Confusion

"There’s too much confusion, I can’t get no relief." These lyrics, sung by Jimmy Hendrix in his famous song All Along the Watchtower, can be used to describe the present state of organized Medicine concerning quality indicators. For almost two decades, there has been a movement toward a uniform set of practice guidelines which would elevate the quality of care delivered to the American public. Practice Guidelines, Evidence-Based Medicine and Comparative Effectiveness are just three of the buzzwords used by the groups promulgating these movements. Medicare has set a number of quality indicators, which they measure accurately, as indicators of how well a practice or an institution is performing in delivering quality healthcare. The problem has become that many of these quality indicators are falling by the wayside. The latest to go is the quality indicator which measures how often Beta Blockers are prescribed after myocardial infarction (heart attack). Beta Blockers were believed to significantly reduce the incidence of second heart attack over the long run. A recent long-term study, published in the Journal of the American Medical Association, seems to have disproved the value of Beta Blockers in this setting. This is not the first, nor will it be the last, quality indicator to have….well….quality issues. Inhaled steroids for asthma have been questioned. Hormone replacement for women has certainly fallen aside; in fact, the incidence of Breast Cancer in the USA has fallen by 15% since hormone replacement therapy, once a leading quality indicator, was exposed as harmful 10 years ago. Yearly mammography, once a solid quality indicator, has been under fire recently, both scientifically as well as politically. Yearly PSA, another quality indicator, has been shown to be more harmful than helpful. Colonoscopy every five years as opposed to every ten years is another. As we look to get more bang for our buck from our healthcare dollars, it appears that what we consider to be quality is somewhat elusive. One can make the argument that Medicine is an evolving science and as such will have forward movement as well as setbacks. The bigger question is why is so much of Medical Research so wrong? Conflict of interest, career advancement, income, regression to the mean and bad public policy are a few of the short answers. The present crisis in Medicine revolves around how little real good we get from all the money that we throw at it. Until we reform how medical research and progress are actually carried out, the course to bad outcomes and bankruptcy will continue to be paved with the best of intentions.