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    "When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov

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    Sunday, June 29, 2003

    How Stupid is Your Doctor? Meant to blog on the news last week that doctors are stupid but ran out of time. Now I have the time, and the story is one that deserves some scrutiny:

    Americans have a slightly better than 50-50 chance their medical problems will be addressed in an optimal way when they visit a doctor's office or enter a hospital, according to a new survey.

    The failure to do the right thing -- or, more precisely, all the right things -- extends across the spectrum of activities physicians are expected to perform

    ...The study built on a previous survey that asked 20,000 randomly chosen adults in 12 metropolitan areas where and how they received medical care. In this study, they were asked to name their physicians and consent to the release of their medical records for the previous two years. A brief medical history was also taken over the phone. Ultimately, copies of hospital charts and clinic notes from about 40 percent of the people surveyed were sent to Rand researchers.

    Twenty nurses then reviewed the records, looking for evidence that specific interventions were done -- or, in some cases, avoided -- in people with particular medical histories, conditions, symptoms, findings on physical exam, habits or laboratory results.

    There’s the first problem. Chart reviews are dependent on the diligence of the reviewer and on the quality of the notes kept by the doctor. Sometimes, interventions don’t get documented, especially interventions that involve counseling. So, the doctor may tell the patient to quit smoking and explain why he should quit, and offer to help, but if the patient says, “no thanks,” it isn’t likely to get documented. Especially if there are other more acute problems to be documented at that visit. (The same goes for other substance abuse issues, and for recommendations for preventive screening.) And in fact, the breakdown of results shows that the largest deficiencies were in just those sorts of areas:

    The researchers also looked at performance based on general type of intervention. Medication choices followed recommended practices 69 percent of the time; immunizations, 66 percent; physical examination, 63 percent; and lab testing, 62 percent. However, physicians asked key questions while getting the medical history for the patient 43 percent of the time. Adequate counseling and teaching were done 18 percent of the time.

    Another factor in these chart review studies is the diligence of the person doing the reviewing. The information often isn’t easy to find, unless you’re the doctor or nurse who uses those charts all of the time. Immunizations, for example, may be within the progress notes rather than in a separate immunization chart. A doctor’s writing may be difficult to read, affecting the assessment of history and physical exam findings documented. Get a lazy, or fatigued, or distracted reviewer, and the results will tend toward the negative. (although the study says that agreement between reviewers in selected samples was “substantial to practically perfect” - a claim that sounds too Mary Poppinish to be believable.)

    The other problem is that the survey doesn’t take into account patient compliance. The indicators for high cholesterol treatment all rely on the presence or absence of laboratory results in the chart. Getting those results requires some incovenience and effort on the part of the patient - fasting and usually a separate visit to collect the blood. But there’s no indication that the authors even considered compliance in their review.

    And then, there are the indicators themselves:

    The recommended interventions were chosen by experts, based on strong evidence of value or harm found in scientific studies. In the case of some conditions, there were many -- 37 for coronary artery disease, 27 for high blood pressure, 25 for asthma. In others there were few -- 5 for alcohol dependence, 5 for pneumonia, 3 for arthritis. In all, there were 439 on the list.

    The percentage of the time that patients got the recommended treatment for a selection of conditions was: cataracts, 79 percent; breast cancer, 76 percent; prenatal care, 73 percent; low back pain, 69 percent; coronary artery disease, 68 percent; hypertension, 65 percent; congestive heart failure; 64 percent; depression, 58 percent.

    The full list of indicators is here (in pdf and it may require money to access), and they are extensive. Of the 36 indicators for congestive heart failure, the first 29 are matters of documentation (documented history and documented physical findings). The indicators for the treatment of menopause rely entirely on documentation of counseling. And as mentioned before, absence of documentation isn’t necessarily the same as absence of treatment.

    In addition, although the indicators of quality of care were “chosen by experts, based on strong evidence of value or harm found in scientific studies,” the actual process consisted of:

    The indicators of quality used in the study were derived from RAND's Quality Assessment Tools system. RAND staff members selected acute and chronic conditions that represented the leading causes of illness, death, and utilization of health care in each age group, as well as preventive care related to these causes. For each condition, staff physicians reviewed established national guidelines and the medical literature and proposed indicators of quality for all phases of care or medical functions (screening, diagnosis, treatment, and follow-up)....

    ....Four nine-member, multispecialty expert panels were convened to assess the validity of the indicators proposed by the staff, using the RAND–UCLA modified Delphi method. The members of the panels, nominated by the appropriate specialty societies, were diverse with respect to geography, practice setting, and sex. Indicators were rated on a 9-point scale (with 1 denoting not valid and 9 very valid). Only indicators with a median validity score of 7 or higher were included in the Quality Assessment Tools system.

    So, a bunch of physicians at RAND looked at the guidelines available in the literature, and chose what they thought represented good care, then a panel of other doctors got together and looked them over and said whether they sounded good to them or not.

    The problem with this approach is that all guidelines are not created equally. Guidelines are, well, guides, to care, but they are not written in stone, or the last word on treatment approaches. Consider the experience of a group of Danish physicians in implementing an alcohol screening guideline:

    Most doctors found that the screening conflicted with establishing rapport (especially among middle aged and elderly patients), because it set an agenda in advance. They were generally surprised at how difficult it was to generate rapport and to ensure compliance with interventions to address risky drinking behaviour or to reduce harm and to arrange follow up consultations.

    ....Some doctors said that a few patients may have been encouraged to take steps to modify their drinking behaviour, but in general the doctors were deeply sceptical about the effect of the intervention on patients' drinking behaviour. The patients' lack of interest in the follow up consultations seemed to confirm this scepticism....

    ...Firstly, the screening and brief intervention programme was seen as awkward to implement in the normal flow of a consultation. It disturbed the agenda, and patients seemed to be distracted from the subject that made them seek health care in the first place. Secondly, doctors could not work in their usual patient centred way because of the agenda setting imposed by the screening. Thirdly, the extra workload was too high, taking resources from other functions of general practice and in general disrupting the pattern of working together in the practice: "To me, just asking everybody about their drinking habits is in part comparable to if I had to do a rectal examination on all patients that came to see me"

    And there, in a nutshell, you have the problem with judging quality of care by adherence to guidelines. We practice in the real world, where time is limited and patients come to us with problems that they want solved. The way we spend our time is, correctly, directed at helping them solve those problems. Sometimes, many times, screening interventions get put on the back burner, documentation of peripheral issues is neglected, although attention to them may not be. Drugs that may be recommended by the guidelines turn out not to be suitable for the patient due to side effects or financial considerations. Ditto for certain surgical interventions. The practice of medicine can never be reduced to cookbook therapy. Or at least it shouldn’t be.

    posted by Sydney on 6/29/2003 03:46:00 PM 0 comments


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