WHY QUALITY CARE IS DANGEROUS
April 10, 2009
The Obama administration is working with Congress to mandate that all Medicare payments be tied to "quality metrics." But an analysis of this drive for better health care reveals a fundamental flaw in how quality is defined and metrics applied. In too many cases, the quality measures have been hastily adopted, only to be proven wrong and even potentially dangerous to patients, say Jerome Groopman, of the New Yorker, and Pamela Hartzband, of the Harvard University Medical School.
How did we get here? Initially, the quality improvement initiatives focused on patient safety and public-health measures. Buoyed by success, governmental and private insurance regulators have turned clinical guidelines for complex diseases into iron-clad rules, to deleterious effect, say Groopman and Hartzband.
One key quality measure in the ICU became the level of blood sugar in critically ill patients:
- Expert panels reviewed data on whether ICU patients should have insulin therapy adjusted to tightly control their blood sugar was permissible, and the consensus endorsed tight control and was embedded in guidelines from the American Diabetes Association.
- The Joint Commission on Accreditation of Healthcare Organizations, which generates report cards on hospitals, and governmental and private insurers that pay for care, adopted as a suggested quality metric this tight control of blood sugar.
- But this coercive approach was turned on its head in March when a study found more than 6,000 critically ill patients in ICUs.
Moreover, another clinical trial contradicted the expert consensus guidelines that patients with kidney failure on dialysis should be given statin drugs to prevent heart attack and stroke.
These examples show why rigid rules to broadly standardize care for all patients often break down. Rather, a system of flexibility should be used. To that end, doctors should exercise sound clinical judgment by first consulting expert guidelines and then deciding on an individual basis what course of care to administer, say Groopman and Hartzband.
Source: Jerome Groopman and Pamela Hartzband, "Why 'Quality' Care Is Dangerous," Wall Street Journal, April 8, 2009.
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