The Health Care Blog regular Michael Millenson wrote a great piece recently in Miller-McCune Magazine on the necessity of practicing more evidenced-based medicine, and why it’s not happening.
Here is a powerful snippet but it’s definitely worth checking out in its entirety.
Experts believe that a stunning 20 to 40 percent of the $2.4 trillion America spends on health care in 2008 will be wasted on misuse (including harmful and fatal errors), overuse (care that’s unnecessary) or underuse ( effective care that’s not provided). If you take a midrange figure — let’s say 30 percent — you end up with $720 billion in savings. That’s enough in health care savings to pay the cumulative costs of the Iraq war (about $560 billion by mid-September 2008) and still have enough cash left over to pay for universal health care and the entire federal education budget. If you simply sent out a rebate check, it would come to some $2,100 for every man, woman and child in the country.And that’s just one year of savings.The failure to follow best practice carries a price tag in human lives, too, and it is equally enormous. Providing appropriate, effective and safe care where we know how to do it — no “medical mysteries” included — could annually prevent the deaths of hundreds of thousands of Americans in and out of the hospital and millions of injuries.
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Tagged: Economics, evidenced-based medicine, Patient Safety, Quality, Uncategorized Sep 24, 2008
Very interesting snippet. I will definitely be reading the entire piece. All of the players in our health system need to contribute to reform. Healthcare providers’ biggest contribution will be to further develop and then practice a system of evidence-based medicine. We must all keep in mind that it’s easy to say that, but it’s not as easy to implement. The human body is a very complex system (almost as complex as the healthcare system}. The standards must be easily accessible to providers, who often have rigorous schedules that don’t allow them to take a step back and redesign their practice. In other words, the move to evidence-based medicine cannot happen effectively and efficiently without other reform efforts happening simultaneously.
I think both (some) doctors as well as (some) patients need to be better educated.
Many, if not most US Americans (I can compare this with my experiences in Europe) think that more care is better. More scans, more drugs, more specialists. Unfortunately, many doctors give in to (explicit/implicit) patient expectations … explaining why an ABx isn’t prescribed takes a lot of time which is often not appreciated by the patient. Prescribing it may take as little as 5 sec. (if you let office staff handle it), and you have a happy patient.
And what Michael unfortunately forgot (maybe because the research on that is difficult and shaky): a physician will never be sued for ordering too many (noninvasive) tests, but he very well may be for not ordering one (“failure to diagnose”).
A survey complaint by a former patient of mine sums it up: I had a fainting spell, and he didn’t even order a brain scan!
Evidence-based medicine is a trial-and-error process of clinical trials to see what might “appear” to be happening. There are limitations involved with randomized clinical trials. Perhaps the greatest limitation is that it is predictive of population trends, and is not definitive. They provide few black and white answers.
The Vytorin link with cancer situation is one good example. The endpoint of studies have been on “lowering cholesterol.” The mindset was on lowering cholesterol. The endpoint was not if it could cause cancer in a subset of the population. Turns out it is causing cancer in a subset of patients.
The cancer drug Taxol is another good example. The original endpoint of studies had been on “tumor response.” The mindset was on tumor response. It ended up being one of the most renumerative cancer drugs in history. The endpoint wasn’t on cancer progression.
It took a study a decade later by Pachmann, et al to discover that Taxol produces the greatest degree of tumor shrinkage, but also the greatest release of circulating tumor cells. The endpoint was cancer progression (tumor cell release). What the study showed was that in three different Taxol containing regimens, as the tumor collapses, it produces the greatest release of circulating tumor cells, which does not reflect improved survival.
Taxol containing regimens didn’t prolong survival over other more conventional and less expensive cytotoxic drugs. It may indeed give clinical response (tumor shrinkage), sometimes impressive, however, these are mostly short-lived and relapses after a response to Taxol are often dramatic.
Science, more often, needs to be thought of “outside-the-box.”