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Quality Indicators Can Cause Harm in Older Patients: An Inconvenient Truth

Quality indicators are used to measure the quality of health care delivered to patients. Quality indicators are used extensively in the VA health system, and efforts are underway in Medicare to tie reimbursement levels to performance on quality indicators.

The motivations for using quality indicators are guided by the best of intentions. There are many problems with the quality of health care in the US, and quality indicators aim to improve this care. When put to their best use, quality indicators can improve care.

However, a recent commentary in JAMA from our UCSF colleagues, Geriatricians Sei Lee and Louise Walter raise serious concerns about unintended harms from quality indicators. Lee and Walter make a compelling arguement that quality indicators, when used indiscriminantly, can actually harm the quality of care provided to the older persons. This is particularly true for the most frail and vulnerable elders.

How is it possible that something designed to improve care can actually be dangerous to the patients they are supposed to help?

A key issue is that quality indicators almost always promote more medical intervention and more medical intervention is not always better. This is especially the case in frail older persons, where the risks of treatments often exceeds the benefits.

Lee and Walter illustrates this problem with the HEDIS quality indicator for hypertension. This indicator measures the proportion of patients with high blood pressure who have a blood pressure of less then 140/90. In most cases, this is a reasonable target. However, in some frail older patients, the focus on blood pressure targets need to be balanced by concerns about side effects. This includes sometimes debilitating orthostatic hypotension (a drop in blood pressure when standing that can lead to dizziness and falls) and side effects of adding additional medicines in a patient with an already very full pillbox.

A doctor who decides it is in a frail older patient's best interest to allow the blood pressure to go over the HEDIS target will appear to be providing poor quality of care. In contrast, a doctor who blindly aims for the HEDIS target in all patients will look very good. Lee and Walter note that HEDIS should balance its hypertension quality indicator by measuring consequences of overtreatment like orthostatic hypotension and syncope.

Lee notes a similar problem with many quality indicators for glucose control in patients with diabetes. Virtually all measure the proportion of patients with glucose levels below a specified target. But virtually none measure complications of aggressive blood sugar control like hypoglycemia. This lack of balance can be dangerous in the older patient, in whom the benefits of tight blood sugar control may be small, but the consequences of hypoglycemia can be catastrophic.

Quality indicators, including HEDIS measures, have undoubtedly improved the health of many patients. But the lack of balance in these measures has likely harmed the health of some frail older patients. Quality indicators need to balance their focus on more medical intervention by acknowledging that more medical intervention is sometimes harmful.

It is time for the quality improvement community to start taking concerns about potential downsides of quality indicators seriously.

by: ken covinsky


Anonymous said…
Amen brother.
Anonymous said…
It is about time. I have a Palliative Care practice, so my patients are hurt by the "Standard of Care" guidelines and requirements.
Jessie350z said…
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.
Helen Chen, MD said…
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.
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Anonymous said…
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.
Anonymous said…
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).

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