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 at which I repeatedly joist.
I shamelessly quote a slightly re-edited comments which 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 of efficacy; when you are in the prevention mode, you had
better have 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. Apparently no one. 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 is 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 ) which has morphed guidelines into requirements with greatly increased power to do good or harm but with seeming impunity.
(edited on 4/24/24 to correct several spelling and grammar issues)
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