Monday, October 10, 2011

Family physicians and the Goldilocks principle

A recent national survey of internal medicine and family physicians published in the Archives of Internal Medicine found that 42 percent of physicians felt that their patients were getting "too much" health care, while only 6 percent thought that patients were receiving "too little." These opinions contrast with multiple previous studies showing that primary care clinicians fall short when it comes to providing guideline-recommended care; a 2007 study, for example, found that children received less than half of indicated care.

So which is it: too much care, too little, or some of both? And how can AFP help family physicians avoid these extremes and strive for the happy medium, which in other fields is known as the "Goldilocks Principle"? In addition to bringing readers the latest Practice Guideline updates, such as the Centers for Disease Control and Prevention's 2011-12 recommendations for influenza vaccination, we provide information that allows you to evaluate these guidelines against the best design criteria previously proposed by AFP Deputy Editor Mark Ebell, MD, MS:

The best guidelines share several characteristics: they begin with a comprehensive review of the literature; they carefully assess the quality of the literature to identify the best studies; they base their recommendations on the best studies; and they tell us the strength of the evidence that supports each key clinical recommendation. In other words, they are founded on the principles of evidence-based medicine, which strives to make decisions on the best available information—“best” implying that the evidence is graded, so that one has a sense of what is good evidence and what is not, and “available” implying that the literature search is comprehensive. Transparency is the key: readers should know why each recommendation is made and whether it represents opinion, theory, or fact. Finally, guidelines should be independent of industry support (an all-too-common occurrence) and should clearly identify any potential conflicts of interest of the authors. Ideally, guideline authors should have no conflicts of interest, which can diminish the quality and validity of the guideline.

There are, of course, many reasons - financial, medical-legal, and practical, to name a few - that care may diverge from that supported by the best evidence-based guidelines. Still, we hope that every section of the journal makes it easier for family physicians to provide care that is "just right."

1 comment:

  1. Part of the reason is found in the study by Hong in JAMA. Pay for Performance was linked to various quality measures. Physicians caring for the underserved consistently had lowest quality ratings. Hong tried to use patient demographics to adjust for social determinant factors but failed. Physicians most connected to caring for lower and middle income, poor, near poor, less educated, CHC, rural, and elderly populations will be rated lower with various quality measures and will be paid less by Pay for Performance. In other words the populations most left behind and those that care for them are most left behind by Pay for Performance.

    And family physicians are most likely to care for all of these populations (Ferrer, Rosenblatt, Bowman, Mold, Graham Center, others).

    We know from Hong and also from a most unique study, the randomization of Medicaid patients in Oregon (Baicker), that various demographic indicators fail miserably as controls for provider outcomes and for health plan outcomes.

    When your belief system is traditional - that the physician shapes the outcomes, you will assign too much credit or too much blame to the physician. When you understand that the patient and their environment and various designs (health, education, economics) shape outcomes, then you can begin to understand the practical matters of health care delivery and why the current designs for research and policy are so flawed.

    You may also begin to understand why the physician or hospital may be more likely to shape outcomes for patients that have highest income, best health plans, and top health personnel whereas physician and provider factors may not matter in lower or middle income populations.