Posted 10/12/11 on Disease Management Care Blog
Sei Lee and Louise Walter, in this Commentary published in the Oct 5 issue of JAMA, argue that the current approach to measuring health care quality often leads to unintended harm for many older adults. That’s because the guidelines-driven and evidence-based measures are “unbalanced.”
The Disease Management Care Blog agrees that the state-of-the-art is unbalanced, but it’s even worse than Drs. Lee and Walter describe.
First, the Commentary…..
Right now, standard methods for assessing the degree of blood pressure control (typically defined as being less than 140/90) doesn’t account for some elders being prone to getting low blood pressure and dizzy when they’re upright. Blood sugar control is a good idea among most persons with diabetes, but for many reasons, older persons are more prone to having dangerously low dips in their glucose levels. Last but not least, there’s also the questionable wisdom of screening for cancer when the likelihood of death from other causes is far greater.
Most nationally recognized clinical guidelines usually have a disclaimer that they are not intended to be used as an inflexible and one-size-fits-all standard of care (for example, read the 4th paragraph of the high blood pressure guideline here). Yet, in contrast to the flexible guidelines, the all-or-none quality approach to measurement (for example) are inflexible and fail to give “credit” when testing or treating in individual patients are unwarranted.
Drs. Lee and Walter propose to fix this by reconciling the measures with life expectancy. If better blood pressure, diabetes or cancer screening can mathematically be expected to result in more years of life, then they should be implemented and only then should credit be given. While this could get complicated (think life expectancy tables being used during a visit with your doctor or, egads, politically underhanded accusations of ageism and death panels), the authors point out that electronic health records’ decision support – despite its disappointing track record – could enable life expectancy awareness during physician office visits. What’s more, doctors wouldn’t necessarily have to follow the decision support recommendations, but the fact that they were considered could be also be rolled into quality measurement.
What does the DMCB think?
It salutes the authors and JAMA for raising an important point. The idea of accounting for clinical benefit in quality measures is intriguing. Yet, the DMCB doesn’t think the authors go far enough in addressing the imbalance. It would go one step further and make the measures depend on the on a rather radical patient-centered approach: if the patient was engaged and became aware of the risks, benefits and alternatives to the guidelines-based testing and treatment, was allowed to make an independent, educated and reasoned judgement and gave either active consent or refusal, only then is credit given. Life expectancy can be part of that shared decision making, but it’s not the only ingredient.
Novel thought hm? It’s not up to any utilitarian calculation of life expectancy. It’s not up to some buggy computerized decision support algorithm. It’s not up to any expert guidelines. It’s not up to national quality setting organizations. Heck, it’s not even up to the physician. That’s all unbalanced.
Want true balance? Once all the above inputs are understood, it’s up to the patient.
Jaan Sidorov MD writes at the Disease Management Care Blog.