Accountable Prescribing — end does not justify means

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Nancy Morden MD MPH with others from the Dartmouth Institute for Health Policy and Clinical Practice published a nice “Perspective” in NEJM 3694;4:299-302.    The essence of the article is the observation that published goals of treatment which don’t specify how to reach the goal lead to prescribers” jumping the gun” with strong expensive medications rather than a prudent step by step approach.

A good example from the article is controlling blood pressure.  Guidelines state the desired blood pressure goal is less than 140/90.  Prescribers tend to skip dietary management, skip lowering the salt intake, skip reducing alcohol consumption and jump right to strong blood pressure medications (with the attendant drug allergies, risks and costs).

Another criticism is stopping a medication too soon.  The example is beta-blocker medication after a heart attack.  It is not enough just to start the medication.  The medication must be continued indefinitely.  Too often the medication is stopped because the reason for starting it is forgotten.

Here are the areas the authors found problematic:

  • Blood pressure control
  • Cholesterol management
  • Diabetes control
  • Clot prevention for occlusive vascular disease
  • Lipid control for coronary artery disease
  • Long term beta-blocker after heart attack
  • Avoidance of antibiotics for acute bronchitis
  • Drug use generally in the elderly

From the patient standpoint:  if a health care provider says you have some condition or diagnosis make sure to ask for a step-wise approach to treatment.  In other words, ask for simple or less expensive things to be tried first.  Then insist on follow-up to see if the first steps work.  If the simple things work, you win.  Make sure to research the diagnosis on the internet to exhaust the simple and low cost alternatives.  Later, if the simple things are not enough move on to the next step.

There are obviously situations where a slow cautious approach is not correct.  If you are having a heart attack or a stroke or a blood clot it’s too late to do simple things.

Make sure to understand how long a medication might be needed — if it is “until something better is found” then stick to it and make sure the providers give a good reason for stopping (particularly if you change providers).

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