No Kidding

I tend to “batch read” medical journals. I usually set aside some time on Sunday mornings, after the New York Times and before the Giants kick-off to skim the cardiology journals that I still get. This past Sunday I saw something in Circulation that caught my eye.

The title of the article was “Medication initiation burden required to comply with heart failure guideline recommendations and hospital quality measures” and it was apparently deemed important enough by the editors to have an accompanying editorial called “Rethinking the focus of heart failure quality measures.” Both were authored by luminaries in the field. The punch-line? Lots of patients admitted to the hospital with heart failure need to start one or more new medications to meet guideline recommendations and hospital heart failure quality measures. This is, of course, hard to pull off, because of the challenges associated with “managing polypharmacy” and “heart failure transitional care.”

In other words, meeting guideline derived quality measures places complex demands on hospitals, which are increasingly on the hook for large numbers of “process of care” measures, as well as on patients, for whom “guideline directed care” often means being on a lot of medications.

Some of this, of course, is good. Hospitals have often done a poor job of preparing patients for discharge, and many heart failure patients are not on medications that are of proven efficacy in reducing symptoms and improving mortality. Fixing both of those deficiencies would benefit many patients.

Here is the problem. Our current approach to quality measurement and improvement seems to be all about “adding more stuff.” Every shortfall in care is approached as an isolated problem, to be assessed with its own quality measure and fixed with a specific solution. The result is a blizzard of quality measures that provider organizations struggle to prioritize and recommendations for care that are predicated on the false premise that each patient has only one problem, for which there is a single good cocktail of treatments.

The only way I see out of this is to move as quickly as possible to abandoning large sets of process measures, and holding provider organizations accountable for the health outcomes of the patients they serve. Not easy, but a lot better in the long run than the mess we have now.

What do you think?

One thought on “No Kidding

  1. Sounds more like engineers than physicians providing medical care. With engineers, just fix that one thing, the isolated problem, when it doesn’t work, change the angle of something that’s another isolated problem.

    Pilots came up with fixes, like Chuck Yeager using a broomstick to securely close a hatch. Korean War pilots demanding that the wing angles be changed to keep up with the MIGs.Many of them had engineering degrees, and were physically dealing with the problems. Now we have bookkkeepers following congressional dictates on how to practice medicine, but most of all save money. It doesn’t save money if it doesn’t work, or it works poorly.

    I’m trying to say that the pilot that has an engineering degree and is flying the patient, er, plane is in a better position to tell how the patient is responding than somebody thats hundreds or thousands of miles away, at least from here in New Mexico. These officials don’t seem to realize that a patient is more than a heart condition, and many things cause heart conditions. We’ve traveled a long way from having to look at the patient’s complexion, and say- Ah, he’s bluish, he’s not getting enough oxygen, probably his large heart muslce isn’t working, and it’s being damaged from the slow heart or the slow heart is damaging the muscle. And they couldn’t do anything about it. Then Dr. Bernard in South Africa did the first heart transplant.

    I’d rather trust a doctor then an algorithm that can’t factor in variants. Are we drones?

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