Monday, January 20, 2014

Can widely accepted guidelines be dangerous?

Projections assuming the wide acceptance of peri operative beta blocker guidelines in Europe suggests the answer is a frightening yes..See here for details of what seems to be a candidate for  the mother of all iatrogenic disasters. The authors of that referenced article suggest deaths may be in the hundreds of thousands.Extrapolations are fraught with great mis -estimates but even with assumptions of much less adherence to the guidelines there have to be a large number of patients that died or experienced non fatal strokes in a terribly misguided effort to save lives. Hubris of the medical planners and the danger of excessive faith in the truth producing power of meta analysis and the dangers of guidelines enforcement  are among the windmills as which I  repeatedly joist. 

I shamelessly quote a slightly re edited comments I made in 2007 following the disappointing results of the POISE trial that cast an unfavorable light on the use of peri operative beta blockers in non cardiac surgery which demonstrated an increased risk of stroke in the treatment arm of the trial.


"quality measures  often drive care and influence the way physicians care for their patients. If a physician should exert great care in deciding what to do for an individual patient it would seem a greater level of concern and contemplation should be expended in writing "rules" that will influence the care of many patients.

I do not mean to imply that physicians who author quality rules take their responsibility lightly but events such as the beta-blocker saga should perhaps make us insist on a very high standard of proof of efficacy and safety be shown before we presume to tell others physician what they should do particularly when those rules are "enforced" by economic carrots or sticks. Further if an intervention is to prevent something, i.e to decrease the risk of a bad outcome, the level of certainty should be higher than in the circumstance when the physician is treating a certain medical condition.  I increasingly wonder if those sweeping recommendations should be based to a large degree on meta analyses. In a seriously ill, patient you often have to act, even to use treatments that lack super solid proof or efficacy; when you are in the prevention mode, you had better behave a much greater level of certainty.

The individual physicians not only have a fiduciary duty to do what it right for the patient but they are held to a legal duty. At least physicians were taught that duty before the days of the New Professionalism as promoted by the ACP with their new ethic and the ABIM Foundation and the Robert Wood Johnson Foundation.See how often you find the word "fiduciary" in the new ethics or the New Professionalism.

The individual physician deals with the stroke patient and has to answer to him and the family, and perhaps to the family's attorney while the quality rule writers have to answer to whom. Being a  public health expert or a guideline author seems to confer immunity for having to say you are sorry.  The individual physician strives to do what it the right thing for his patient and hopes that what he does is right, the quality rule makers seem presume to know what is good for everyone. Obviously, they frequently do not. Oh well, you can't make an omelet unless...

When guidelines were operationally what they claim to be now suggestions their benefit and their potential harm was limited. Enter the ever increasing hegemony of the third party payers (government or private insurers ) has morphed guidelines into requirements with greater increased power to do good or harm.




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