Why ‘adherence to guidlines’ is the wrong way to measure primary care
Guidlines tell us how to maximize the treatment of a condition or organ system. They are incredibly helpful tools that guide us in optimal care of diabetes, hypertension, AHDH, etc.
As I noted in my last post, overall health and wellness is not necessarily the same thing as maximizing the treatment of an organ system. There are times when guideline adherence is the wrong thing for some patients.
Example:
In the treatment of Type II diabetes we see an increase in depression when we maximize adherence to self-testing of blood glucose. Since self-testing of blood glucose is not strongly linked to better outcomes for Type II DM and depression is strongly linked to worse outcomes, we might posit that strict adherence to the guideline may in fact hurt some of our patients.
Example:
Patients with diabetes who have hemoglobin A1c less than 7.0 have fewer complications. A logical quality measure pushed by the NCQA and other bodies says primary care docs like me should be judged based on the percent of our patients with diabetes who have A1c less than 7.
The problem is that studies show us that elderly patients with diabetes who achieve A1c less than 7.0 fare worse - they die more often.
This is an example of a seemily logical goal that leads to increased risk of death, an outcome most people would accept as more meaningful than A1c.
The examples highlight the essential work of primary care - to help people find their own ideal balance between guidelines and their lives. Fully informed adults may choose goals that deviate from the guidelines. Who’s right?
Measuring primary care by ‘percent guideline adherence’ ignores the fundamental value of primary care and forces us to behave like minispecialists. Guidelines are good tools to measure specialty care but poor ones to measure primary care.
Let guidelines guide good care and let’s use other more meaningful and appropriate approaches guide primary care measurement.
