Fascinating Information

Fascinating information has emerged. There have been several trials of medications revealing unexpected results. They keep on coming out. I know the reason: the sophistication in analysis of outcomes research. We are getting better at finding out what we want to know. Years ago they made up a new composite outcome measure. This means that when we do a trial we measure something. This is called the "primary outcome measure". The one we made up recently was "Vascular event". We now use this consistently in trials. It is the combination of either death or stroke or heart attack. Is this sensible? I don't know what this is. I know what stroke is. I know what death is. I know what heart attack is. But I don't know what the combination of all three of these is. What about very mild heart attacks? If I prevent many very mild heart attacks but very few deaths and major strokes is this the same as if I prevent many major strokes? I don't think so. We have another trend which is to measure the carotid artery thickness. If we prevent increased thickness (amount of athersclerosis) then this may indicate a reduction in "vascular events". So we don't even have to measure "vascular event". We also are using cholesterol levels instead of "vascular events" as a measurement of success.
A series of trials now is showing that our "substitute measures" are not working out as we had thought. Zetia was very effective at lowering cholesterol, but not the substitute measure of carotid artery athersclerosis. Now it's getting worse. Medicines that lower sugar more in diabetes are causing increased rates of death. Medicine combinations that lower blood pressure better than one agent alone are causing increased death rates than one medicine alone.
This is a problem because our insurance industry is getting very aggressive about measuring "quality of care". They are pushing "pay for performance" where physicians get paid more (or less) depending on whether they are meeting the appropriate outcomes. This pressures physicians to "perform". However, it's turning out that we don't actually know how we're performing. Things that we think are good are turning out to be bad. Perhaps there are a few "bad doctors" who are actually doing a better job at things. I've come up against some of my colleagues from time to time. I guess I don't know who is right and wrong. But a lot of times I want blood pressures "too high". That's because the medications are causing dizziness. They other doctor wants to have "high quality care". I want the patient to avoid falling and breaking their hip. But my quality of care is not good. Except now it's turning out more and more that we don't really know. There is no study on lowering blood pressure in dizzy patients.