PART I of III: IN DEFENSE OF THE DOCTOR WITH A BAD REPORT CARD WHEN NOT ADHERING TO PAY FOR PERFORMANCE [P4P] GUIDELINES

Doctors suffer bad report cards by medical insurance carriers for not adhering to “quality of care guidelines.”

Doctors say these guidelines are more cost saving/profit making for the insurance companies than medical quality.

Who is correct?

Currently less than one tenth of 1% of the total. $2 trillion spent annually on health in the United States is spent on evidence based medicine to ascertain and establish competent medical clinical guidelines.

The demand for better evidence to guide healthcare decision-making is growing rapidly due to the variation of healthcare interventions, the frequency of medical errors, and the adverse consequences of care administered without adequate evidence.

The Roundtable on Evidence-Based Medicine in the office of the Institute of Medicine [IOM] have set a goal that, by the year 2020, ninety percent of clinical decisions will be supported by accurate, timely, and up-to-date clinical information, and will reflect the best available evidence on what works best for whom, and under what circumstances. http://www.iom.edu/CMS/28312/RT-EBM/55282.aspx.

To this end the American Recovery & Reconstruction Act of 2009 commits $1.1 billion to Comparative Effectiveness Research, and $19 billion to increasing health information technology.

Let’s look at an example of what such studies would look like in patients. --In this instance patients with Diabetes.

Almost 200 million people worldwide have type 2 diabetes. Coronary artery disease (CAD) is a major health concern and the leading cause of death in individuals with type 2 diabetes. CAD is often asymptomatic in these patients until the onset of myocardial infarction or sudden cardiac death. Type 2 diabetes is also widely recognized as a CAD risk equivalent. Thus endorsed by professional organizations screening of patients with type 2 diabetes and no symptoms of CAD were recommended in the absence of prospective outcome studies supporting its utility. Screening for CAD in patients with type 2 diabetes especially with 2 or more cardiac risk factors, though not an evidence based recommendation like many such guidelines had been also endorsed previously by an expert panel of the American Diabetes Association.

The strategy of routine screening for CAD in patients with type 2 diabetes is based on the premise that testing could accurately identify a significant number of individuals at particularly high risk and lead to various interventions that prevent cardiac events. However, in a study by Young L.H.et al, Cardiac Outcomes After Screening for Asymptomatic Coronary Artery Disease in Patients With Type 2 Diabetes;The DIAD Study: A Randomized Controlled Trial .JAMA. 2009;301(15):1547-1555 the results of the DIAD study would appear to refute this notion.

Although type 2 diabetes is considered to be a CAD equivalent participants had a low cardiac event rate (average, 0.6% per year) and the identification of participants with abnormal screening results did not serve to eliminate their risk over 5 years of follow-up.

The current standard of care for type 2 diabetes emphasizes the reduction of cardiovascular risk factors. However, there has also been substantial interest in the early detection of asymptomatic CAD by screening of patients with type 2 diabetes. Recent studies have shown that CAD can be detected noninvasively in a significant number of these individuals. Inducible ischemia and coronary artery calcium each have been shown to be associated with worse cardiac outcomes. However, the potential of routine screening to alter treatment and to prevent cardiac events in persons without clinically apparent CAD is largely unknown.

Thus, although endorsed by some professional organizations, screening of patients with type 2 diabetes and no symptoms of CAD remains highly controversial in the absence of prospective outcome studies supporting its utility.

In the light of the author’s findings, routine screening for inducible ischemia in asymptomatic patients with type 2 diabetes cannot be advocated for 4 reasons.

• First, the yield of detecting significant inducible ischemia is relatively low.
• Second, the overall cardiac event rate is low. Indeed, even our participants with moderate or large defects and the highest event rate would be conventionally assigned to an intermediate-risk category.
• Third, routine screening does not appear to affect overall outcome.
• Finally, routine screening of millions of asymptomatic diabetic patients would be prohibitively expensive.