On the Wall Street Journal‘s Op-Ed page, Jerome Groopman and Pamela Hartzband cite the shortcomings of a quality metric-based system in Massachusetts and describe various misguided quality metrics. Groopman and Hartzband are both on the staff of Beth Israel Deaconess Medical Center in Boston and on the faculty of Harvard Medical School.
Initially, the quality improvement initiatives focused on patient safety and public-health measures. The hospital was seen as a large factory where systems needed to be standardized to prevent avoidable errors. A shocking degree of sloppiness existed with respect to hand washing, for example, and this largely has been remedied with implementation of standardized protocols. Similarly, the risk of infection when inserting an intravenous catheter has fallen sharply since doctors and nurses now abide by guidelines. Buoyed by these successes, governmental and private insurance regulators now have overreached. They’ve turned clinical guidelines for complex diseases into iron-clad rules, to deleterious effect.
Groopman and Hartzband cite several examples of regulations later proven questionable or even harmful, including the monitoring of ICU patients’ blood-sugar levels, the provision of statins to patients with kidney failure, and the monitoring of blood sugar in certain diabetics.
These and other recent examples show why rigid and punitive rules to broadly standardize care for all patients often break down. Human beings are not uniform in their biology. A disease with many effects on multiple organs, like diabetes, acts differently in different people. Medicine is an imperfect science, and its study is also imperfect. Information evolves and changes. Rather than rigidity, flexibility is appropriate in applying evidence from clinical trials. To that end, a good doctor exercises sound clinical judgment by consulting expert guidelines and assessing ongoing research, but then decides what is quality care for the individual patient. And what is best sometimes deviates from the norms.
Groopman and Hartzband cite studies showing that quality metrics had “had no relationship to the actual complications or clinical outcomes” of hip and knee replacement patients at 260 hospitals in 38 states and that, in 5,000 patients in 91 hospitals “the application of most federal quality process measures did not change mortality from heart failure.”
Sounds like it could be fodder for discussion at the “Medical effectiveness: Is there a NICE in U.S. future?” panel at Health Journalism 2009 on Saturday morning.