Study says physicians miss care guidelines
Thursday, June 26, 2003
Doctors fail to take nearly half the recommended steps for treating common illnesses such as high blood pressure and diabetes, suggesting that health care in the United States isn't nearly as good as many people thought, researchers say.
Treatment guidelines, many written by medical specialty organizations, outline recommended approaches to many common ailments, ranging from painkillers and exercise for arthritis to surgery for breast cancer.
However, the guidelines are often ignored, indicating that even people who have good insurance and doctors they like don't always get the best care, said Elizabeth McGlynn, a researcher with the Rand Corp. think-tank who led a study published in today's New England Journal of Medicine.
"I think most people assume the big problem is, 'Can you get in to see a doctor if you're ill?'" she said. But that turned out to be just the first step: "Once you're in the door, there is no guarantee you will get the full mix of services you need to protect your health."
A local physicians says that while the rigors of the profession can lead to sub-standard health care, most doctors in Southeast Missouri are providing effective treatment.
"Occasionally, there may be problems if a physician is overworked and doesn't have time to follow-up with patients," said Dr. Charles Lastrapes, a family physician with Cross Trails Medical Center in Cape Girardeau. "But I think most people in this area are doing what they're supposed to."
McGlynn's study documents a broad range of lapses in treating and preventing run-of-the-mill illnesses. For instance, patients studied did not receive one-third of the recommended immunizations, one-third of the standard medicines for heart disease or half of the recommended care for diabetes.
The report, based on a review of medical records for 6,712 people in 12 cities, looked only at how often their doctors followed the rules, not whether they suffered any ill effects from the lapses.
"This study showed that there is substantial discrepancy between what we say doctors ought to be doing and what they are doing," said Dr. Earl Steinberg, an adjunct professor at Johns Hopkins University and head of a company that develops computer programs for doctors.
The presidents of the American Academy of Family Physicians and of the American College of Physicians said their organizations have been discussing the problem for some time.
"I don't think it surprises anybody in the health profession to know there is no real uniformity of health care," said Dr. James Martin, AAFP president.
One problem is that there are so many guidelines and so many steps. The study looked at 30 medical conditions, plus preventive care. All of those guidelines added up to 439 actions, recommendations or other steps.
"The days of everyone being able to keep it all in your own head is long gone," Martin said.
He also noted that a recent article in the journal Public Health estimated that if the average doctor did everything recommended for annual health exams, the checkup would last 90 minutes instead of 15 to 20.
He and the ACP's president, Dr. Munsey S. Wheby, said affordable electronic systems that help doctors keep track of the latest guidelines could play a big part in solving the problem. Such systems run into six figures, Martin said.
In the study, alcoholics got the least amount of standard care, the study found. Their doctors took only 11 percent of the recommended steps, such as proposing treatment programs for them.
Also at the bottom of the scale were broken hips, irregular heartbeats, and heartburn and ulcers, which were grouped together. Each had 10 or fewer items in their guidelines, but doctors followed them only about one-quarter to one-third of the time.
On the other hand, even though doctors treating pregnant women had 39 separate steps, they followed them about 73 percent of the time. McGlynn credited a detailed form distributed widely by the American College of Obstetrics and Gynecologists.
"It pays off in really getting it right more often," McGlynn said.
Cataracts in the elderly and breast cancer got the best treatment, overall, with more than three-quarters of the steps being taken.
Wheby said most doctors want to do the right thing for their patients, but he added: "It's a matter of time, a matter of effective systems of reminder, at times knowing the correct guideline or the correct procedure."
Staff writer Callie Clark contributed to this report