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Kendrick asks..... is the QOF turning GPs into dangerous prescribers?

Our clinical columnist Dr Malcolm Kendrick asks why – in a world of evidence-based medicine – the QOF was introduced with none

Our clinical columnist Dr Malcolm Kendrick asks why – in a world of evidence-based medicine – the QOF was introduced with none

Medicine used to be – and still is occasionally – about responding to patient demand. However, during the past 30 years there has been a shift from patient-led demand to healthcare-led intervention, and the QOF is the final push towards the state taking control. It is the end of medicine as we know it. Soon, we will no longer respond – we will intervene and prevent.

This enormous shift has mainly been driven by the simple, some might say simplistic, concept that prevention is better than cure. That's true – in an ideal world. But we don't live in one.

Vaccinations against diseases such as polio, tetanus or smallpox may be an inarguable good but few other preventive interventions provide such clear-cut benefits.

Dangerous polypharmacy

Breast cancer screening, for example, was introduced without any controlled studies. It was assumed that picking up early stage breast cancer must be a ‘good thing'. But once the programme was up and running, a great number of downsides started to emerge including massive cost, false positives, false negatives, high exposure to radiation and the creation of worried well.

But the most important problem is that breast screening seems to be much less effective at reducing deaths from breast cancer than was hoped1.

Undaunted by important issues such as this, the QOF was introduced without any pilots. If we're supposed to be carrying out modern, evidence-based medicine, why didn't we trial the QOF? A huge barrage of targets was just introduced with no evaluation.

Okay, so you might argue that many of the QOF indicators didn't need to be trialled, because we already knew that the interventions were effective – such as using an ACE-inhibitor in heart failure. To an extent this is true, but when you introduce indicators for heart failure, high blood pressure, diabetes, CHD and angina simultaneously, you are creating a possibly dangerous ‘multi-intervention' that has never been evaluated in any clinical trial.

In effect, we now have a situation whereby the QOF in one area – such as congestive heart failure – overlaps with others – diabetes and hypertension – leading to potentially dangerous polypharmacy. I see many patients who are now taking more than 10 different drugs at the same time – each one mandated by the QOF.

There is no doubt that an ACE-inhibitor improves survival in CHF – by a small amount. But once you add an ACE inhibitor to a ß-blocker, to spironolactone, to metformin, to a glitazone, to a statin, to insulin, to aspirin and a thiazide diuretic – and on and on, ad infinitum – it's likely you are doing more harm than good. And this is especially true in the elderly.

Iatrogenic disease burden

A study in the USA estimated that among 38 million Medicare patients there were nearly two million adverse drug events per year, with 7% of hospital admissions caused by iatrogenic disease. Furthermore, they estimated that there were in excess of 180,000 life-threatening or fatal adverse drug events per year2. The more drugs prescribed, the greater the problem. This huge iatrogenic disease burden must be set against any possible gains.

In fact, the gains from reducing drug use on mortality and morbidity were highlighted by a study in Israel where researchers made great efforts to reduce the number of drugs prescribed to 119 older patients in a nursing home.

An amazing average of 2.8 drugs per patient were stopped – with no significant adverse effects. The overall rate of drug discontinuation failure – where patients had to return to the drug – was 18% of all patients and 10% of all drugs. The one-year mortality rate was 45% in the control group but only 21% in the study group. The patients' annual referral rate to acute care facilities was 30% in the control group, but only 11.8% in the study group.

In short, stop the drugs and improve both quality of life and life expectancy.

It is especially ironic that the elderly are likely to be the ones who are most exposed to multiple drug interventions by the QOF, when hardly any of the studies on which it is based have been done on the elderly.

As an analysis published in the BMJ last year pointed out, evidence from younger populations is extrapolated to elderly ones3. Worries about age discrimination mean we have no upper age limit for assessing cardiovascular risk despite scant evidence for the prevention of heart disease with drugs in older people.

Removal of decision-making

The authors of this analysis looked particularly at the use of statins in CHD. Only one study has been done in an elderly population – PROSPER4. In this group the statin showed no benefit over placebo for any outcome in elderly women, and all-cause mortality stayed the same in all groups. Risk of new cancer diagnoses was significantly increased.

And to quote from the authors of the BMJ analysis: ‘Preventive use of statins shows no overall benefit in elderly people as cardiovascular mortality and morbidity are replaced by cancer.' 3

In the end, the QOF removes decision-making from the clinician and concentrates on centrally imposed targets and rigid algorithms. If this improved clinical outcomes, then it could be worthwhile, despite the negative impact on morale and the inevitable withering of clinical judgment.

But there is no evidence that it does and increasing evidence that it could end up seriously damaging patient care, especially in the elderly exposed to polypharmacy. One thing is for sure – the QOF represents the end of medicine as we know it.

Dr Malcolm Kendrick is a GP in south Manchester

Could we improve survival by stopping drugs in some of our patients? Could we improve survival by stopping drugs in some of our patients?

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