Quality Metrics and Hb A1C

This NY Times articles clearly points out, without knowing it, the problem with grading doctors on bogus metrics.  I have been pounding my chest about this issue on this blog for years.  It is unethical to pay a doctor on the lab test results of his or her patients. The article in questions describes the dilemma of using drugs to treat diabetes.  The issue is that “it’s becoming clear, researchers say, that there’s far too little evidence on how diabetes drugs affect the heart to make rational evidence-based judgments.”  But evidence be damned when you allow doctors to be paid on the Hb A1C levels. And the article inadvertently shows the results of this:

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  • While this measurement is a good predictor of risk, “the question is, who benefits from intensive blood sugar lowering and which drugs are best for whom?” said Dr. Harlan Krumholz, a cardiologist at Yale.
  • The target level varies among patients, though many do not realize it. They and their doctors often aim, at times obsessively, for an A1C level of seven.
  • None of that has stopped doctors from urging patients to lower blood sugar at all costs. But many of their patients, particularly older ones, often take other medications, too.
  • “They were always upping the dosage of drugs, wanting to get to seven” he said. “One doctor was very adamant and very demanding. He told me if I didn’t do what he said, I would not be here much longer.”

Who benefits? Obsessively aiming for an A1C of 7? Urging patients to lower blood sugar at all costs? Adamant? Demanding?

This is what you get with “pay-for-performance”.  It needs to be abolished.

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