The Politics Of Evidence Based Medicine

Lewis Miller

The US Preventive Task Force revised recommendations on the frequency of mammography couldn’t have come at a worse time. I guess the only sensible conclusion about the timing has to be the head-in-the-ivory-tower attitude of academics to life in the real world.

Congress has now decided to debate the politics of evidence based medicine. I wish them luck. Can you imagine Senators Grassley and Baucus reviewing thousands of studies purporting to represent the best evidence for diagnostic and therapeutic procedures and treatments? Both have fought hard for transparency in gifts and payments to physicians by the pharmaceutical industry. Maybe they can find a way to make clinical research techniques and analysis equally transparent. Better they should stick to creating a viable health care reform law that extends coverage, reduces costs and improves quality.

Of course, that brings us back to evidence based medicine, which is part of the answer to improving quality and reducing cost. For the moment, forget about the latest recommendations to reduce the number of mammograms and pap smears done annually. Instead, let’s focus on some simple steps regarding hospital and nursing home costs and care.

1. There is sufficient evidence to demonstrate reduced costs and improved quality of life when we reduce hospitalizations. The gurus at Dartmouth Medical School have shown very clearly that hospitalizations are more frequent in urban areas with plenty of beds and specialists than in rural/small town areas with fewer beds and specialists – with no real difference in morbidity and mortality, except for the incidence of life threatening infections in hospital patients.

2. There is sufficient evidence that falls in the elderly are a major cause of morbidity and mortality – whether at home, in nursing homes or in hospitals. We have not mounted an aggressive campaign in all locations to improve safety precautions and prevent more falls – even though efforts are being increased in institutional settings.

3. There is sufficient evidence that ill elderly patients do as well or better with home care than with institutional care. Yet we compensate so poorly for home care that we have low-paid ill-trained workers and inadequate systems for making such care easily available.

I remember Barbara Barnes MD, associate dean at University of Pittsburgh medical school, characterizing medical practice in terms of available evidence: 25% can be based on evidence, 25% is pure chaos, and the rest is in between. Medicine is still more an art than science. We do need more evidence – but we also need systems to ensure the application of best evidence when it should be applied. A pathway to accomplishing this is through the use of electronic health records (EHR). That is only a pathway, however.

EHR is only truly valuable if a clinical decision support system is incorporated. Doctors and nurses need to see how their planned diagnostic tests and treatments compare with nationally recognized guidelines – as they make their decisions, not retrospectively. We don’t favor a requirement that guidelines must be followed, except to prevent high-risk actions. But point-of-care reminders are valuable educational tools that can make a difference in cost and quality.

There are many other issues that result in the high cost and mediocre quality of U.S. health care compared to other developed nations. But we need to start somewhere – with steps that don’t require reform of the payment or delivery systems in this country. If politicians would pay more attention to such simple steps, and provide incentives for their achievement, they wouldn’t have to worry quite so publicly about mammograms, pap smears and death squads.

Is that too much to hope for?