Exception reporting… again
Civitas, 16 April 2009
A few weeks ago the DH released the conclusions of its consultation on the Quality and Outcomes Framework in general practice – a series of clinical guidelines GPs are expected to meet that is linked to c.20 per cent of their income. Predictably, the responsibility for its evidence-base is being turned over to NICE: a risk.
The QOF, for all its failings, has been relatively successful in biomedical terms largely because it is seen to be ‘owned’ by the profession and clinically relevant. NICE, by contrast, is a fairly distant body to those in general practice and, using QALYs to reach its decisions, is not that well-placed to deal with the complexities of general practice (with its important interpersonal elements and expertise in dealing with patients with complex co-morbidities). Thankfully, however, the contract for researching the evidence-base for indicators has, at least, been won by the National Primary Care Research Centre (at the University of Manchester), staffed largely by current or past GPs committed to quality improvement, but well aware of general practice’s historic strengths. NICE’s work in this area is also to be chaired by a former chair of the Scottish Royal College of GPs.
Of perhaps greater concern though is the preference of the DH – expressed in the same consultation document – to consider exception reporting (that is, to remove patients from counting toward overall QOF scores, and thereby income) ‘unacceptable’. To be sure, exception reporting opens up the possibility of gaming. Unscrupulous GPs could use exception reporting to cheat the system and strike awkward patients off the QOF register in order to boost scores, which leaves obvious question marks about the quality of care such patients might be receiving.
But, as we argued in a recent piece on the QOF, exception reporting also has a very good clinical rationale. There are many things beyond the control of a GP where treating a patient along QOF guidelines would be inappropriate; such as age, a lack of responsiveness to treatment, an unwillingness of the patient to be treated, and contra-indication for therapy. If such patients were included in the QOF, it could unfairly penalise practice income, produce perverse incentives for inappropriate treatment, or encourage practices to remove ‘unusual’ patients from their lists in order to maximise payment.
To put it in medical speak, you can never perform the gold standard of random control trials on every kind of patient GPs meet every day of the week, so their freedom to use their experience and apply an ever-expanding base of sound research findings to individual patient care, particularly those with complex co-morbidities, must remain.
Exception reporting may sound a bit trivial to the bystander, but the issues surrounding it cut to the heart of what the practice of medicine is about. To be sure, there are now evidence-based principles and protocols that, in the general case, it would be churlish bad medicine not to follow. However, as the Harvard Medical School professor of medicine Jerome Groopman has argued powerfully, follow evidence-based too rigidly and you can undermine what may be in an individual patient’s interests – based either on the biological particularities of their case, or their specific preferences. Algorithms, he said, ‘quickly fall apart when a doctor needs to think outside their boxes, when symptoms are vague, or multiple and confusing, or when test results are inexact’.
In fact, they can be downright dangerous. A randomised study published in the New England Journal of Medicine last month showed more patients dying in intensive care units when patients received insulin to tightly maintain their sugar in the normal range (a clinical guideline), compared with those on a more flexible protocol. Similarly, two studies published in June 2008 cast serious doubts about maintaining normal blood sugar in ambulatory diabetics with vascular problems (another clinical guideline) has been a key quality metric in assessing physician performance.
Medicine is, as yet, an inexact science. If the QOF (itself a serious of guidelines with financial incentives attached) is to remain, then so must the provision to exception report.