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Quality indicators are supposed to encourage better health care.
But in the case of the elderly, they may lead to “unintended harms,” according to a commentary published in the Journal of the American Medical Association.
In general, these indicators encourage physicians to provide more care deemed appropriate, not to pare back on care that is inappropriate, says Sei Lee, an author of the piece and an assistant professor of medicine in the geriatrics division at the University of California, San Francisco. (His co-author is Louise Walter, also at UCSF.)
That means a hypothetical doctor who prescribed medications to everyone who came in the door, whether they needed them or not, could look great according to the indicators, Lee — who is also staff physician and associate director of the VA Quality Scholars Fellowship at the San Francisco VA Medical Center — tells the Health Blog.
The elderly population is much more heterogeneous, health-wise, than younger folks, he says. Some 65-year-olds are very active and taking maybe an aspirin a day, while others have had numerous heart attacks and are basically debilitated. Given that variety, “it’s more important to think about targeting” people to be sure they’re getting appropriate care that won’t result in harmful side effects, Lee says.
For example, one quality measure looks at what percentage of patients have their blood sugar controlled. But there’s no routine measurement of how many people develop too-low blood sugar, necessitating emergency glucose tablets or even a trip to the E.R., says Lee. An indicator measuring how many women receive mammograms could be balanced by one reporting “the rates of inappropriate screening mammography (i.e. in patients with preexisting advanced cancer or dementia who are unlikely to benefit),” the commentary says.
(A study published last year found a significant number of people with advanced, incurable cancer were still receiving screenings for other cancers.)
To help make sure preventive care goes to those likely to benefit, quality indicators could account for how long a person is likely to live and encourage “prevention only in those patients whose predicted life expectancy exceeds the intervention’s lagtime to benefit,” the commentary says. For example, rather than rating a physician on whether he or she offers colorectal cancer screening for adults aged 50 to 75, it could encourage screening for people with a life expectancy of more than seven years.
That would help ensure an 80-year-old with no major health problems would get screened, while protecting a 70-year-old with a serious, incurable condition from an invasive test that isn?t likely to help.
A study recently published in the Archives of Internal Medicine found primary-care doctors cite the incentives created by quality indicators as a reason for treating patients more aggressively than is ideal.
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