Quality indicators that kill: high blood pressure in the elderly

In the Universe that Medicare is scripting, one that is designed to reshape and reform medical care, doctors will be paid for the quality of their work, not just the quantity of their visits and procedures. Our Accountable Care Organization recently laid out the 2015 Medicare clinical guidelines to which we need to comply in order to prove that we practice high quality care. Ultimately much of our salary will be tied to our adherence to such guidelines. One particular guideline stated that every patient with a blood pressure over 120 must be monitored and be offered advice and treatment. Any pressure under 120 is considered by Medicare to be optimal. Once pressure exceeds 140, then even more stringent interventions are required for us to prove that we are practicing with quality. The bottom line is that pushing blood pressure as low as possible in the elderly is endorsed by Medicare. The lower the better; there is no blood pressure that is too low in Medicare’s novel quality-based Universe.

I have discussed the danger of low blood pressure in the elderly both in this blog and in my book, but it is worth reiterating some of what we know by discussing two recent articles. The New York Times in its June 23rd edition published an article entitled: “Lowering blood pressure reduced heart attacks, but the optimal level is unknown.” The article reviews the controversy surrounding the use of medicines to lower pressure in the elderly, stating that few good studies have demonstrated what optimal blood pressure levels are. We know from an old study called SHEP that pressures consistently over 160 lead to more strokes in the elderly (although sporadic elevations may not), and we know from smaller recent studies that pressures below 120 can trigger more strokes and heart attacks among elders who have had prior heart attack or stroke. A recent presentation of data at the American Geriatrics Society meeting showed that driving blood pressure below 120 leads to increased cardiovascular events such as heart attacks, more falls, and worse memory. Most concerning was that 18% of people in the study were on medicines that drove their pressures below 120; all of those people were doing what they were told by clinical guidelines, despite evidence that disputed the worth of their actions. From my experience, and from other studies that have been done on the elderly, these low pressures also lead to fatigue, dizziness, confusion, weakness of muscles, and a general sense of feeling lousy.

But of course, Medicare wants us to lower pressures below 120; in fact, they demand it if we want to be considered to be quality physicians and qualify for their payment bonus. Why the contradiction? Why would Medicare reward us for treating patients in a way that is known to cause harm, while chastising us for keeping people at pressures that have never been shown to be harmful and which likely help the elderly to live better lives? The answer is unknown, but the problem is pervasive in so many of Medicare’s “quality” indicators. That is but one example of why generic measures of quality are dangerous and actually prevent doctors from practicing quality care.

Recently one of my assisted living patient’s daughters insisted that her mom go to the hospital for a few blood pressure readings near 200; most of her readings had been 140-150, which are normal by everything we know from the medical literature, but the number 200 frightened her daughter and the facility nurses who felt her mom was in imminent danger. In the hospital my patient was given a medicine called clonidine, which drove her pressure below 100. She was lethargic and more confused. I immediately told the nurses to stop the clonidine, while I explained to them the dangers of low blood pressure, especially in a demented woman who could hardly walk. Rather than focus on the number 200, which scared everyone based on what they had read and been told, but in reality which was sporadic and posed no immediate risk, they should have been more concerned about the low pressure caused by inappropriate intervention by a hospital, and which could have caused substantial harm if it were sustained for even a day or two. In the world of Medicare, the hospital was practicing quality medical care and I was not. In the world of reality, the hospital almost killed my patient, and at the very least would have exacerbated her dementia and fall risk. It is time we stop relying on false assumptions about blood pressure, stop being tied to a leash by rigid and inaccurate quality indicators, and realize that optimal pressure varies from patient to patient. What is considered quality by Medicare can kill and maim. Those of us who eschew so narrow a definition of quality may be docked in our pay, may receive letters of recrimination, but in the end we are taking care of our patients. Let’s hope that Medicare realizes this and starts to reform its reformers.