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Recent Articles
Use HIT and CE to Drive EBM
Is it possible to wrap more jargon into a headline? Allow me to translate: Use health information technology (HIT) and comparative effectiveness studies (CE) to drive evidence-based medicine (EBM). So sayeth the odd-couple (actually threesome) writing on today's op-ed page of the New York Times -- Billy Beane (who's he?), former Republican House Speaker Newt Gingrich and Sen. John Kerry (D-MA).
Using a baseball analogy, the writers point out that statistics-driven analysis has allowed executives running cash-poor franchises like the Tampa Bay Rays to sign underrated ballplayers at cheap prices and deliver a prize-winning product. Health care should do the same thing, they assert.
Their models? The Cochrane Collaboration, an international and voluntary coalition of objective physician-analysts who write best-practice guidelines, and Intermountain Healthcare, a non-profit group in Utah that operates with salaried physicians who use evidence-based practice guidelines. Let me repeat those principles: objective analysis of medical research by experts without conflicts of interest; and salaried physicians not driven by fee-for-service medicine.
Here are the key paragraphs:
Evidence-based health care would not strip doctors of their decision-making authority nor replace their expertise. Instead, data and evidence should complement a lifetime of experience, so that doctors can deliver the best quality care at the lowest possible cost.
Working closely with doctors, the federal government and the private sector should create a new institute for evidence-based medicine. This institute would conduct new studies and systematically review the existing medical literature to help inform our nations over-stretched medical providers. The government should also increase Medicare reimbursements and some liability protections for doctors who follow the recommended clinical best practices.
Welcome aboard, gentlemen. I, along with most other book writers who have analyzed the health care system in recent years, have ended their tomes with a plea for a comparative effectiveness agency. Sen. Hillary Clinton has championed the cause in the Senate before her run for the presidency. Sen. Max Baucus, chairman of the powerful Senate Finance Committee, has recently introduced a bill. Sen. Barack Obama (and the fading presidential hopes of Sen. John McCain) have endorsed the concept. So have think tanks from the right to left on the political spectrum. Perspective pieces in the leading medical journals debate its structure.
But what everyone forgets to emphasize is that objectivity, independence and eliminating conflicts of interest must be the watchwords of the new comparative effectiveness agency. It is important that physicians, insurers, drug companies, device companies, and hospitals be given a stake in the governance of this new agency -- which some have pegged as needing to grow to a $5 billion-a-year effort. Without their buy-in, its pronouncements will never be taken seriously.
But "special interests" -- and that is what each one of those groups is -- can have absolutely zero say over what work gets done, how it is organized, and who gets to sit on the panels that evaluate the evidence. The special interests could be given a say about the final analyses and guidelines produced by the new agency through a notice and rulemaking period. This was proposed by Georgetown law professor Gregg Bloche, an adviser to the Obama campaign, last summer.
But patients and physicians will only have faith in the best-practice pronouncements of the new agency if its work process is thoroughly insulated from commercial pressure. Does the public have such faith in the Food and Drug Administration today? Whether accurate or not, the perception has grown that it has become the handmaiden of industry, and that has eroded public confidence in its ability to protect consumers against unsafe food and drugs.
Without protections against special interest manipulation, the new agency will become just another shouter in the health information marketplace, albeit one with a louder voice. Let's not forget that the Cochrane Collaboration, after nearly 20 years of putting out wonderful best-practice guidelines, is largely ignored by large swaths of the medical profession.
It is only through a universal belief that the work product of the new comparative effectiveness agency has met the highest standard of scientific rigor that payers like Medicare and the insurance companies will be able to use its information to drive EBM throughout the system, and thus maximize the chance that this long-sought reform will actually improve health care outcomes while lowering costs.
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Comments
Of course data is important but it MUST stand firmly on a values based platform without which good data is rendered almost useless.
Dr. Rick Lippin
Southampton,Pa
ralippin@aol.com
Spot on.
There's one other little detail.
Leaving nursing out of the statistical analysis is a gross miscalculation (forgive the pun).
Divorcing physician treatment from nursing care is not a valid and reliable predictor of patient outcome, efficacy and cost control.
Leaving out the team members who provide 95% of all of the reimbursed health care services (The Commonwealth Fund) is unforgivable.
Nursing is arguably the most under-valued, under utilized and under-represented profession.
And no one (except a few nursing researchers) is even studying it. When they do, they discover that patients have significantly better outcomes and significantly less morbidity and mortality when care for by nurses with at least a baccalaureate nursing education. (Aiken, IOM)
Go figure. ;)
You're exactly right, Annie. A new comparative effectiveness agency should look at all the inputs into health care to determine what makes for the best, most cost-effective care. You've emphasized nursing. I've been looking at prevention lately, another area where myths and myopia trump evidence and common sense. Prevention pays, if you just do the right things, which aren't lung cancer screening or PSAs for old men.
Prevention and health coaching are two key services that professional nurses provide within their scope of practice. Using a community health model of ambulatory care which has a proven track record of high patient outcomes, quality and cost effectiveness, nurses drive and manage the health resources.
Instead of top down (tertiary, high tech, catastrophic, high cost) health care tweaking, it would make mutter use of extant resources to redesign bottom up.
Nursing is the most under valued, underutilized and under-represented segment of health care. The saddest part is that nurses are leaving in droves simply because they don't have professional autonomy and authority for nursing practice. Turn the dynamic around and set up frameworks of self governing professional practice organizations with nurse, physician and licensed therapist membership, allow them to directly contract services with groups of patients, groups of self-employed and small business owners and patient care organizations, and I think that we'd get somewhere.
Instead of pitting providers against one another, the framework would provide incentives for collaboration, cooperation, high quality (they would have to produce evidence of meeting/exceeding contractual performance benchmarks), cost efficacy and resource efficiencies. The commercial insurance aspect could be carved out of preventive and essential services. The ambulatory care model could supplement and synergistically affect public health services around school health, disease surveillance, prevention, treatment and containment. This, in turn, would bolster emergency preparedness resource allocation.
Employee and school absentee rates would decline. Since services could be provided in employment/school settings, time away from work would be decreased, and schools would be able to stretch scarce school nurse resources. Etc., Etc.
Instead of a cost-risk-shortage-access-affordability negative feedback loop, instead there would be increased worker/student productivity -lower costs associated with sick time - lower catastrophic care costs and resource allocation - increased professional work satisfaction - increased patient satisfaction (from convenient access and affordability) - decreased costs for catastrophic care - decreased administrative fees - reduced catastrophic insurance premiums (theoretically) - decreased hospital admissions - decreased recidivism - increased customization of care based on local specific needs.
Well, I do go on....
I may be coming from left field here, but data-driven baseball wouldnt stand a tinkers chance of being cost-effective if league statisticians were allowed to receive undisclosed bribes from players to inflate their stats.
Likewise, data-driven health care is only effective if the medical statisticians (university researchers) arent receiving millions in undisclosed payments from Big Pharma to cork the bats of their clinical trials.
This year weve seen a string of Balco-sized scandals, revealing that medical researchers have received millions in undisclosed Big Pharma payments, and that these payments may have tainted their evidence-based recommendations. (Think Cox-2 inhibitors, Lyme disease, and psychiatric drugs, to name a few.)
The quickest fix is to pass the Physicians Payment Sunshine Act, which would require drug and medical device manufacturers to disclose payments to physicians and researchers, bringing the honesty and accountability back into our countrys medical research.
Kris Newby
Senior Producer
Under Our Skin: An infectious film about microbes, money, and medicine
http://www.underourskin.com