The zeal to rapidly implement quality measures to improve patient care has had some unintended consequences.
Bob Wachter writes about the latest episode, namely, tight control of glucose in intensive care patients.
Initial studies in 2001 showed a marked improvement in mortality when sugars were closely monitored, but since then, recent data has actually concluded the opposite.
Citing a recent NEJM study, not only were deaths, most commonly from severe hypoglycemia, increased, but Dr. Wachter also notes that the resources needed to monitor sugars that closely rapidly padded health care costs.
So, while it is preferable for more doctors to adopt evidence-based practices, we’re now realizing how difficult that could be. It often takes 10 to 15 years for the literature to “mature,” and there are now several cases where follow-up studies have shown that what was initially thought to help patients, actually led to their harm.
Related posts:
- Are quality measures doing more harm than good?
- How following hospital quality measures can kill patients
- Are patients looking up quality data before a doctor or hospital visit?
- Do physician quality measures tell patients who’s a good doctor?
- Unnecessary hospital admissions cost money and can harm patients
- Can patients and doctors handle the truth?
- Why today’s quality measures do not improve health outcomes
{ 1 comment }
This particular story is very interesting, and I’m glad that Dr. Wachter has written about this.
First, it doesn’t necessarily take 10-15 years for the literature to “mature”. This particular time period came from the IOM report citing that it takes approximately 15 years for us to broadly implement a practice of medicine that we do know to be safe and effective based on the literature.
However, that being said, the literature on this particular issue was not even close to being vetted prior to its firestorm introduction into our ICUs. The Van den Berghe article published in the NEJM in 2001 was fantastic in its risk reduction in mortality. For reasons unclear to me, this single article was picked up by the intensivist professionals and enacted with vigor. There were many subsequent articles following the original that clearly debated its findings and put into question its methods. In this case we should have waited before we broadly implemented the particular strategy used in the original study.
Therefore, I want to caution the readers that this particular instance of tight glycemic control in the critically ill population is not a story that should slow down the push for EBM practice. In fact, this is a story of implementing a strategy of therapy essentially based on a single study because at face value it appeared to be plausible AND easy to do. In reality neither were true.
JFS
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