Humphrey Taylor from Harris mentioned to me earlier this year that one thing Americans don’t realize is how much other health care systems are changing—while ours seems stuck in 1987. One case in major point is the UK where serious changes in terms of more money being spent on health care (a designed increase of nearly 2% of GDP), a reorganization of primary care called Primary Care Trusts, a major investment in IT for healthcare, and a significant change towards paying primary care docs for outcomes have all been going on in the last few years. In fact probably the most Americans realize about this is the scene in Sicko where the British GP discusses his salary (much higher than PCPs get in the US), shows off his fancy car and nice house, and explains that he gets paid more for keeping his patients healthy. All true and all recent phenomena.
Behind this is a move towards the UK valuing evidence based-medicine
in reality rather than just rhetoric. What we know about EBM is that
it’s really hard to figure out.
So when I got some email from a company in London called Bazian
asking for some of my slides, I asked them what they were up to. (OK,
they flattered me by saying that a talk I gave last year was mandatory viewing for an introduction to US health care for their team).
Bazian has some pretty neat stuff. One is an introduction to the
concept of EBM (or as the Brits call it EBHC). You’ll also find out
that they’re named after the guy who gave us Bayesian probability, and yes I never quite figured out what that was in my stats class either! Take a look at the presentation
(the guy in the first slide is the non-exported British sci-fi hero Dr
Who—which occupies a place in British culture that’s the equivalent of
Star Trek crossed with Dick Clark!). Once you’re done with that, they
have an excellent and very short slide set of check lists on how to use EBM in health care purchasing. (Of course you could use that check list for cancer drugs….if you can afford the bodyguards!)
So who are these guys? I asked my correspondent Tom Donald:
Snapshot about us: Bazian
was founded in 1999 by two of the doctors who designed BMJ’s Clinical
Evidence – a landmark publication in the evidence-based world. Company
has been the “Intel Inside” key UK evidence-based products including
Clinical Evidence and the Map of Medicine. We’ve pioneered the
industrialisation of evidence such that we can do evidence-based
analyses in 1-3 months that take other groups 12-24 months, at a
fraction of the cost. We also provide rapid and responsive
evidence-based technology assessments to NHS PCTs and cleared NICEs
backlog of tech assessments in 2002. So traditionally we’ve
sold customised EB content to publishers and the NHS, but we’re
“Grove-ing” (see Eating the Big Fish by Adam Morgan) from supplier to
developing our own products, from NHS-dependent to new markets
including the US.
In other words, like Deming’s quality initiatives, this may be
another American concept (EBM) getting a better hearing abroad, and
then returning to bite us in the rear a la Japanese cars in the 1980s.
They are also the first to introduce me (at any rate) to the new
profession of “evidologist”. And given the stated desire of everyone
from plans to employers to politicians in the US to look into evidence
based medicine, I suspect they’ll be getting very busy.
Ironaically, the UK’s efforts at computerization have suffered from some of the same issues that healthcare itself suffers from.
This is a cautionary tale:
Granger says he is ‘ashamed’ of some systems provided
http://www.e-health-insider.com/news/item.cfm?ID=2854
EBM not an American concept. Roughly originated with David Sackett at Oxford; McMaster Univ in Ontario, Canada = North American “epicenter.”
EBM has taken on its own American twist and become “insurance based medicine”. It gets translated into “your insurance won’t pay for something unless there has been a double-blind randomized controlled trial showing it works,” (unless it is something insurance has always paid for and the insurer doesn’t care).
Estimates are that less than half of accepted medical procedures and treatments have ever had a randomized controlled trial conducted to show they work. Medical care involves art, craft, intuition, and science. Limiting care to the scientifically proven is a stupid, short-term strategy.
I’m all for conducting experiments to determine the best clinical care, but opportunities for manipulation abound. And, rejecting an obvious treatment because no one has yet done a clinical trial costs Americans money and good health.
The trouble with EBM is that it originated as a concept that would help physicians make sense of the literature (at least that’s how it was introduced to me: “critical assessment”)
Naturally, the next logical step was to influence physicians’ practice patterns, which is frought with the complexities of change management in a huge headless system.
Then, the insurance companies got a hold of it and figured out there was a way to save money and increase profits.
Now we all hate EBM, managed care and insurance companies.
Too bad; they all have critical functions in any health system, no?
Matthew: thank you for the write up. Nice surprise, especially as long time readers. Thank you for the slides, too.
Bradley: you’re right. The epicenters of EBM during its invention and development were McMaster (Canada) and Oxford (UK).
Ed: “insurance based medicine” sounds awful indeed. As a company founded by medical doctors, we agree that caring for sick people requires more than just science (though getting the science bit right really helps). Healing is a complex business that requires more than stats and numbers. We never forget this.
Zagreus: unfortunately EBM has, in many circles, become a “dirty word” through its blunt application by insurers and regulators, as well as its devaluation by groups (mostly published products) who say they’re evidence-based when they’re not. EBM does, however, play a critical function, as you note. So it’s time for a fresh start. The sullying of its reputation leads us all to evidology – aka EBM 2.0. Evidology recognises that “getting evidence based” requires a new specialisation, one which sits between the clinical front line and the bean counters, assuring quality care without wasteful expenditures. As a company, we’re working towards the day when evidology bridges the clinicians’ world to the bean counters’ world, allowing them to better understand each others needs, requirements and decisions.
It took radiology nearly 40 years to become recognised as a legitimate specialty with its own Royal College. We reckon the Royal College of Evidology is about 20 years out, unless the Bloomberg School of Public Health gets really cutting edge.