A Matter of Opinion

In an op-ed in the New York Times this week, my fellow Harvard physicians Pamela Hartzband and Jerome Groopman argue that it’s pernicious to reward physicians for meeting quality standards. These measures of performance, they say, are “population-based and generic, and do not take into account the individual characteristics and preferences of the patient or differing expert opinions on optimal practice.” Really? Are there no practices that physicians should routinely follow if they are to practice good medicine?

The answer revolves around the concept of “preference sensitive care,” articulated by Jack Wennberg and Elliott Fisher of the Dartmouth Center for the Evaluative Clinical Sciences. Preference-sensitive care involves treatments that involve significant tradeoffs affecting the quality and or length of life. It is contrasted with effective care, which involves essentially uncontroversial treatments that are unambiguously optimal, or for which there are no viable alternatives. What Hartzband and Groopman are arguing is that essentially all care is preference-sensitive and there is no such thing as effective care. Therefore, they conclude, there is no way that we can legitimately grade treatment as inherently good or bad—it either reflects patients’ wishes—or physicians’ recommendations—or it doesn’t.

The view that there are no medical practices that constitute “effective care” and that all medical care is preference-sensitive strikes me as profoundly misguided. In 2003, RAND evaluated the quality of medical care in the US and found that only 55% of adult patients surveyed by telephone had received recommended medical treatment. These treatments included counseling on smoking cessation to patients who had had heart attacks and long-acting inhalers for people with chronic asthma. Did the 45% of patients who did not get standard treatment actually receive care that, while not consistent with expert recommendations, conformed well to their preferences? Could 45% of physicians have deliberately and thoughtfully chosen a course that deviated from expert recommendations because they had unique insight about what was best for their patients? Is there a plausible reason why physicians should not advise cardiac patients to stop smoking or patients with at least moderately severe asthma to use inhalers? I doubt it.

What about older people? Perhaps this is one population where most treatment is preference-sensitive. After all, as I have often argued in this blog, what makes sense for people who are frail, dying, or have dementia depends heavily on their goals of care. Even a seemingly clear-cut decision such as whether to have surgery for a broken hip might have a values component. A patient who is dying, for example, and whose only goal of care is his comfort, might choose to have bed rest and pain medication rather than the rigors of surgery. So are there quality indicators, those “metrics” that Hartzband and Groopman vilify, that apply to the geriatric population?

I looked at the most recent HEDIS (Healthcare Effectiveness Data and Information Set) measures, the set of indicators used by health insurance companies throughout the US to evaluate physician performance. These were designed by the NCQA (National Committee for Quality Assurance), a non-profit, non-governmental, independent body that relies on expert judgment and public feedback to determine quality indicators. It turns out that there are 5 HEDIS measures for older adults, addressing physical activity, pneumococcal vaccination, osteoporosis testing, medication management, and fall risk management.

The 5 domains were chosen for good reason. Physical activity plays a role in maintaining physical function as well as in staving off depression, cardiovascular disease, and other chronic illnesses common in old age.

Pneumonia is very common in the elderly and it’s a killer. When it doesn’t kill, it causes shortness of breath and confusion, often resulting in hospitalization, and may trigger other conditions such as a heart attack. Osteoporosis is responsible for tremendous suffering, mainly in the form of pain and impaired mobility, and predisposes to fractures. Falls, like osteoporosis, are the cause of an enormous amount of misery in old age. Nobody, and I mean nobody, wants to fall, just as nobody wants to have osteoporosis. Medications are commonly used by older people—on average, they take about 5 prescription drugs—and the more medications a person takes, the greater the likelihood of side effects.

If the targets are reasonable, are the specific quality indicators themselves? In general, the answer is yes. The pneumonia metric, for example, looks at the percentage of adults 65 and older who report ever having received a pneumococcal vaccination. The only people for whom getting a pneumonia shot doesn’t make much sense are those who are dying. And even patients who are dying presumably weren’t dying a year or two years ago, at which point they should have gotten immunized against pneumonia. Since the measure asks if a person has ever been vaccinated, the only older patients for whom this is inappropriate are those who develop a lethal illness at age 65 or those who regard life as worse than death (usually also people with a fatal illness) and who hope they will get pneumonia. There will always be people who refuse the shot out of a misguided belief that it will cause them harm. Some people will have religious objections—though I have yet to find an established religion that forbids vaccination (the exception is Christian Scientists but they aren’t likely to go to doctors in the first place). So physicians will rarely achieve a score of 100% on the vaccination metric. But the question is not whether vaccination can always be achieved; it’s whether vaccinating against pneumonia constitutes good medical practice.

It would be nice to have separate measures for patients  who are near the end of life, for those who meet the criteria for enrollment in hospice (whether they have chosen to enroll or not). At the very least, for patients with a limited life expectancy, the physician should be able to indicate that the quality indicators are “not applicable.” But apart from this concern, the quality measures strike me, on balance, as entirely reasonable.

According to a report just released by the NCQA, 54% of the US population (171 million people) now have health insurance from a plan that uses HEDIS measures. Over the last 3-5 years alone, 46% of the HEDIS measures have shown consistent, statistically significant performance gains. Surely this is progress. Some treatment decisions are preference-sensitive and for these cases, we should find a way to determine if physicians are eliciting their patients’ preferences and treating them accordingly. For those treatments that constitute “effective care,” the quality indicators make good sense.