely to favorably respond to an agent than the more seriously ill patients.This results in less ability of the trial to detect a true difference.

Secondly, RCTS typically exclude patients with multiple chronic diseases,

" Only to have findings subsequently generalized from young trial-eligible patients to these older,complex patients whose mortality from comorbid conditions reduces treatment effectiveness."

So, on the one hand more false negative trials and on the other hand, trials with less external validity which may be used anyway to make quality rules for groups of patients who may differ markedly and in important ways from those patients who took part in the trial.

More and more decisions are taken out of the hands and minds of the individual physician and the individual patient and determined by third party rules which in turn are increasingly "enforced" by the devilish P4P system. The work of Kravitz, Greenfield and others make it clear how flawed RCTs can be and it follows that rules and rule-derived payments to physicians based on these RCTs can result in clinical mismanagement and harm to patients.

So we can look forward to more quality rules that , in one sense, backfire and which will be enforced by the powers inherent in the economic hegemony that third party payers enjoy over physicians.

I have written about physician's spiraling downward pride and ethics (now known as professionalism) before as have others. Many hospitalists and emergency physicians are either employees of a hospital or are contracted with a hospital. When such things as the four hour rule and give almost everyone peri-operative beta-blockers become institutionalized as quality indicators it is not difficult to imagine the position a physician find herself if she dare object or worse refuse to play by those rules.Accusations of being a disruptive physician may be hurled and what happens to employees who do not play by the boss's rule.Of course, it is not just ED docs and hospitalist impacted by these rules and their enforcement mechanisms and not just those whose pay checks comes directly from a hospital. I still believe that physicians still want to act primarily in the best interest of their patients and many times still do but it gets hard and harder to continue to do so.

I am reminded of the old saw version of the Golden Rule (He who holds the gold makes the rules) . The economic reality of today's medical practice makes it harder and harder for the physician to act in the fiduciary interest of the patient and this is all the more bitter as we become more aware and educated in the foibles and weaknesses of the "knowledge" base on many of the quality rules allegedly derive from.

The blogger, The Happy Hospitalist, in his recent entry "Dr. Government Vs Littol Sally" and those who posted comments all sound the note that the good physician is the one who can determine when it is appropriate and in the patient's interest and when it is not to go with the guidelines. The constraints, incentives and feedback that physicians face constitute a practice environment that could not be less conducive to "dong the right thing".

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