When Quality Measures Neglect Common Sense

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This comes from a loyal reader and points out the insanity of what is going on with quality measures, pay-for-performance, etc:

Ok, so my husband—70 years old with no cardiac history at all—goes to his doc because he has a pain in his chest—non radiating—like a pulled muscle.  He is getting over a cold and has shoveled snow several times before and during the pain.  It has not increased—as a matter of fact it seemed to be a bit better.  But he thought he should get it checked out.  BAM!!  To the hospital (even though the ekg in the office showed no changes from a prior Ekg and the pain was now about 3 days old).  To his credit the dr. did make it our choice but my husband opted to follow his instructions—“You’ve been my patient over 25 years and I’d hate to miss something.”  So he had the full workup except no cath when it became increasingly obvious that this was not cardiac pain—which is what I told him in the first place but then I’m only a retired RN with 22 years’ experience.  He was discharged within 24 hours.

This is only in introduction to what really set me off.  The RN admitting us told us that he would be getting heparin shots and TED hose to “prevent” a blood clot.  When I objected she only said that blood clots were a big problem and this was their protocol.  When I suggested that he might refuse she then said basically that if he got a clot it wouldn’t be the hospital’s fault because they offered the heparin.  My husband then opted to go ahead with the heparin.

So when I got home I checked several places including the hospital’s own website, PubMed and a general Google search and I couldn’t find anywhere where they have studied this tx with people without a history of clots.  More disturbing to me was the fact that we didn’t receive any info to make an informed decision—it was just presented to us as something to be done.  I fired off a patient complaint to the hospital and the next morning received a call from someone in the hierarchy who explained to me that they use some sort of scale to rate patients as they come to the hospital and if your score is over 2 you get heparin.  I expressed amazement that they would start such therapy on a patient who was only there for tests and was ambulatory and in fairly decent health.  Well, he’s over 70 and if you’re 70 or above you’re a 2—he’s overweight so that’s another 2 and bingo!!  Here comes the heparin!!  I asked the lady for (1)a copy of the protocol; (2) a copy of the scale they use; (3) any journal articles or research that backs up the use of TEDs and heparin as a deterrent to blood clots; (4) the hospital’s rate of blood clots before and after the initiation of this protocol.  We’ll see what they come up with—this is the hospital that I practiced at and they are notorious for starting protocols but not evaluating whether they really do any good or not.  The other thing that entered my devious little mind was that wouldn’t most clots be prevented if the patients were ambulated on a regular basis?  Oops, wait, that would mean we would need staff to get them out of bed and help them—much cheaper (better reimbursed, too) if we just stick them with some heparin and put those TEDs on—which most places state don’t work anyways.

I worked in this Alice in Wonderland atmosphere for 22 years—the last 4 were getting worse and worse and further and further away from why I went into nursing.  I could afford to retire so I did.  Now being on the other side of the mirror so to speak isn’t much better.

Thanks for listening—I enjoy your gazette and generally agree with your take on things.  My dad was an old time GP and he would have told my husband you pulled a muscle—if it gets worse go to the hospital.  Common sense no longer exists in medicine.

This example is great and I would love to hear more from you guys out there.  Please send them to me so I may share them with the world.

 

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  16 comments for “When Quality Measures Neglect Common Sense

  1. macf
    January 15, 2014 at 5:11 pm

    Again, with all the respect to the author, as a 22 year “experienced” RN, you know that you could have signed AMA any time during this whole episode and go somewhere else if you were not happy with the service and people trying to help your husband.
    Hospitals have something called “performance measures” and DVT prophylaxis is one of them. Nothing that you can do about it, and as health professionals we have to abide to them.
    We all agree on patient’s right for information, but there has to be a minimun level of trust here and you did not seem to be showing that for your husband’s caretakers.
    I hope that your husband is doing well.

    • Mary K
      January 16, 2014 at 12:01 pm

      Well, I haven’t heard a thing from the powers that be about the scientific evidence that supposedly underpins the necessity for this DVT prophylaxis. Shouldn’t the average consumer know WHY he is receiving the meds rather than be given a quick “to prevent clots” statement? Yes we could have signed an AMA but my husband has complete faith in his dr. and I doubt I could have talked him into it. All I want to know is 1. What was the rate of DVTs at my hospital before the DVT and 2. What is the rate now? This hospital that I worked at for 22 years has a habit of starting something with great fanfare but never evaluating it after a time period–it just continues and continues until someone–usually from the outside–says we don’t do that anymore–it didn’t work.
      I’m gunshy because of my history with this particular institution. Do others out there have any info about the efficacy of the DVT protocol?

  2. January 15, 2014 at 1:38 pm

    As an emergency physician who treated an acute ST-Elevation MI patient 9age 43) with two normal EKGS before #3 showed the problem in Nov 2013, I don’t think that a normal EKG is so comforting.

    However, what is really important is the big picture. I wonder how much of this expensive misadventure would have happened if the USA had a sensible medicolegal system. And the lady makes some good points.

    Also, be aware that the prudent emergency physician works two parallel thought processes here, because missed opportunities to intervene when the source of pain is cardiac are bad for the patient. In other words, we are always thinking not only “What’s most likely?” (as the source of the problem) but also “What’s most lethal (if it is overlooked)?”

  3. Ms4
    January 13, 2014 at 10:50 pm

    I’m sorry, a 70yo M who had chest pain after shoveling snow would warrant a cardiac work up at any hospital in the country. What is his chance of an MI? 1/1000? Ten thousand? Hundred thousand? I can guarantee you if he was having a heart attack, this patient and his wife would sue the original dr so fast for one to ten million dollars easy. In retrospect it would be so obvious he was having an MI. Better to send him to the hospital than risk losing your livelihood and reputation over something so obviously easy to argue as a heart attack in his case.

    we didn’t receive any info to make an informed decision—it was just presented to us as something to be done. I fired off a patient complaint to the hospital
    – it’s wonderful that the nurse and dr trying to do their job and help your husband are getting complaints because you felt your husband was too good for heparin shots, something that is done in every hospital for every patient in the country…

    I asked the lady for (1)a copy of the protocol; (2) a copy of the scale they use; (3) any journal articles or research that backs up the use of TEDs and heparin as a deterrent to blood clots; (4) the hospital’s rate of blood clots before and after the initiation of this protocol.
    – can you imagine working at a hospital where every patient asked for this kind of information before any lab or treatment?

    Dr: your husband is having a heart attack. I suggest aspirin, plavix, statin, ace inhibitor, etc. etc.
    Pt: I want you to write an essay in the pros and cons of all of those treatments and then back it up with multiple research papers then give me your hospitals data and the data on your performance vs your colleagues and then get me a smoothie for me and my homies while your at it or else I’ll file a complaint!

    • Pat
      January 14, 2014 at 9:36 am

      Boom !

    • Mary K
      January 16, 2014 at 12:05 pm

      Wow, I really rocked your boat!! I was not asking for the info prior to getting the heparin–my husband had already agreed. I was only asking for info afterwards which, by the way, I haven’t received. In YOUR hospital do you have info on the efficacy of the protocol or are you doing it because its a performance measure? I did a quick Google and PubMed search and couldn’t find any studies on the DVT protocol.

  4. John Parkin
    January 12, 2014 at 10:48 pm

    I recently was called to see a patient who had fallen and hit his head in a hospital room. Upon reviewing his chart, I found that he had been admitted in a confused state possibly due to a seizure and/or ETOH with drawl. He was considered a fall risk ; monitored for that, and was treated with Ativan. Because he met the DVT risk criteria, he was started on Lovenox. He suffered a major intracranial bleed and died within a few hours. I don’t recall seeing fall risk or confusion in the DVT protocol as negative points and feel that this may have contributed to his demise. This is the kind of crap that happens when some regulatory agency focuses on one issue and clinical judgement is pushed aside. Please let us deal with the entire patient as clinicians not let the protocols take over patient care.

    • Doug Farrago
      January 13, 2014 at 6:35 am

      Amen

  5. Dr Bonz
    January 12, 2014 at 5:34 pm

    While I completely agree with the author, I would hope that she realizes that the entire impetus behind all of this is 1) Government/insurance company driven and 2) liability driven. Anyone who insists on “(1)a copy of the protocol; (2) a copy of the scale they use; (3) any journal articles or research that backs up the use of TEDs and heparin as a deterrent to blood clots; (4) the hospital’s rate of blood clots before and after the initiation of this protocol.” would also very likely be the first one to call a malpractice attorney if the hospital DID NOT treat the patient for possible DVT and he got one, and DID NOT order the tests they ordered and he then suffered an MI.

    • Pat
      January 12, 2014 at 5:58 pm

      I’m sensing a theme here…

      • Dr Bonz
        January 13, 2014 at 7:06 am

        Yep…..

    • Mary K
      January 16, 2014 at 12:13 pm

      After reading several of the comments I see that the idea of patients suing IF the protocol isn’t followed or if the workup wasn’t done is ingrained in healthcare workers. I come from a family of dr.–father was a GP, father-in-law was a GP, and brother is an OB-GYN. My father would have told my husband come back if it gets worse and would use a little common sense–EKG unchanged from the past, no cardiac history, non typical chest pain, etc. But in today’s society the dr. was using the best judgement in doing the workup–I have no issue with that. My issue (and apparently an issue with some of you also) is the protocols that spring up seemingly with no foundation–we use heparin to treat DVTs maybe they’ll work prophyactically. Is there any followup or studies out there? I couldn’t find them on the internet.

  6. Ken
    January 12, 2014 at 12:00 pm

    The treatment that I think would have done around here, is a set of labs, EKG ,cxr, and if normal then a treadmill in the ER. If normal then no admission, especially if the pain does not sound cardiac. The trouble with CP, is that physicians essentially have to be correct 100% of the time–any mistake and we likely get a visit from our administration, the medical board, and an attorney. And a furious family. I always tell my patients that if they don’t want me to work up their problem then don’t tell me about it, and that getting involved in the medical system is not benign process, testing and treatments, both inapprriate and appropriate can be hazardous to one’s health.

  7. Pat
    January 12, 2014 at 11:26 am

    With sincere respect for the author’s professional experience, a 70 year old with chest pain nonetheless is a legal liability; the treating physicians and hospital know very well that should undiagnosed cardiac disease be missed, or DVT prophylaxis not be employed, then any poor outcome will be followed by a visit from the compassionate attorney.

    Standard of care is dictated by liability and meeting the benchmarks set by the payer. You complained to the same hospital that will have to meet JCHAO standards, satisfy Medicare payment hoops, and which in the near future could have reduced payment based on patient/family complaints. And you wanted an “Informed decision”? I say with all sadness, that your husband was a commodity that was treated accordingly.

  8. Sir-Lance-a-Lot
    January 12, 2014 at 11:05 am

    The important detail is unclear here: Was this 70yo gentleman going to be confined to his bed for a day or more, or was he going to be ambulatory?

    It is my impression (No, I’ve never read the studies) that studies clearly show a benefit from LMW heparin and / or inflatable leg cuff doohickies in people who are not ambulatory, but, of course, if this patient is in good health, then he will be ambulatory on his own, and should not need any of this.

    As for the initial treatment of the patient, once again, the important details are unclear.
    I see patients of all ages c/o chest pain all the time. In a 70yo male who has been undertaking vigorous activity without an increase in pain, and whose pain is not otherwise suggestive of myocardial ischemia, I would pay close attention to the musculoskeletal exam – it I could get him to say “Ouch!” by making him move his left arm against resistance in a certain direction or by pressing on his chest, and he could tell me clearly that that pain was the same pain he was c/o, I would tell him to get lost.
    If, however, I could not nail the pain down to any musculoskeletal site, then a 70yo with vague chest pain and a pretty EKG would definitely get a line, O2, ASA, and NTG and a ride to the ER. I don’t have X-ray or ultrasound vision, and cannot check a troponin with a tricorder like Dr. McCoy.

    • Mary K
      January 16, 2014 at 12:15 pm

      Sorry I couldn’t have given more detail but he was the gentleman that you would have sent home.

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