N Engl J Med 2013; 369:299-302July 25, 2013DOI: 10.1056/NEJMp1301805
Physicians spend a lot of time treating numbers — blood pressure, cholesterol levels, glycated hemoglobin levels. Professional guidelines, pharmaceutical marketing, and public health campaigns teach physicians and patients that better numbers mean success. Unfortunately, better numbers don't reliably translate into what really matters: patients who feel better and live longer. Often the health benefit gained by reaching a goal depends on how it is reached. When physicians strive for numerical goals without prioritizing the possible treatment strategies, patients may get less effective, less safe, or even unnecessary medications.
Many quality measures reinforce a focus on numerical goals. For example, performance-measure targets for hypertension control, as defined by the Healthcare Effectiveness Data and Information Set (HEDIS) and the Physician Quality Reporting System (PQRS), are met if a blood pressure below 140/90 mm Hg is reached after treatment with any antihypertensive medication, without a trial of dietary and exercise interventions (see table Selected Quality Measures That Encourage Different Levels of Accountable Prescribing.). Medications are the quickest and easiest way to reach the goal. Targets for cholesterol-control measures are met if a low-density lipoprotein (LDL) cholesterol level below 100 mg per deciliter is achieved in patients with coronary artery disease using ezetimibe before trying simvastatin, even though only the latter has been shown to reduce myocardial infarction risk. Similarly, for patients with diabetes, the performance target can be met if the glycated hemoglobin level drops below 8.0% with pioglitazone treatment before metformin has been tried — so clinicians are rewarded for using a less effective, less safe drug. Pioglitazone and the other thiazolidinediones carry black-box warnings indicating that they may cause or exacerbate congestive heart failure; they have never been shown to improve outcomes, and they cost more than seven times as much as generic metformin.1