Nails in the coffin – the 4 hour rule

Dr. RW provided a link to Dr. Wachter’s excellent article reviewing the 4 hour rule and why it failed.  For those who do not have access to the Annals of Internal Medicine, here is the abstract:

The administration of antibiotics within 4 hours to patients with community-acquired pneumonia has been criticized as a quality standard because it pressures clinicians to rapidly administer antibiotics despite diagnostic uncertainty at the time of patients’ initial presentations. The measure was recently revised (to 6 hours) in response to this criticism. On the basis of the experience with the 4-hour rule, the authors make 5 recommendations for the development of future publicly reported quality measures. First, results from samples with known diagnoses should be extrapolated cautiously, if at all, to patients without a diagnosis. Second, for some measures, "bands" of performance may make more sense than "all-or-nothing" expectations. Third, representative end users of quality measures should participate in measure development. Fourth, quality measurement and reporting programs should build in mechanisms to reassess measures over time. Finally, biases, both financial and intellectual, that may influence quality measure development should be minimized. These steps will increase the probability that future quality measures will improve care without creating negative unintended consequences.

Actually, what Bob and his colleagues are recommending is that quality measures should pass the common sense test!

Readers of the blog know that I have railed against the 4 hour rule for many years.  This rule did not pass the "sniff" test.  Any experienced clinician could have predicated the unintended consequences that this rule created.

I have an additional suggestion (to the excellent suggestions of Wachter and colleagues.)  We should never adopt a performance measure until we have a prospective trial of that measure.  We should do research on measures prior to using them.

We "require" research on new drugs or devices.  Why did the quality gurus think they could bypass this necessary step? 

I suspect that the "quality gurus" are suffering from religious passion.  They worship at the altar of measurement.  They rarely continue to practice medicine (if they ever did) and thus have lost the context necessary in understanding the complexities of practice.  They worship their databases and their sophisticated mathematical tools  They believe that what works for airline pilots will work for medical care.

They forget that patients do not come in standard sizes, with standard diseases.  Patients do not come to the ER with a diagnosis tatooed on their chest.  Patients have multiple diseases.  We deal with too much complexity to simplify our quality to simple quality measures.

But as I have written previously, the "quality gurus" will persist because our society is infatuated with measurement. I once again recall the wonderful quote from Onora O’Neill (famed British philosopher):

Bogus numbers can be more than an expensive irrelevance. They can create perverse incentives, especially when numbers are published in league tables for the public without the complex information needed to set them in context.