A “crisis” in evidence-based medicine (and a roadmap), conflicted surgeons, and a NICE update on Sovaldi
June 27, 2014
The RightCare Weekly is a newsletter that helps you stay on top of important news in the ongoing quest to move the U.S. health care system toward delivering the right care to all patients. We’ll bring you the most important stories, news articles, and opinion pieces of the week, along with our interpretation of why they’re important for patients, doctors, and communities.
A recent BMJ article recounts a brief history of evidence-based medicine, and asks whether 20 years on, the movement is “in crisis.” While the focus on quality evidence has had remarkable successes, the authors suggest that the trappings of the movement have been co-opted by drug companies and other vested interests that don’t prioritize good science and patients’ needs.
To restore the soul of evidence-based medicine, the authors suggest that it’s important to return the patient to the center of practice: evidence is essential, but it’s only useful when it helps patients make good decisions, and produces better outcomes for patients. Their list of “What is real evidence-based medicine, and how do we achieve it” is a roadmap brings us much closer to the right care.
From the BMJ: http://bmj.com/content/348/bmj.g3725
Responding to the BMJ paper, Bill Gardner of The Incidental Economist writes that it is the clinical algorithms that reduce patients to “a relatively small number of critical factors” that can make evidence-based medicine appear to be management-driven, rather than patient-centered. These algorithms often don’t apply well to patients with multiple chronic illnesses – and such complex patients are a common and important challenge in modern medicine. That complexity means it’s important for doctors to learn not just the algorithms, but also how to apply them. Seeing patients as more than a single diagnosis to be treated is a critical step toward improving outcomes.
Jordan Rau of Kaiser Health News writes that under the Affordable Care Act, hospitals that have high rates of HACs (Hospital Acquired Conditions, such as hospital acquired infections or injuries associated with physician error) will be penalized beginning in October. These hospitals will lose one percent of all Medicare payments for one year. This is the third leg of Medicare’s “Pay-for-Performance” program, which also penalizes hospitals for high rates of readmission and awards bonuses based on other quality measures. However, Harvard School of Public Professor Ashish Jha points out that these programs, which aim to penalize less safe hospitals, might do more harm than good: the way HACs are measured can vary from hospital to hospital, so hospitals that are doing a good job of identifying and reporting complications and safety problems might be in a position to be penalized for their honesty.
“Treating the disease instead of the patient” – Dr. Leana Wen tells the story of the disconnect between a patient, who felt ignored and alone while being treated for a heart attack, and the team who treated him, that believed they had done everything right in his case, moving him through the system quickly and efficiently. The NPR story captures medicine’s essential role in guiding and comforting people during vulnerable times in their lives. It’s an important message for the health care system: at a time when institutional changes and quality improvements are centerstage, we cannot allow technical fixes to drive the humanity out of medicine.
A follow-up on the series we posted last week on Sovaldi (sofosbuvir, the new hepatitis C drug): While insurers in the US are deciding how to deal with the prospect of covering an incredibly expensive new drug, it looks like much of the UK’s National Health Service (NHS) won’t be encouraging use of the drug for the immediate future. NICE, the system’s evidence-appraisal body, is “minded not to recommend sofosbuvir” until Gilead, the company making the drug, provides better evidence about how effective the drug will be in specific patient populations. That may prove wise: once a treatment is on the market, it’s incredibly difficult to stop using it, even if it’s later shown to be ineffective or dangerous.
Ezra Klein wrote an article this week for Vox, debunking the idea that the American healthcare system is better than those in other developed countries because the US has higher survival rates for some cancers. This is a recurring argument, and Klein once again points out that survival rates are plagued by lead-time bias. Since the US screens for cancer more aggressively than other countries, we diagnose more early cancers that elsewhere would never have been detected and never would have caused symptoms. Looking at actual death rates from cancer tells a different story – the US doesn’t look nearly as good as with survival rates. The difference between trends in survival rates and mortality rates also exposes the huge overdiagnosis problem in American medicine. For more on survival rates versus mortality rates, check out this Healthcare Triage video by Aaron Carroll.
In an interview last month with Oregon Public Broadcasting, Republican Senate candidate and pediatric neurosurgeon Monica Wehbly claimed that 20 percent of healthcare costs can be blamed on defensive medicine, the idea that doctors order tests and procedures to protect themselves from lawsuits, rather than because they’re necessary for the patient. Ordering unnecessary tests may not actually protect physicians from lawsuits, but the fear of litigation is undoubtedly real. But in a recent radio interview, Dr. Charles Kilo argued that the real driver of unnecessary tests and procedures is poor communication between doctors and patients. When patients trust their doctors (and vice versa), they’re more likely to believe they don’t need a treatment they have asked for, rather than to see a doctor’s refusal as an attempt to deny care that they really need.
Austin Frakt writes on The Upshot that while the creation of ACOs may improve quality of care and reduce spending on ineffective procedures in Medicare, the consolidation of hospitals and other provider organizations has the potential to drive up the prices those organizations charge private insurers. We also worry about who is in charge of those highly-consolidated organizations: to be sure they focus on what’s good for patients, rather than what’s good for the hospital. we think it’s best to keep primary care physicians in charge.
Even when elderly patients have clearly expressed wishes about the kinds of medical treatment they want (or don’t want) at the end of life, they are often ignored. Paula Span at the New York Times’ New Old Age blog writes that many factors, including family members who disagree, difficulty locating or communicating a patient’s wishes, and the habits and biases of emergency medical personnel can override what patients wanted. Often, that means dying in the hospital or ICU when they would have preferred to stay home.
Recent efforts to encourage people to think and talk about their end-of-life wishes have been successful in increasing the number of people with advance directives. But medical culture needs to adapt to that new information: for patients at the end of life, understanding their treatment preferences can be just as important as understanding what brought them to the hospital in the first place.