There is a growing awareness among researchers, including advocates of quality measures, that past efforts to standardize and broadly mandate "best practices" were scientifically misconceived. Dr. Carolyn Clancy of the Agency for Healthcare Research and Quality, the federal body that establishes quality measures, acknowledged that clinical trials yield averages that often do not reflect the "real world" of individual patients, particularly those with multiple medical conditions. Nor do current findings on best practices take into account changes in an illness as it evolves over time. Tight control of blood sugar may help some diabetics, but not others. Such control may be prudent at one stage of the malady and not at a later stage. For years, the standards for treatment of the disease were blind to this clinical reality.
Orszag's mandates not only ignore such conceptual concerns but also raise ethical dilemmas. Should physicians and hospitals receive refunds after they have suffered financial penalties for deviating from mistaken quality measures? Should public apologies be made for incorrect reports from government sources informing the public that certain doctors or hospitals were not providing "quality care" when they actually were? Should a physician who is skeptical about a mandated "best practice" inform the patient of his opinion? To aggressively implement a presumed but still unproven "best practice" is essentially a clinical experiment. Should the patient sign an informed consent document before he receives the treatment? Should every patient who is treated by a questionable "best practice" be told that there are credible experts who disagree with the guideline?
That's Jerome Groopman, the full article is here, interesting throughout, and I thank someone — alas I have mislaid the email address – for the pointer. My apologies to the person who sent this in.
I am sure that many of these shortcomings of”best practice” guidelines are real, but this is not in comparison with a world in which standards of care are high, this is in comparison with a world where, according to one influential study (NEJM I think) patients receive, on average, about half of the necessary treatment, as recommended by the appropriate professional boards. I want to spend lots of money on healthcare, but I want to get what I am paying for. We aren’t..
remember comparative effective research when fully instituted in ObamaCare will devolve into the COMPARATIVE effectiveness of (for example) spending money on cataract surgeries for old people versus vaccines for kids.
We should not look at process versus overall outcome, as has been discussed here before, but instead at who evaluates the outcome.
As in Groopman’s excellent paper, and in:
Orszag’s Bureau: “On average we succesfully managed these patients’ diabetes over a 12 month period, by checking for complications only once”
Patient: “but I went blind and went on dialysis, because you checked me only once”
Orszag’s Bureau: “but on average….”
Baumol’s cost disease is what is really the issue here. Instead of ‘approaching’ the rising cost curve through improved quality (measured by whom?), we should bend the cost curve by increasing doctors’ and nurses’ productivity. Unfortunately, health IT has not been of much help there yet.
Why do dozens of nations get much more for their health care dollar than the US?
Right away we have a laboratory for comparative effectiveness that requires no ethical disclosures to the test subjects to the effect “this study may harm you”.
The number of potential test subjects getting health care that is twice as cost effective as in the US is double the number of people in the US, and they are so ethnically diverse that a match can be found for every population group in the US outside the US.
Lots of opportunities for detailed matching of subjects as well as the gross population regression analysis comparisons.
Is the only explanation for the US getting half as much for its health care spending as other nations is that the US made a pact with the devil, as Pat Robertson would explain it?
“Why do dozens of nations get much more for their health care dollar than the US?”
Okay, mulp. Do they? Why do they?
The most effective, most efficient treatment should be preferred, but need not be exclusive. Less effective treatments need only be renumerated less. If their use can be more closely targeted, say by those for whom the best treatment is inadequate, they may be renumerated more. The tradeoff is between the more effective less efficient treatment and the less effective more efficient one. Putting dollar amounts on these would be difficult, but they are the start to rationalizing treatment.
Comments on this entry are closed.