THE SIXTH COMMANDMENT
Thou shalt not bow down to treatment targets designed by committees, for these are but graven images
Traditionally, elevations of single risk factors such as blood pressure or lipid levels have been labelled hypertension or hyperlipidaemia, and individuals (typically without symptoms) have been urged to take drugs to reduce them to a certain level. The very large NNT for such treatment is often not known by clinicians and seldom discussed with recipients, who now acquire a disease label and become patients, followed up at regular intervals for the rest of their lives.
This traditional model has become embedded in many guidelines and in the (UK’s) Quality and Outcomes Framework. Clinicians are paid for the achievement of a surrogate outcome such as systolic blood pressure, total cholesterol, or glycated haemoglobin. This can act as a disincentive to the essential process of dialogue and shared decision making, which always needs to take precedence over the achievement of externally imposed targets.
Let us know if you have any suggestions
The tyranny of guidelines. Ann Int Med 2015
Yudkin JS, Lipska KJ, Montori VM.
The idolatry of the surrogate. BMJ 2011