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"For every complex problem, there is a solution that is simple, neat, and wrong." - HL Mencken
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"I hear and I forget. I see and I remember. I do and I understand." - Confucius
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"The good physician treats the disease; the great physician treats the patient who has the disease" - Sir William Osler
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" The best test of a person's character is how he or she treats those with less power." - Bob Sutton
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"Those are my principles, and if you don't like them - well, I have others." - Groucho Marx
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"The difference between genius and stupidity is that genius has its limits." - Albert Einstein
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"It is hard enough to remember my opinions, without also remembering my reasons for them" - Friedrich Nietzsche
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"Anyone can make the simple complicated. Creativity is making the complicated simple." - Charles Mingus
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"Not everything that can be counted counts, and not everything that counts can be counted." - Albert Einstein
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"A foolish consistency is the hobgoblin of little minds, adored by little statesman and philosophers and divines. With consistency a great soul has simply nothing to do." - Ralph Waldo Emerson
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"This ain't no party, this ain't no disco, this ain't no fooling around." - Talking Heads, Life During Wartime
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"What is hateful to you, do not do to your neighbour. This is the whole Torah; all the rest is commentary. Go and learn it." - Hillel, Talmud, Shabbath 31a
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"You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing." - Thomas Sowell
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"An idealist is one who, on noticing that a rose smells better than a cabbage, concludes that it will also make better soup." - HL Mencken
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"If you only have a hammer, you tend to see every problem as a nail." - Abraham Maslow
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"A great teacher is one who realizes that he himself is also a student and whose goal is not to dictate the answers, but to stimulate his students creativity enough so that they go out and find the answers themselves." - Herbie Hancock
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"There are no facts, only interpretations." - Nietzsche
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"An education isn't how much you have committed to memory, or even how much you know. It's being able to differentiate between what you do know and what you don't." - Anatole France
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"In character, in manner, in style, in all things, the supreme excellence is simplicity." - Henry Wadsworth Longfellow ====
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Performance measure overdose
24 Jul2009
Tight Glucose Control Raises Mortality Risk in Heart Failure
Now we have even more data that the HgbA1c goal of < 7 may have adverse effects. The very tight control mafia will argue that this is a heart disease specific problem. I say "balderdash."
Almost every drug and treatment has benefits are risks. As we saw with erythropoeitin too much of a "good thing" can actually be detrimental.
I suspect that the problem here relies in the number of medications needed to lower the HgbA1c below 7. As the number of medications increases, so do the adverse reactions. Perhaps the problem is hypoglycemia, masked by the beta blockers used for heart failure.
I continue to caution that performance measures are interventions, and thus should be evaluated as such. Off the top of my head I can cite the 4 hour rule, HgbA1c < 7 and Hgb >13 (for CKD) as examples of failed performance measures.
We have too many “experts” who want to use short cuts to assess quality. They forget H.L. Mencken’s admonition – For every complex problem, there is a solution that is simple, neat, and wrong. Quality is complex, and really cannot be assessed using scorecards or league tables.
As I have quoted many times before, the noted British philosopher Onora O’neill wrote in 2002:
Yet faith in performance indicators is hard to dislodge. Every time one performance indicator is shown to be inaccurate, shown to encourage perverse behaviour, or shown to mislead the public, eager people imagine that they will find other performance indicators free of such adverse effects. Experience suggests that they are as mistaken as those who produced the last lot of indicators.
How right she is!
Related posts:
- Performance indicators need testing
- My position on performance measures
- Another performance measure challenged – BP goal
- Time to reconsider the HgbA1c targets
- Measurement – the good and bad
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- In: Medical Rants
3 Responses to Performance measure overdose
Mary Andrawis
July 24th, 2009 at 8:55 am
Thanks for a thought-provoking post! I think it comes down to the use of strong, evidence-based clinical guidelines in the development of these quality metrics. Quality IS complex, but if we could just find a better way to PRACTICE what the guidelines deem as good care, I think care can, and will, improve.
curious
July 24th, 2009 at 1:03 pm
Tell us, please: since Onora O’Neill is such an unquestionable source of Truth, what solution does she suggest? Implicit quality review? Kudos, if that’s the case! (if only we could realign payment rules to support implicit review activities)
I doubt she supports a state of blissful ignorance or believes there are no deficiencies in the quality of care delivered to patients.
lilane
August 15th, 2009 at 1:31 am
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