What is your opinion of the Minnesota Community Measures’ “D5” criteria for diabetes management? What are the risks and benefits of adopting guideline-driven care? Do the D5 measures reflect a friendly contextualization of care?
I think the topic of guideline-driven care is an important one, and I find myself having mixed feelings about it. As a medical student and learner faced with a new or complex problems, I think guidelines can serve as a starting point for reading or from which to build a care plan. In the context of the D5, for example, the guideline gives me an idea of what aspects of evidence-based care I should be thinking about when I am beginning to get to know a new patient with diabetes. However, I think solely utilizing guidelines comes with risks. They assume every patient is similar and therefore can be managed in a similar manner. A guideline can put patients into boxes, and can quickly take away from personalized clinical reasoning. It would be easy to go throughout your day just checking boxes and following algorithms, but this approach may often miss the bigger picture of looking at the patient as a human with a host of social, behavioral, and economic challenges that all play into their health.
I remember my preceptor mentioning the D5 guidelines to me before going into a patient room last week, asking to make sure the patient was taking their aspirin and if they were still smoking, as those are aspects we are now evaluated upon. In one sense I think the D5 guidelines are helpful as they do aim to improve health outcomes and have been shown to reduce the risks for diabetes complications including heart attack and stroke. They provide a guide for patients, outlining a clear set of key action items that a patient can work on together with their health care team. However, I think it’s important to realize these shouldn’t be the sole focus of patient care and can/should be adapted to fit the individual needs of the patient at hand. I think it’s also difficult to assess a physician based on how many of their patients are meeting specific guidelines. Each patient and patient population is different. Having good control of blood pressure or blood sugar may l
ook different in a completely healthy person versus a patient with multiple other comorbidities, and guidelines or evaluations may need to be adapted to reflect this.
Mary Rolfes wrote the following as part of her 3rd-year family medicine clerkship at the Mayo Clinic School of Medicine.
This is an excellent essay with which I agree. An additional idea is that if payers/regulators insist on measuring our “performance” based on guidelines, they become de facto mandates. I think that is the primary threat to patients’ autonomy. Since we all like “getting good grades” (and often money), metrics put us at risk of having to chose between our self-interest and the “best interest of the patient”.