Wednesday, September 12, 2012

Inverse Benefit in the Trenches: Primary Care Providers Treat Chronic Illness

My esteemed anthropologist colleague, Dr. Linda M. Hunt, and her graduate student Meta Kreiner at Michigan State University set out to do a study of how concepts of race influence physicians' treatment of patients with common chronic illnesses like hypertension and diabetes. Along the way they became so impressed with issues they were seeing about how drugs are prescribed that they chose to report a separate study on that latter topic. Recognizing the relevance of my own work on the Inverse Benefit Law (, they very kindly invited me to participate in the final data analysis and discussion, with the results just now appearing in the Annals of Family Medicine (

Hunt and Kreiner interviewed 58 clinicians and 70 patients at 44 primary care clinics in Michigan, oversampling clinics treating low-income and minority patients. They also observed 107 office visits. What did they find?

First, they noted that their sample mirrored CDC data reporting that 40% of people over age 60 now take 5 medications or more; the average prescritions per patient in their sample was 4.8. While one might imagine that providers in low-income, minority-serving clinics might be a model of enlightened social awareness, they found that 72% of the clinicians they talked to had regular contact with drug reps and 62% saw more than 10 reps each week. While protesting that they always were alert for commercial bias, 77% reported finding the information they received from the reps useful.

These clinicians were basically sold on the standard practice guidelines that set target numbers for blood pressure and blood sugar, and were unfazed by the likelihood that patients would need to be on multiple medications to reach the targets--as one family physician said: "I tell most new diabetics that the sad news is that they’re going to be on 5 meds…. That’s just what’s going to happen because their cholesterol parameters are lower [and] their blood pressure parameters are lower…. It’s usually a pretty frank talk: 'You have a deadly disease and it’s going to kill you. How long you have it is up to you.' (Laughs)"

Many of these clinicians are being reimbursed in ways that include pay-for-performance bonuses for meeting targets, and this influences their practices: "I was being a little bit lackadaisical with the A1c goal as 7.0[%] or less. I wouldn’t really like to admit it, but the insurance companies making a financial carrot is probably one impetus for really cracking down on my diabetics to get them 7.0[%] or less. 7.1[%] don’t cut it…anymore. It has to be 7.0[%] or less."

Time out--a while ago I blogged about a study ( that showed that there's reasonable evidence that patients with diabetes do well when their glycohemoglobin (A1c) level is around 7.5%, and that trying to get it super-low down to 7.0% actually does harm to patients. I also have blogged repeatedly about studies that show that diabetics are not any healthier, in the long haul, with tighter control of their blood sugar or A1c levels ( Despite study after study on this topic, the drug companies continue to push drugs that lower blood sugar but fail to improve long-term outcomes; groups dependent on drug company money like the American Diabetes Association continue to promulgate guidelines that stress strict control of blood sugar; and as this study shows, physicians in practice toe the line--especially when paid to do so.

Back to the Hunt-Kreiner findings. What happens when you throw a lot of medicines at patients with diabetes and hypertension, trying to make their numbers look good in the chart? At least three bad things. First, their drugs cost a lot and some of the patients go crazy trying to pay for them. Second, the patients get a lot more adverse reactions. Third, the prescribing cascade kicks in--physicians either don't recognize the adverse reations as due to other drugs, or else feel they have no choice but to prescribe those drugs because of the guidelines; and so even more medications are then prescribed to treat the side effects of the first medications, which further raises cost and risk of side effects, and so on: "A number (24%, 14 of 58) discussed the challenge of managing multiple medications, pointing out adverse effects of common medications that may worsen other conditions, requiring even more drugs, for example, β-blockers aggravating asthma symptoms, or antipsychotics elevating blood sugar. When discussing these complicated issues, only 1 clinician mentioned prescribing fewer drugs; all the rest focused on reaching goal numbers by either adding or changing medications."

The impact this had on patients is dramatic, as one fairly typical case report showed: "Her diabetes medications cause diarrhea and bouts of hypoglycemia, which interferes with her ability to leave her home because she must eat and go to the bathroom so frequently. She also had 5 visits to the emergency department in 1 month for excruciating headaches, before they were determined to be an adverse effect of the additional hypertension medication she had been prescribed after her diabetes diagnosis. ... At her most recent appointment, her physician happily told her: 'Your blood pressure is 130/78 [mm Hg], your A1c is 7.0[%], and your cholesterol was normal. Very good!'"

As Hunt and Kreiner comment, "On the basis of current standards, the clinician classified this patient as healthy, a success story; however, this classification does not address the broader question of her well-being. Getting test numbers into the stipulated range jeopardized her employment and led to repeated hospitalizations and serious financial burden." And, I would add, with precious little evidence that at least some of these medications were improving the patient's long-term health.

Sadly, these hard-working, dedicated, and undoubtedly smart clinicians seemed both puzzled and resigned in the face of these outcomes: "I’ve got patients on 4 different medications and their blood pressure is still uncontrolled. We try sending them to the cardiologists, and they say, 'Just keep adding stuff because there’s really nothing we can do about this.'…Some people whose blood pressure that we do get normal again, they don’t function very well at all. I’m not sure why."

After all the usual warnings about not generalizing qualitative studies beyond the small sample included in the research, I worry that this peek into the trenches of clinicians actually caring for patients with common problems strongly validates the worries I have expressed in this blog in more theoretical form, especially in The unholy alliance of drug company marketing, pay-for-performance, and unrealistic and commercially biased practice guidelines are ganging up on these patients to make them sicker rather than healthier--and the clinicians seem helpless to do anything about it.


Joseph Arpaia said...

This is so relevant.

We forget that people are not the sum of a set of numbers, or that quality of life is not summarized by lab values which measure an infinitesimal of what what is going on with the patient.

Since many of these indices are negatively influenced by stress, the stress of paying for the medications, keeping the doctor visits, dealing with the side effects, ... is itself a cause of the problem

Joshua Daly said...

Thanks for enhancing my knowledge area. Hypertension and diabetes is often present as part of the metabolic syndrome of insulin resistance also including central Obesity and Dyslipidemia.
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Marilyn Mann said...

I don't know if you saw these ADA guidelines that came out earlier this year, but they have more flexibility re: blood sugar targets.