Chronic disease is a big problem in America with almost half of adults with one or more chronic disease diagnoses. In this post we are continuing to look at “The Changing Face of Chronic Illness Management in Primary Care: A Qualitative Study of Underlying Influences and Unintended Outcomes” from the Annals of Family Medicine. I encourage everyone to read the full article at the link. In today’s post we will look more closely how lowering diagnostic thresholds and doctor incentives lead to increased prescription drug use.
Lowering Diagnostic Thresholds
The study focuses around two chronic diseases – diabetes and hypertension (high blood pressure). Both diseases have had the criteria for diagnosis change since the early 1990’s. The thresholds have been lowered and there is even a special lower threshold for hypertension in diabetic patients.
| 1992 | 1993 | 1998 | 2003 | Increase in cases | |
| Diabetes: fasting plasma glucose, mg/dL | |||||
| Diabetes | 140 | — | 126 | — | 10.3 million |
| Prediabetes | None | — | 110 | 100 | — |
| Hypertension: blood pressure, mm Hg | |||||
| Non-diabetic patients | 160/95 | 140/90 | — | — | 22.0 million |
| Diabetic patients | — | — | — | 130/80 | — |
| Prehypertension | None | — | — | 120/80 | — |
So changing the thresholds has resulted in 10.3 million more cases of diabetes and 22.0 million more cases of hypertension. Now you may think that catching and treating these diseases sooner with the lower threshold is a good thing. The authors noted that with changing guidelines, treating ‘pre’ condition status has become more common and that those considered ‘healthy’ a few years previous are now considered to need treatment. But what is the treatment often given? Of the physicians observed in the study, most of the visits revolved around medications almost to the exclusion of other options like lifestyle changes.
Something else mentioned in the study is that with lower thresholds, people are being treated with mild or marginal disease. What this means is that the benefit of treatment is relatively lower, while the potential for negative side effects remains the same. Also treatment of mild elevation in either blood glucose or blood pressure is more likely to result in problems with low blood glucose or blood pressure.
Doctor Incentive
There are several programs that look at performance of doctors and offer rewards for better performance. These programs could be from insurance companies, the doctor’s employer, or other entities. It seems to make sense to be rewarded for better performance, but how is performance measured? Often it is measured by having the lab values for patients being within those established by guidelines. Now there are a couple of issues here. One is that if lab values are the measure of performance, this does not necessarily take into consideration the well-being of the patient. Another is that having tightly controlled lab values may not lead to better long-term outcomes.
Here is an example from the study of ‘good’ lab values not equating to improved well-being.
“Sherie, a 54-year-old African American woman, is a recently unemployed cosmetologist who lost her health insurance several years ago. She has been taking hydrochlorothiazide and a β-blocker for hypertension for 13 years. Two years ago, she started taking metformin and glipizide after a random glucose reading of 130 mg/dL, as a preventive measure, because of a strong family history of diabetes. After her diabetes diagnosis, her doctor used a lower diagnostic threshold for hypertension and for high cholesterol, and she was prescribed a third antihypertensive and a statin. Sherie is currently taking 8 prescription medications: 3 for hypertension, 2 for diabetes, 1 for high cholesterol levels, and 2 for depression…. Her diabetes medications cause diarrhea and bouts of hypoglycemia, which interferes with her ability to leave her home because she must eat and go to the bathroom so frequently. She also had 5 visits to the emergency department in 1 month for excruciating headaches, before they were determined to be an adverse effect of the additional hypertension medication she had been prescribed after her diabetes diagnosis. She was able to change hypertension medication with the help of the Pfizer program. At her most recent appointment, her physician happily told her: ‘Your blood pressure is 130/78 [mm Hg], your A1c is 7.0[%], and your cholesterol was normal. Very good!’
On the basis of current standards, the clinician classified this patient as healthy, a success story; however, this classification does not address the broader question of her well-being.”
This does not sound like a healthy person to me even if their lab values are within limits! The point is that rigid conformity to a range of lab values does not equal health. There is also evidence that strictly controlling lab values within a range with drugs does not always lead to better outcomes in the long run. Something is wrong with the system when the patient takes a back seat to their disease. William Osler said “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” I think the way the medical system is going, they are losing sight of this.
Conclusion
Changing diagnostic thresholds may be necessary at times as we continue to learn more about how the body functions, but are they always good changes? And who benefits the most from changes in guidelines? If it is not the patient, then there is definitely a problem. And while it makes sense to have rewards for better performance, I don’t believe the standards used always measure better performance. It is obvious to me that these changes at least play a part in the increasing use of prescription drugs in the US. If the overuse of prescription drugs worry you, find out about other options that your doctor might not be sharing or even know about. You are the one in control of your health.
