Thursday, March 12, 2009

A Look Ahead

"Pay for Performance"

"Comparative Effectiveness Research"

"Quality Assurance"

These terms to health care policy wonks are like Viagra, Cialis and Levitra are to a middle-aged divorced man.

With the emphasis on "cutting costs" and "efficient us of health care resources," we're heading toward these presumed cornerstones for health care delivery lock, stock and barrel, never stopping to ponder the consequences of these policy initiatives to those most likely to use the system: the elderly.

Michael Oliver, professor emeritus of cardiology, University of Edinburgh in this week's British Medical Journal gives us a sneak preview in his editorial entitled, "Let's not turn our elderly into patients:" (subscription required)
"Many older people, often retired, are summoned by their general practitioner for an annual health check. They may feel reasonably well, but the NHS does not always permit such euphoria. They may be told that they have hypertension or diabetes or high cholesterol concentrations; that they are obese; that they take too little exercise, eat unhealthily, and drink too much. The quality and outcomes framework (QoF), the scheme that rewards NHS general practitioners for good performance, awards points, with related payments, for each documentation. Many of these patients are told to have more investigations. Eventually, most are started on pills. Few seem to be considered not at risk for something. Thus, of those who thought themselves healthy, a number will return home as patients. And they may be scared and no longer comfortably aging.

What kind of medicine is this? It is politics taking preference over professionalism, obsession with government targets superseding common sense, paternalism replacing personal advice. It seems that many Western governments regard all people aged over 75 as patients.

This trend has many causes. These include overenthusiastic and uncritical interpretation of various guidelines, the payment of GPs by NHS trusts for ticking boxes, the demands of government health economics and of insurance companies, and the relentless pressure from the drug industry."
He argues that many doctors do not know the difference between relative and absolute risk, that most studies to evaluate therapies are not performed on the elderly, and that the numbers needed to treat to help one patient might subject as many as 74 others to therapy.

Additionally, he argues that guidelines should be guidelines for therapy, not mandates and concludes:
"Primary prevention among young and middle aged adults should be encouraged and supported. But should this apply equally to fit elderly people? Nowadays few elderly people are allowed to enjoy being healthy. A bureaucratic demand for documentation can lead to overdiagnosis, overtreatment, and unnecessary anxiety. Preventive action may be irrelevant and even harmful in elderly people."
And, in turn, I might add, drive unnecessary costs.

If you can, read the whole thing.


Addendum: Scottish Review: One patient's take from the article - I particularly liked the last paragraph.

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