Practice Guidelines and Quality Care

As I have noted previously I have a “love-hate” relationship with practice guidelines. Love because it is often helpful to refer to a set of evidence-based recommendations as part of clinical decision-making; hate because of all of the shortcomings of the guidelines themselves, as well as the evidence upon which they are based.

A recent piece in JAMA and the editorial that accompanied it  reinforced my ambivalence.

The research report addressed a straightforward question: how often do “Class I” recommendations change in successive editions of guidelines on the same subject from the same organization. Recall that Class I recommendations are things that physicians “should do” for eligible patients. They are particularly important, because these recommendations often form the basis for quality metrics, against which physician performance is measured, increasingly with financial consequences. It is not hard to understand why.  First, the recommendations are, by nature, definitive – if a patient meets certain criteria (e.g., has evidence of ischemic vascular disease, and no allergy to aspirin), then she should get the indicated therapy or intervention (aspirin), making the quality assessment fairly straightforward. It is also generally easy to detect if the intervention was made. Finally, it is also easier to engage clinicians using quality metrics that detect “underuse” (patient did not get something he should have) than “overuse” (patient got a treatment or service he should not have).

The authors limited their study to guidelines published jointly by the American College of Cardiology and the American Heart Association. These are generally well-respected documents, and are often held up as models for how guidelines should be developed and promulgated. (Disclosure – I am a card-carrying fellow of both organizations.) They categorized the status of the original Class I recommendations in the subsequent guideline as either retained, downgraded or reversed, or omitted.  So what did the study find? The findings are summarized in this table:

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Overall, about 9% of the recommendations were downgraded or reversed in the follow-up guideline.

I don’t know about you, but that seems like a lot to me, especially since the median time interval between the paired guidelines was 6 years. This is even more disturbing when you think about how many years it takes to develop quality metrics based on these guidelines, making it inevitable that some quality metrics will be based on discredited recommendations. The discordance of the newest cholesterol management guidelines   with the widely adopted HEDIS measure for LDL management is just one example where this is already the case.

I think this is just one more reason why quality measures built around “process” (did you do this or that in the care of a patient) have to give way to measuring outcomes (how well did the patient do under your care).

What do you think?

3 thoughts on “Practice Guidelines and Quality Care

  1. Statin toxicity–I joined the best medicare Advantage program that I could find in my area. The focus was-and probably still is-stroke prevention-CVA prevention-well CVA prevention care except for Carrier Vessal Attack, like the John F Kennedy, the Hornet, the Enterprise that won WW II.

    I was bullied into taking low dosage chloresteral pills-10 mgs/day. for prevention. I was scared that I would loose my benefits. I was told that medicare’s number one priority was preventing CVAs-they listed them, as they thought that I was too dumb to understand the term. I’d been in the military system, where doctors are called to the front-or if a doctor gets mad, you are sent out to the civilian community.Then diabetes is an epidemic in this state. The sites and the FDA now say that statins can cause diabetes type 2. It looks like diabetes type 2 caught up with me this spring. This makes me the very first person in my family to get this. I can’t exercise very well because of the damage and fatigue caused by the statins.

    I kept telling the doctor that I lifted weights, walked my hounds a mile or 2 almost every day, worked in my yard, just built a covered patio. And I asked him and others why they weren’t giving me forms for cancer history? I finally got that form for that when I entered oncology as a patient in 2012. Both sides of my family had GI cancers-intestines and bowel.

    I thought that I’d get sick-throw up, get a rash from the statin. I didn’t realize that statin was the key word for Internet and medical research. All I found was how good this poison is. I kept complaining that the FDA didn’t even have the correct version of side effects on the warning label. They now have -heavy feeling legs- not tired legs. Tired legs don’t feel better when you get off of them-heavy legs do feel better. I wish that I had lied and never took the pills, but said that I did so the nobody would know. I just wasn’t raised to lie to my doctor.

    I hate Medical guidelines as you are talking about- I hate narrow tunnel visioned war on diseases that seem to be fueled by big Pharma.

    I really doubt that my PCP, and his clinic reported that I urinated black for over 90 days, that I temporarily lost my ability to walk without assistance. I’ll probably just be one more stat for diabetes. At least the cancer left untreated, would have killed me quickly.

    Someone might say- Stage 2 diabetes, another person that didn’t exercise or eat properly.

    I hate modern American medicine. My PCP said, “Sorry, I thought that statin toxicity was psychomatic and CoQ 10 was a placebo.” Of course that’s not on my record.

  2. My thought/s:
    The definition of evidenced based medicine seems to change every few minutes.
    Perhaps we should follow the advice of our mentor Dr. Valentin Fuster:
    1-“Where is the data?”
    2-“I don’t want to be dogmatic.”
    What do you think?

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