Well intended interventions with bad outcomes for patients

"Help me convince my little-old-lady diabetics to listen to me." - a plea from a doc working in a community health center after I had given a presentation on quality improvement in health care.

"They don't follow my instructions and I'm totally frustrated.  Most of them are 75 years old or older and just smile and say 'Yes, Doctor" but don't do anything I say."  She goes on:  "I'm supposed to get my diabetics to have a HbA1c less than 7.  I get in trouble if I have too many diabetics with c more than 7."

It is this kind of anecdote that makes me want to bang my head on the table.  

Helping people with diabetes keep their blood glucose under control is a good thing.   Low HbA1c means better control.  How low should it go depends on who is writing the rules.  Many insurers snap up the NCQA or Bridges to Excellence rules that set "percent of diabetic patients with HbA1c less than 7" as the goal.  The problem is that this goal doesn't work for all people with diabetes.  For some people - especially the elderly - getting the HbA1c less than 7 actually increases death rates.

"Mrs. Jones, I know that pushing your blood sugar lower increases your risk of death, but I'm part of a quality improvement program and am being judged here.  Can you just work with me on this?  You don't want to be non-compliant do you?  I'd hate to have to fire you from the practice...."

Another problem is that most of our patients have diabetes as one issue woven in with another or several other important health issues (nice piece in the NYT on this).  Because all these issues are in one person, none work in isolation - but we're judged on an isolated component of the person's health.  This creates a perverse incentive for us to solve one problem for a person even if it results in worsening of other parts (a great study showed that pushing diabetic patients to test their own blood sugar more resulted in increased rates of depression: BMJ 2008 doi: 10.1136/bmj.39534.571644).

I pointed this out to the community health center doc.  "Your patients are right to stick with their own plans as tighter control could be bad for them."  

"Yes, but I'm being judged.  What do I do?"

What should she do?  She's powerless in a system that's totally broken.  Even attempts to improve care are forcing her to perceive that she's being a bad doc, when the rules would actually result in harm to her patients.

Our system for measuring quality in the US is broken. Flogging health professionals to get them to toe the current party line is wrong.  "Improvement strategies" build on faulty rule sets are not going to improve the health of our patients.

Gordon 

Comments

[Don Stewart]

Although it is a few years old, another large study of treating depression in patients with diabetes done at Group Health Cooperative in the Seattle area showed that the group of diabetics with depression who were given more intensive depression treatment ended up with poorer control of their diabetes than the depressed diabetic patients in the control group who were not given extra depression treatment.

One possible explanation of this is that patients with chronic illness have limited personal resources to improve their condition, and that investing energy for improvement in one domain of functioning may necessarily result in less energy to invest in other domains of functioning, with a resultant decreased level of function in the other domains.

I think that helping patients decide which aspects of their health are worth trying to improve is one of the most important functions of high-quality primary care. I don't see how any kind of disease-specific protocols can capture that kind of function, which is really what patient-centered care is all about.

[Connie Davis, ARNP]

Bravo! I really enjoyed the session at the IHI Office Practice Summit with Barbara Starfield, James McCormack, Mike Allan and Dee Mangin who provided a great overview of the challenge of using guidelines with real people, what really makes a difference in outcomes and how little evidence there is for the targets set in most guidelines. I think the rewards should be for "reliably considering the guidelines" not for a target!