Thursday, May 6, 2010

Evidence Based Medicine – Addendum 1

Another hellish work week. My head meats are generally scrambled due to overworked synapses, and I’ve not had time or free neurons to expand much on this topic. I did want to post something, though, to keep the thoughts as current as possible and to perhaps continue the conversation. I hope to address SckGrl’s comments in short order as well, but I make no promises. The topic of health care is so vast and varied that – sweet Jebus in a jumped up Jaguar – I couldn’t hope to get all my thoughts together in one or two or a thousand blog posts, even given limitless time and energy to do so. Despite that, it’s important to keep talking about it, and picking away at the details.

In my previous post, I was unintentionally too black and white when I stated, “the physician should be directing care, not the individual.” The idea I meant to convey is that the physician should be directing care in terms of advising the patient with regard to the testing and treatment options available, based upon the evidence of illness the patient presents. As Crommunist rightly stated in his comments, the methodology for establishing a mode of treatment needs to first be addressed at the policy level. At this level, specific illnesses would not be addressed; rather, the criteria with which to determine how to move forward sensibly with testing and treatment are codified. Of course, both the patient and the physician require discretionary leeway to make “on-the-ground” decisions, but a policy that establishes reasoned, evidence based approaches to health care would certainly ease the current strain on the system as a whole. This process is of particular importance in the realm of emerging treatments as a way to determine when a particular treatment is ready for the general public – or, ready to be funded, as it were.

In the US, I’m not sure a high level policy like this is possible as we don’t actually have a health care “system” per se. As most of the health care and insurance providers are profit driven, the economics of the thing becomes too big a distraction. As such, we will remain over-treated, over-tested, and over-medicated; costs will continue to climb, pricing more of us out of our health insurance. While I’m hopeful that the current health reform legislation will get us started on the right path, as it stands, it simply does not do enough.


  1. A colleague of mine (if I can be so immodest as to call him a colleague - he's the head of a research team that does similar work to mine) wrote an article last year in which he describes the results of an investigatory exercise asking health-care admins in Cali what they thought of health economics and "rationing". His conclusion, very generally, is that he thinks the ground is softening on the idea of evidence-based managed care and priority setting.

    The problem in the USA is a very knotty one, and it's essentially impossible that y'all will summarily dump your health care system in favour of a European-style one. I get that. But there are some specific things that can be done to make better far-sighted decisions, one of which is to have established protocols and guidelines (oncologists do it through the NCCN.

    Another thing to keep in mind is that Canada doesn't have "a health care system" either. We're a dominion, meaning that while some responsibilities are federal, many are provincial (including health care and policy). We just have a federal act that basically says "no matter what your health care system does, it has to meet these basic criteria." We have the same fights over "states' rights" that y'all do south of 49.

    Baby steps, I say. If any country can marshal the collective will to make major, positive change, history shows us it's the USA.

  2. That's an interesting abstract and interesting conclusions. I find it amusing (frustrating) that a major roadblock for implementing CEA becomes a matter of semantics. The word "rationing" is inherently negative from the American perpsective (What?! I can't have everything I want and more?!). As the author says, we'll have to re-frame this in order to move forward.

    And your right, of course. Baby steps are fine, as long as we keep stepping forward. I think the recently passed reform bill does set some good ground rules. It requires everyone to have insurance, it removes lifetime caps, etc. These are good moves and could be the start of some real change.