Quality indicators can harm the elderly

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.

Ken Covinsky is Professor of Medicine, University of California, San Francisco who blogs at GeriPal.

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  • http://www.facebook.com/profile.php?id=655523194 Jeanine Satriano-Pisciotta

    As a geriatric nurse for 26 years, I 100% agree. Each patient needs to be a case by case, not a target number.

  • Anonymous

    “Quality indicators, including HEDIS measures, have undoubtedly improved the health of many patients.” 
    There is no evidence to support that statement.

  • David Lawrance

    Care of individuals must be individualized. Nevertheless, HEDIS quality goals are still applicable for most patients. This is well understood within the quality community. It doesn’t seem to be as well appreciated outside of it. If you want to go with a good managed care organization, then look at their HEDIS performance measurements. Organizations that achieve high HEDIS scores don’t manage all patients the same. They manage them appropriately.

    • Anonymous

      HEDIS scores are important because high HEDIS scores are highly indicative of . . . high HEDIS scores?

  • David Lawrance

    There is no evidence to support that statement.

    • Anonymous

      If you can show me that the long term health of any patient population has been imrpoved significantly by the initiation of HEDIS measurements, bring it on.

  • http://www.facebook.com/profile.php?id=1556913841 Cindy Martinetto

    …and weren’t we taught to treat the PATIENT and NOT just the NUMBERS?

  • Bradley Evans

    Yes. When a patient is admitted with a fever, the thermometer reads a high value. The patient’s temperature is a quality indicator for that patient. The easy solution is to put the patient on ice.

    There are at least 2 problems with quality indicators. First, there are both good and bad consequences from using the qualtiy indicators. In the rush to get “buy-in,” quality engineers ignore the bad. It is traditional before changes are made to patient care that advocates show their data. So, I agree with southerndoc1, where’s the data? The second is that the measurement itself is treated as the problem. Too many C-sections? Then, stop doing C-sections. The patient is ignored in their analysis.

  • http://www.facebook.com/AnthonyZahraMD Anthony Zahra

    What is probably needed are more complex quality indicators, which account for the risks as well as benefits, approaching what should be done judiciously at every pt encounter

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    There has been little or no research into the chronic health problems of senior citizens. There was no money in it so nobody looked at it. Its that sad and that simple. That being said, there need to be different levels of normal values  for individuals at different stages of life. Until good studies prove what those levels are then HEDIS is worthless in the elderly.  Care in the elderly must be individualized and tailored to their unique clinical and social situation. This concept is very difficult for those individuals who do not care for patients to perceive when they are trying to construct quality guidlines that could be used to build a Japanese auto, but they make great sense to all the doctors, nurses, health care givers and family members who actually care for senior citizens

  • Anonymous

    This is so true in my experience as health care proxy for my 97 year old father.  No one ever discusses the side effects of treatment and no one seems to know what those effects are likely to be in a very old body.  In all cases I’ve found that less treatment is the best course of action although not always the one that is recommended.

  • Anonymous

    Dr. Covinsky is absolutely correct. Many times I have seen our older clients see a specialist and be put on the “correct medicine” and then watch the resident have side effect after side effect. The staff then attempt to change the medicine to improve the quality of life, and the resident is reluctant to do so because”that’s what the specialist ordered. Once again, let’s take a look at the whole person, not just what the indicators say