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QUALITY: More evidence on the scantity of EBM

In this post, a little more from last week’s IFTF meeting. The variation in practice of evidence-based medicine was described in a speech by Bern Shen, as one of the major "impediments" to health and healthcare. THCB readers, MedRants readers and all health policy wonks (via Wennberg’s work at Dartmouth) have long known about this problem. A typical example was in the Journal of the ACC (here’s the abstract) last week, showing that heart patients usually don’t receive appropriate post-discharge drug therapy:

    Dr. Javed Butler from Vanderbilt University in Nashville, Tennessee and colleagues assessed ACEI (ace inhibitor) use among 960 hospitalized heart failure patients. They discovered that 55 percent of the patients were discharged with an ACEI order. By postdischarge day thirty, 77 percent had filled their ACEI prescription, but by one year only 63 percent were still taking the medication. "Although we expected the rate of long-term use to go down over time, we were surprised at the magnitude to which it did," Butler said in a statement.

    Moreover, if patients are not prescribed an ACEI at discharge, the chance of initiating one in the outpatient setting is "very unlikely," Butler told Reuters Health. For patients with no discharge order for ACEIs, only about 12 percent had been prescribed one by 30 days. By one year, only 19 percent of were current ACEI users.

Of course, as I’ve blogged about before, the solution is not that simple. It’s very hard for physicians to practice the "right" way all the time and even harder for them to communicate this to their patients. It requires education of physicians and patients, and the installation of sophisticated tracking information technology. None of these three are particularly in evidence in the US, although as I’ll describe in a post later this week, the Brits are marching down this path, at least for primary care.

At the meeting Dr. Catharina Maulbecker Armstrong described a service she’d been involved in running in Switzerland, where high end executives were advised about what their course of treatment should be based on the latest protocols. The service consulted with the patients’ doctors about their clients’ treatment course, but soon found that the doctors were calling them asking advice about treatment protocols for other patients. As she put it, the doctors otherwise were relying on their 20 year old memory of their medical school professors’ 20 year old memory of what to do! OK, so that’s a little over-simplified, but it does reflect the underlying the problem–physicians are taught to be independent actors relying on their memory, working on one area of the body. Moving to a medical education system based on doctors leading a team (which includes the patient), using information systems to apply the latest medical knowledge and viewing the care of the patient holistically is a non-trivial challenge.

However, Michael Millenson,author of Demanding Medical Excellence and the quality bete noir of many doctors, was also at the meeting. Although he had some uncharacteristically charitable words for some hospital folks who were making the effort to improve quality across the board (in the pursuit of reduction of medical errors), he was a little scornful of their pleas for grant funding to help them do it. As he pointed out, the folks in the room from GM and other big manufacturers probably didn’t rely on Foundation grants to improve their quality–it’s part of what the market demands. It’s the interference with that "market" demand by the medical profession that has radicalized Millenson. (I’ll be reporting on his upcoming speech to a bunch of doctors at the end of the month, or maybe I’ll be carrying back his body to his family!)

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