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Tag: screening guidelines

The Vital Role of Guideline Narratives

A few weeks ago, I presented Family Medicine Grand Rounds at Georgetown University School of Medicine on resolving conflicts between screening guidelines. During the question and answer session, Department Chair James Welsh, MD asked how evidence from carefully conducted clinical trials can possibly overcome powerful emotional stories of “saved lives.” I answered that evidence-based medicine’s supporters must fight anecdotes with anecdotes. For every person who believes his or her life was extended by a PSA test or a mammogram, statistics show that many more are temporarily or permanently injured as a result – and their stories matter too. As blogger Kevin Pho, MD wrote about the USPSTF’s recent prostate cancer guideline, “Task Force advocates will need to put a human face on the complications stemming from prostate cancer screening” in order to convince physicians and patients that it’s okay to stop. Indeed, news stories about PSA test-related complications such as this one by Associated Press writer Marilynn Marchione will go a long way in balancing the scales.

An insightful commentary published in JAMA last month took this point one step further by asserting that narratives deployed to support evidence-based guidelines should include not only patients’ stories, but the story of the guideline developers themselves:

“Typically, experts present a “clean” version of their findings without any narrative about how they made sense of the data. This fulfills the scientific virtues of objectivity, coherence, and synthesis. When the USPSTF released its report on screening mammography to much controversy, it included no narrative about the process. Only later was the story of the task force deliberations revealed. This narrative, with multiple characters operating within the context of historical precedents, timing mandates, and a messy political milieu, created a substantially more compelling perspective. But the account came too late to engage a confused and angry public with the task force’s conclusions.”

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Me too! It’s not fair! The Tragedy of the Commons in the Health Care Marketplace

There are at least two conversations going on in the health care marketplace today, each focused on one of two key questions. One is: How can we achieve the Triple Aim? The other is: Why do they get to do that?  (It’s not fair! I want more!)

Until we stop asking the second question, we can’t answer the first question. Why? Because all too often the answer to the second question is the equivalent of: It’s OK, Timmy, I’ll buy you TWO lollipops; pick whichever ones you want.

It’s the tragedy of the commons, transposed to the health care marketplace.

Recent cases in point:

  • Avastin
  • Tufts Medical Center – Blue Cross Blue Shield of Massachusetts grudge match
  • Mammography and PSA guidelines

1.    Avastin.  Late last year, the FDA yanked its breast cancer treatment approval for Avastin, based on a finding that it does not meet the “safe and effective” standard. CMS says it will still pay for the drug anyway, as will many commercial payors, based on physician judgment.

2.    Tufts Medical Center – Blue Cross Blue Shield of Massachusetts. The contract negotiation (out in public view) focused, in part, on Tufts’ complaint that BCBSMA pays way more for health care services provided by another network, Partners Health Care, and that it should be compensated on the same scale.  (Others have noticed this disparity too, and have found that higher payments were not accompanied by higher quality — see reports by Massachusetts state agencies.)  In the context of the present discussion, we may wish to consider whether Partners should be paid less, rather than whether Tufts Medical Center should be paid more.  This episode, according to some, will pave the way for more regulations.

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