The Covert Rationing Blog

More Guidelines - Fighting For the Children

August 4th, 2008 by DrRich

A few months ago, DrRich addressed certain disadvantages that will arise from a policy of forcing physicians to practice medicine by guidelines. Essentially, once we decide to measure physician quality and determine physician pay according to how well they “perform” in following handed-down clinical guidelines, we will open a Pandora’s Box of dysfunctional and contradictory guidelines that will make the IRS code - or even the Medicare policy manual - seem straightforward and logical.

Payers are placing much hope in guidelines. They envision great cost savings through the simple expediency of adopting guidelines that leave out certain medical services they would like to avoid paying for.

But the payers have made the grave strategic error of fully embracing the “guideline movement” before securing for themselves control of the guideline development process. Apparently they missed the obvious fact that, if the practice of medicine is is reduced to following sets of guidelines, then any healthcare group and any medical organization with any stature whatsoever will begin manufacturing guidelines that direct doctors to do whatever it is that advances that organization’s agenda. That is, if guidelines determine who gets paid for what, then guideline development will become the chief byproduct of the healthcare system. We are beginning to see this chaotic process in action now.

DrRich, who delights in attempting to tease order from chaos, has suggested several specific categories of the dysfunctional guidelines that will inevitably flow from such a process. One of these categories he labeled “predatory guidelines.”

As an example of predatory guidelines, DrRich pointed to the recent recommendations advanced by the American Heart Association (AHA) urging that children with ADHD be screened with ECGs before they are placed on stimulant medication. Those ECGs, the AHA went on to explain, should be interpreted not by the pediatrician, but instead by “a pediatric cardiologist or a cardiologist or a physician with expertise in reading pediatric electrocardiograms.”

In making this recommendation the cardiologists of the AHA have attempted to encroach upon the turf of the pediatricians, ostensibly to save the lives of innocent children, but in a manner that will inevitably increase business for cardiologists by a) generating hundreds of thousands of ECGs for them to interpret at $25 - $50 a pop, and b) generating tens of thousands of echocardiograms and other cardiac tests that will be necessary to evaluate all the equivocal (and to a very large extent false positive) ECGs that will result from this routine screening, while c) explicitly leaving the pediatricians themselves out of the process.

DrRich predicted at the time that the pediatricians would not allow this invasion of their turf to stand, and that they would find it necessary to counter with their own set of guidelines. And so, what began as “predatory guidelines” from cardiologists would likely degenerate into “dueling guidelines” between cardiologists and pediatricians.

DrRich is delighted to report that his prediction has now come to pass.

The American Academy of Pediatrics (AAP) has just released a policy statement suggesting that the AHA is guilty of promulgating bad advice. Indeed, the AAP finds, it is not necessary to perform routine ECGs on children with ADHD prior to giving them stimulant medication. Further, the AAP pointedly demonstrates that the AHA’s recommendations were based on faulty science (that is, the AHA failed to follow the principles of evidence-based medicine), and that those recommendations give at least the appearance of being self-serving. Finally, the AAP notes that since routine ECG screening produces many false positive results, which themselves require further cardiac testing, this screening actually produces more harm than good. So, the AAP concludes, not only is there no need to do routine ECG screening, but also doing the screening would produce net harm. The AAP statement stops just short of accusing the AHA of malfeasance.

And so, DrRich would like to thank the AAP for so clearly bearing out his prediction that “predatory guidelines” will always tend to yield “dueling guidelines.”

Needless to say, the cardiologists are not happy about this new development. Dr. Steven Nissen (famous of the Cleveland Clinic, and also famous for producing inflammatory statements pretty much on cue) tells TheHeart.org (professional registration required) that “the AAP statement is misguided.” Nissen also suggests, perhaps a bit gratuitously, that the pediatricians (and their friends, the detestable shrinks) are tossing amphetamines around like candy. He says, “This is the second time in a few weeks where the AAP has issued poorly thought out guidelines that promote inappropriate drug use in children. The previous statement promoted statin use in children as young as 8 years of age.”

(DrRich is sympathetic to the notion that the diagnosis of ADHD might be a tad overdone these days, to the point where being a boy is all but an official disease, for which drug therapy is frequently urged and often prescribed. But still, in the debate over whether children diagnosed with ADHD should have ECG screening before being drugged, the assertion that they are being overtreated in the first place is actually beside the point.)

Both sides in this now-very-public debate seem to have some valid points, and to DrRich’s estimation neither side is obviously completely right or completely wrong. Cardiologists are correct in pointing out that stimulant drugs do have cardiovascular effects, and it is logical to think that kids who are susceptible to cardiac arrhythmias might be at higher risk on these drugs, and that screening these kids might save some lives. But the pediatricians are correct in pointing out that the data that has been collected so far does not show any increase in sudden death in kids on drug therapy for ADHD when compared to the general population, that the same cardiovascular effects caused by these drugs are also caused by everyday activities such as running, jumping, and the sort of emotional outbursts that children with untreated ADHD may have from time to time, and that, besides, doing ECGs on all these kids has a known downside in terms of unnecessary procedures and increased cost.

So, in addition to being unseemly, these dueling guidelines create a dilemma (instead of guidance) for doctors who are actually attempting to care for children with ADHD. One set of guidelines says that screening is necessary to save lives; the other (from an equally regarded professional organization) says that not only is screening unnecessary, but also harmful. Whatever the doctor does, if there is a bad outcome the plaintiff’s attorney will come pre-armed with one set of guidelines or the other which will prove that, no matter what the doctor did, it was the wrong thing.

These dueling guidelines also demonstrate that many important medical questions are simply not suitable subjects for guidelines. Guidelines are fine when a medical issue is resolved, that is, when there is substantial agreement among experts (of all relevant factions) as to how patients with a certain medical condition ought to be managed. But guidelines are helpful only when the clinical question is sufficiently ripe. Premature guidelines - the ones promulgated for some other reason than that the optimal clinical pathway has been resolved - will cause harm (and often, ironically, will increase cost).

Nonetheless, the notion that the practice of medicine can be completely reduced to sets of guidelines (a notion vitally attractive to insurance companies and government bureaucrats), now has been broadcast with great fanfare across the land. It is through guidelines that we will finally homogenize healthcare, and establish the tools by which clinical excellence can be tabulated and costs can be controlled. So, as a consequence of this generally agreed-upon fiction, swarms of guidelines are now flying out of the medical establishment like bats out of a cave. We can expect many of these guidelines to be created not because clinical science warrants them, but instead to covertly ration care, to protect professional turf, or to aggressively extend one’s interests onto entirely new turf.

And so, spectacles like this one, where cardiologists and pediatricians have become engaged in a rather nasty turf battle (fighting for the children, as it were), will be repeated countless times across the medical landscape.

Cry havoc, and let loose the dogs of guidelines!

Posted in Guidelines, Abuse of

5 Responses to “More Guidelines - Fighting For the Children”

1. Dr. Val wrote on 08/4/08 at 11:04 am :

   “Guidelines are flying out of the medical establishment like bats out of a cave.” Classic. Great post, as always - Dr. Rich. Please kindly consider joining medpolitics.com and submit excerpts or original contributions to the site. We need your poignant analyses to get in front of as many eyeballs as possible.

2. Seamus MD wrote on 08/4/08 at 11:33 pm :

   “Whatever the doctor does, if there is a bad outcome the plaintiff’s attorney will come pre-armed with one set of guidelines or the other which will prove that, no matter what the doctor did, it was the wrong thing.”
   In my community the Pediatricians are tending to follow the AHA guidelines rather than the AAP. I presume this is for defensive purposes. They think that in the event of an adverse outcome it is more defensible to have done a screening test than not. As with most defensive medicine, the end result will tend to be increased cost without demonstrable benefit. I can’t wait until the government is writing the guidelines instead of “expert” organizations!!

3. Dr. Wes wrote on 08/6/08 at 6:24 pm :

   Dr. Rich-

   Oh Great Wise One, your insights are paramount to glimpses of genius.

   To point (and almost predictably), there are now companies sprouting up that will assure guidelines are followed meticulously and automatically, using the wonders of the EMR, prompts, and automatic order placement in an effort to force compliance with the guidelines, thereby assuring handsome bottom lines to all who follow…

   We love guidelines…for they impart nothing but “quality:” quality care, quality prevention, and potentially, quality profits.

4. ERMurse wrote on 08/7/08 at 9:47 am :

   My only question is how are you going to get those ADHD kids to sit still so you can get a good EKG tracing for the Peds cardiologist to read. Perhaps give them a sedative but before that there is probably some diagnostic test in a guideline somewhere to make sure they are healthy enough to receive the sedative.

5. Vijay Goel, M.D. wrote on 08/9/08 at 2:21 pm :

   It’ll be an interesting paperchase. Predatory guidelines, defensive guidelines. Guidelines on making guidelines. Guidelines on enforcing guidelines. Guidelines on integrating with other guidelines.

   Just think. We could create a whole papertrail that is just as evidence light and arbitrary as the way medicine is practiced today. Think of the bureaucratic opportunities!

   Seems a lot more straightforward than actually trying to track outcomes…

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