Comments on GeriPal - Geriatrics and Palliative Care Blog: Quality Indicators Can Cause Harm in Older Patient...

It's not the quality indicator that is the pro...

2012-01-03T05:19:45.047-08:00

It's not the quality indicator that is the problem.

It's the stupid, inappropriate, indiscriminate use of a quality indicator that is the problem.

I quickly tire of these commentaries that blame the indicator. They implicitly accept the notion that the existence of a quality indicator renders physicians too stupid to know when not to follow it. I'm sorry, but if you think achieving a quality indicator threshold is bad for an individual patient, then what the hell are you doing trying to meet it? No quality indicator absolves a physician of benificence.

Show me a real-world system that actually causes harm in trying to achieve 100% quality indicator compliance, and I'll show you a system designed by an absolute idiot (or more likely, a committee of them).

Bottom line, it's time to clean up this cesspool of half-baked arguments. 1. Find an example of real-world concrete harm. 2. Find the cause of this harm (and look more widely than just the existence of an indicator).

This is an excellent point and I am very glad to s...

2011-11-23T10:24:14.208-08:00

This is an excellent point and I am very glad to see someone making it so well. Very soon, Hospice will be subject to publicly shared quality standards. It looks like the standard will be the following: Pain controlled to a comfortable level with 48 hours of admission to Hospice.
While this is certainly a fair and important quality indicator for many patients (especially those with acute cancer pain), I am very concerned about the effect it will have on the treatment of chronically ill, elderly patients with long-standing pain syndromes when they enter hospice care. Many patients who are referred to hospice care experience long-standing discomfort and pain such as arthritis and a variety of causes. Many have been working with their physicians and specialists regarding that pain. Imagine the scenarios that could unfold if the hospice feels it is incumbent upon it to immediately rid the patiet of such pain. Anxiety that hospices simply start pushing narcotics as soon as they admit a patient already cause delays and avoidance of hospice care. A publicly reported quality measure such as this could make that a very valid concern.

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2011-11-17T08:09:42.653-08:00

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Thank you, Ken. Raising this issue often leads to ...

2011-11-16T11:53:19.742-08:00

Thank you, Ken. Raising this issue often leads to intimations of ageism, which is really not the point. I support aggressive management--regardless of the age of the patient--if the benefits truly outweigh the risks. And, in addition to the physiologic harms, there are also economic and psychosocial harms. Slavishly following guidelines and quality indicators may potentiate tremendous polypharmacy and precipitate a fall into the part D doughnut hole. In addition, intensive interventions may lead to other unintended consequences. For example, since RCFE/assisted living facs aren't able to manage insulin in California, prescribing intensive insulin management to "achieve" guideline driven targets may result in nursing home placement.

The IOM, Medicare, Medi-Cal states we need to prov...

2011-11-14T10:31:33.127-08:00

The IOM, Medicare, Medi-Cal states we need to provide "individualized care" and develop individualized care plans. As an example, I am a professor in nursing and I see students get upset when they see their elderly patients with BP reading outside of the "standard". We need to educate our students to individualize and look at the whole picture of each individual patient as a team to determine the best individualized care standards for the individual patient situation. I am worried about how this will be interpreted by our new healthcare professionals as they are learning to work with their patients as a team member.

It is about time. I have a Palliative Care practi...

2011-11-14T09:38:08.113-08:00

It is about time. I have a Palliative Care practice, so my patients are hurt by the "Standard of Care" guidelines and requirements.

Amen brother.

2011-11-13T15:44:50.233-08:00

Amen brother.