I often rant about performance indicators – Exploring the concept of stratification – implications for performance measures
Yesterday, the NEJM released several important articles which challenge blood sugar tight control as a means of decreasing complications. The NY Times covers these articles very well – Tight Rein on Blood Sugar has no Heart Benefit.
At the SGIM 2007 annual meeting I heard Tom Lee argue in favor of performance measurement. He co-authored the editorial on these articles – Redefining Quality — Implications of Recent Clinical Trials.
How, then, should guidelines and performance measures change? First, we should no longer support the use of targets without reference to the strategies used to achieve them. Guidelines and performance measures should reflect the evidence about interventions that are known to be beneficial. For example, guidelines for lowering lipid levels should be based on tested strategies and should make it clear that the strategies with the strongest evidence are preferred. A quality measure that incorporated the use of statins into an assessment of lipid-level control would be more scientifically sound than the simple assessment of the proportion of a physician’s or practice’s patients in whom a specific LDL cholesterol level was reached by any strategy. A quality measure for tight glucose control should require evidence that a proven strategy provides a strong net benefit for patients. We know that we are setting a high standard for developers of performance measures, but advances in our knowledge demand nothing less.
Second, guidelines and performance measures should incorporate more sophisticated and explicit considerations of the risks of disease and adverse consequences posed by the intervention. In patients with a low likelihood of a particular poor outcome, an intervention designed to protect against that outcome is unlikely to provide substantial benefit — so if the intervention carries even a small risk, this risk can offset or even outweigh the benefit. In sicker patients and those with more complex conditions, certain interventions (such as maintenance of tight glucose control) may be more likely to produce adverse effects than they would in healthier patients, either directly or through their effect on adherence. For these patients, we need evidence that the strategy is safe and has a substantial net clinical benefit despite the greater risks of treatment.
The assessment of net clinical benefit should be based on events averted or lives improved. The promulgation of those strategies that are shown to be effective will serve as an incentive for drug and device developers to provide evidence about patient outcomes, not just about how a drug or device affects intermediate outcomes. Moving practice toward evidence-based strategies and becoming more accountable for what we do for patients represent important advances in our delivery of health care, but we must ensure that in implementing quality measures we are always acting in the patient’s best interests. ACCORD, ADVANCE, and other recent studies remind us that practice is complex and that ultimately we need to understand a strategy’s effects on people, not just on surrogate end points.
Wow! Now the performance measurement advocates have seen the light. Many thoughtful writers (including this blogger) have attacked the current performance indicator movement with vigor. These articles (and the Vytorin article) will hopefully bring reality back to the movement. This editorial may be the most important editorial published in the NEJM during my career.
We have ranted about the unintended consequences of current performance indicators. Now the advocates have discovered the problem. I guess I am gloating. Yes, I am gloating – I TOLD YOU SO!
