Wednesday, March 23, 2011

Exceptions to the rule

Our health system recently started sending us quality measure reports - % of our patients with blood pressures under 140/90, % of our patients with coronary artery disease on cholesterol-lowering medicine, etc.  These reports include system targets for each condition, e.g., 90% of patients with hypertension with blood pressures under 140/90.  Health plans are beginning to provide bonus payments to physicians who meet these targets; eventually, some may begin penalizing those who don't.

Although some of my colleagues are unhappy with having "one more thing" to keep track of (and I can't say that I blame them), I am glad to have these numbers.  I want to know where I can improve my care.  And, I am currently working on a new quality improvement curriculum for our residents, so these statistics give me something pragmatic to incorporate into their teaching activities.

I was recently reminded, though, that while having targets and working toward them are laudable, there are a few patients who will and should not meet them.  I have a patient whose breast cancer has recently returned with a vengeance - widespread bony metastases.  She failed two courses of radiation but does not wish to pursue further curative treatment.

She also has hypertension, but I frankly don't care if her blood pressure is under 140/90.  Patients and physicians work together to control blood pressure to prevent future heart attacks, strokes, kidney failure - all problems that she is quite unlikely to live long enough to face.  This patient and I spend our appointment time talking about her goals of future cancer treatment and trying to maximize her current quality of life.  Her blood pressure of 152/94 - don't care.  (And, for the record, neither does she.)

Certainly this case should be the exception and not the rule.  One of my titles at the residency program I work for is "Director of Practice Improvement," and I truly believe that system changes are an important avenue for improving patient care.  I also would not advocate for arriving at determinations about any patient (such as "let's mostly ignore your blood pressure") without including him/her in the decision making.

But this patient reminds me that we need to leave at least a little space in our QI efforts for those exceptions who shouldn't fit the rules.  Improving this patient's blood pressure would make my personal practice report look better, but it would also be expended time and expense toward a goal neither my patient nor my best clinical judgment find important.

Yes, we should optimize care for most - but not by losing the importance of personalizing care for all.

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