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Quality is not easy to measure
Submit responseLindenauer and colleagues (1) should be commended for analyzing the care of a huge number of COPD patients and attempting to measure the quality of existing care. Unfortunately, their efforts are hampered by inadequate primary research and limitations in their patient database.
Clinical research involving COPD care has not clearly defined good quality care. The guidelines manuscript that the authors used to define quality markers indicates that the evidence supporting many of the recommendations is relatively weak because of the small number of trials, often involving small numbers of patients, and because the trials frequently rely on surrogate outcomes, such as FEV1 (2).
Lindenauer and colleagues imply that patients with COPD exacerbations who do not receive oxygen, steroids, and antibiotics have received suboptimal care (1). The practice guideline is far less proscriptive. It indicates that patients should receive oxygen if hypoxic, and “our first research objectives must include untangling the questions surrounding selection of patients for antibiotic and steroid treatment” (2). Unfortunately, it does not seem that Lindenaur and colleagues' database allowed them to determine which patients were hypoxic, which had increased (or any) sputum production, or which might have had contraindications to systemic steroids.
In addition, there is no evidence to suggest that mucolytics are harmful. The authors of the guideline acknowledge that “there is a possibility that these agents improve symptoms” (2). Further, it is easy to imagine that sputum testing may have a role in some patients; for example, some severely ill patients at high risk of bronchial colonization or infection with resistant organisms may benefit from culture-directed antibiotic adjustments, and some patients in whom lung cancer is suspected may benefit from sputum cytology. Considering any use of these measures to indicate inappropriate care is too inflexible.
Guidelines are useful for guiding clinicians, but ultimately clinical judgment is required to apply the most appropriate, individualized care to a patient. We do need to strive to improve the quality of care we provide, but we should focus on measures that are unequivocally proven to benefit the patient population that we are assessing.
References:
1. Lindenauer PK, Pekow P, Gao S, Crawford AS, Gutierrez B, Benjamin EM. Quality of care for patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease. Ann Intern Med 2006;144:894-903.
2. Bach PB, Brown C, Gelfand SE, McCrory DC. Management of acute exacerbations of chronic obstructive pulmonary disease: a summary and appraisal of published evidence. Ann Intern Med 2001;134:600-620.
Conflict of Interest:
None declared
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Time is on our side
Submit responseTo the Editor:
Kudos to Lindenauer et al. for their study on quality of care in COPD exacerbations, published in the Annals in June[1]. Their work exemplifies the careful yet thorough health services research that is possible utilizing well-validated commercial data sources. They also rightly point out that COPD exacerbations lend themselves well to quality improvement efforts, given COPD’s important clinical (4th leading cause of death, with mortality increasing over the last 2 decades [2]) and health economic ($16,487 per discharge, or >$10 billion nationally per year [3]) consequences. However, in my view the present work offers only the description of the baseline (pre-guideline) state of affairs.
The study enrolled patients discharged between 1 January 2001 and 31 December 2001 to explore adherence to a published clinical practice guideline (CPG). Given that the CPG was only published in April of 2001, is it realistic to think that this is enough time to allow for a broad implementation of the CPG recommendations into clinical practice? One need only look to several cases in the cardiology literature (e.g., beta- blockers in and lipid-lowering agents in myocardial infarction, as well as aspirin) to appreciate that translation of evidence into practice can take years, if not decades [4]. That is not to say that we as the medical profession or consumers should accept such a protracted course. The question is, what is a reasonable minimal time period that one can expect to achieve substantial penetration of evidence into practice? Though the answer to this is unclear, given the education and the infrastructure needed to implement a new CPG at the bedside, the time frame in the current study is almost certainly not adequate.
Nevertheless, Lindenauer et al. identified a tremendous opportunity to improve the processes around COPD exacerbation management. With their study, they have provided a valuable tool for measuring current and future progress in adoption of the COPD exacerbation CPG into practice, and, more importantly, its impact on outcomes.
1. Lindenauer PK, Pekow P, Gao S et al. Quality of Care for Patients Hospitalized for Acute Exacerbations of Chronic Obstructive Pulmonary Disease. Ann Intern Med 2006; 144: 894-903
2. Mannino DM, Homa DM, Akinbami LJ et al. Chronic Obstructive Pulmonary Disease Surveillance --- United States, 1971—2000. MMWR 2002;51(SS06);1-16
3.http://hcup.ahrq.gov/HcupNet.asp?Id=63158C7FE73B176A&Form=SelDXPR&JS=&Action=%3E%3ENext%3E%3E&_DXPR=PreRunDCCHPR1; Accessed July 11, 2006
4. Lenfant C. Clinical Research to Clinical Practice —Lost in Translation? N Engl J Med 2003;349:868-74
Conflict of Interest:
Dr. Zilberberg is an employee and a stock holder of Johnson & Johnson. This letter does not necessarily represent the views of Ortho Biotech Clinical Affairs, LLC or Johnson & Johnson, its parent company.
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The Frog who Aspired to Become as Big as the Ox (1)
Submit responseImproving care quality was a difficult task. Now, in comparison, Graal quest is journey arranged by a tour operator! Indeed, Lindenauer et al created a new definition for quality: “ideal care, defined as all of the recommended care processes and none of the nonrecommended ones”.(2) Moreover, this term “ideal care” was confirmed in the Editor’s note.
Quality is the satisfaction of a need or a requirement. Satisfaction comes from the latin "satisfacere" : "satis" = enough or sufficient + "facere" = to do. To do enough is not to do the ideal. “Quality of care is the degree to which health care is expected to increase the likelihood of desired health outcomes and is consistent with standards of health care”. (3)
Jean de La Fontaine, wrote a parody to warn people about the dangers due to greediness and vanity: a puny, pretentious frog swelled up so much that she croaked.(1)
Gene therapy was an example. A few decade ago, great announcements for gene therapy are still unrealistic expectations. Quality must not repeat the same mistake. Do not hope too much, or too little, just hope for what you need.
1. http://lafontaine.mmlc.northwestern.edu/fables/grenouille_boeuf_vv.html
2. Lindenauer PK; Pekow P; Gao S; Crawford A S; Gutierrez B; Benjamin EM. Quality of care for patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease. Annals. 2006;144: 894-903.
3. http://www.nlm.nih.gov/nichsr/hta101/ta101014.html).
Conflict of Interest:
None declared