Issues with Guideline-based Care

By April 19, 2018 Commentary

Evidence-based medicine and use of care guidelines can also be considered one-size-fits-all medicine, which has dangers that should be obvious to policymakers, given the complexity and variability of human biochemistry and health.  Articles in the Journal of the American Medical Association illustrate this danger in the case of using beta blockers in heart attack patients.   (JAMA Article)   The backdrop to the particular patient case discussed is that as guidelines have proliferated and compliance with them is often used to judge and penalize or reward providers, the guidelines have become embedded in standardized order sets.  So a patient comes in, is diagnosed with certain issues and the physician uses the standard order set, which is then used for treatment.  Uh oh, what if there were aspects of the patient or his or her presenting symptoms that might have cautioned against use of the standard treatment.  A 58 year-old man who had a heart attack was admitted to the hospital and he had complete heart block and heart failure.  In these circumstances, a beta blocker is contraindicated but that is exactly what the standard order set for a heart attack patient calls for, and while the contraindication is recognized, it wasn’t easy to ensure that a beta blocker still wasn’t part of the order set.  Upon review of this patient’s care, three other similar cases were found at the same hospital in the previous 12 months.  One factor was clearly HIT systems that made it hard for the doctor to recognize exceptions and to change the orders and that gave a “warning” that using beta blockers was a performance measure.  Administering beta blockers was thought to be performance measure for these patients and the hospital understandably wanted to maximize its score.  The measures themselves are a cause of this bad care because it is hard to exempt a particular patient from the measure.  In this particular case, it was even worse, this measure had been removed because of issues that had arisen with the recommendation, but wasn’t out of the order set.  So a lot of screw-ups, which is what you can expect when you try to reduce care to standardized guidelines and you rely on HIT to enforce those guidelines.

Reducing variability is generally thought by quality experts to improve overall quality, but that is frankly bullshit in medicine, where there is a lot of clinician judgment needed to ensure optimal care and patients vary greatly, so they need variable care.  HIT could be helpful if it guides physicians in recognizing all the variables and factors they should consider, but not when it rigidly enforces standards because of fear around performance on “quality” measures.  If you could subcategorize every patient and create some standards for every subcategory, maybe that would work, but that is a huge task and really leads back to initially approaching each patient as an individual case and identifying the factors affecting the best treatment.  Enforced guidelines may reduce variability but they may increase patient harm.  It is time for CMS and others to back off until they come up with a better method of ensuring that each patient gets the most appropriate treatment.  Reducing variation is an inappropriate goal.

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