Monday, May 28, 2018

Requiem for the National Guideline Clearinghouse

Absent a last-minute, lifesaving intervention, after 20 years of reviewing and summarizing clinical practice guidelines in a continuously updated database, the Agency for Healthcare Research and Quality's National Guideline Clearinghouse (NGC) will go offline on July 16th. Prior to its untimely death due to budget cuts, the NGC not only served as a one-of-a-kind online resource for clinicians, researchers, and educators, but raised the bar on guideline development, recently introducing the National Guideline Clearinghouse Extent Adherence to Trustworthy Standards (NEATS) assessment tool to evaluate how well guidelines meet the National Academy of Medicine's (formerly Institute of Medicine) standards for trustworthiness.

To be sure, some will not mourn the deaths of the NGC and its companion online resource, the National Quality Measures Clearinghouse (NQMC). Front-line clinicians have viewed guidelines with increasing suspicion as recommendations with tenuous links to patient-oriented outcomes that matter (e.g., lower hemoglobin A1c targets) have been unwisely converted into formal performance measures that are linked to physician compensation. The Performance Measurement Committee of the American College of Physicians recently evaluated the validity of 86 primary care-relevant measures included in the 2017 Medicare Merit-based Incentive Payment System (MIPS) Quality Payment Program and found that only 37% were valid, 35% were invalid (the majority due to insufficient supporting evidence), and 28% had uncertain validity.

It is also clear that the universe of medical quality, especially in primary care, is not and cannot be restricted to adherence to recommendations in evidence-based guidelines. Dr. Richard Young and colleagues have previously critiqued the application of traditional quality improvement processes to the "complex adaptive systems" of primary care practices and proposed some reasonable alternatives for assessing quality:

Our priorities for primary care quality management include patient-centered reporting; quality goals not based on rigid targets; metrics that capture avoidance of excessive testing or treatment; attributes of primary care associated with better outcomes and lower costs; less emphasis on patient satisfaction scores; patient-centered outcomes, such as days of avoidable disability; and peer-led qualitative reviews of patterns of care, practice infrastructure, and intrapractice relationships.

That being said, the premature ends of the NGC and NQMC will make it more difficult for clinicians to identify good clinical practice guidelines and are unlikely to slow the momentum of the "paying for value" movement, which aims to reward clinicians for their outcomes of care rather than the volume of services they provide. Killing these resources to save a few hundred thousand dollars per year is a penny-wise, pound-foolish decision, and your health and mine will be poorer for it.