| “When doctors graduate from medical school, one of the things they’re always told on the day they graduate is, ‘Half of what we’ve told you in these four years are wrong. The trouble is, we don’t know which half.’ The point is that lifelong learning has to be incorporated into your practice.” Meg Durbin MD, primary care physician and Regional Director for Managed Care at Palo Alto Medical Foundation |
Evidence-based medicine promotes the use of sound scientific evidence to support patients and their doctors in choosing the safest, most effective treatments.
2. Wait a minute -- Isn’t all medicine science-based?
Definitive evidence on which treatment works best for which patient is surprisingly scarce. Even when it is available, it is not always widely disseminated, understood and applied as doctors and their patients work to make wise choices.
3. Don’t new drugs have to undergo clinical trials before they go on the market?
| “You’re not going to find a drug company that wants to sponsor a trial that says the old pill is better than the new one.” Michael Zimmerman MD, Chief Medical Officer for Affinity Medical Group, representing 600 private practitioners in Alameda and Contra Costa counties |
To earn Food and Drug Administration approval, a new drug has only to show that it works better than a placebo, or sugar pill. For the most part, there’s little to guide doctors and patients on whether new drugs outperform other similar drugs already on the market. Much of the research that does exist comes from the drug companies themselves.
4. What is comparative effectiveness research?
Evidence-based medicine calls for comparative effectiveness research including independent head-to-head comparisons not just for drugs, but for medical procedures, tests, surgeries, and medical devices. For example: Do medication and physical therapy work as well as surgery for some conditions? Under which circumstances is “watchful waiting” a better option than any treatment? Is the hospital the best place to treat an elderly patient who has pneumonia? These are the kinds of questions that need to be answered with solid research about which choice is best for individual patients under similar circumstances.
Yet, of the more than $2 trillion spent on health care each year in the United States, less than 1/10 of 1 percent is invested in comparative effectiveness research. We can do better than that.
5. What gets in the way of doctors applying the evidence that is available now?
| “Clearly it’s not practical for an individual to keep up with all the new scientific evidence in the field on one’s own. If I read two hours a day seven days a week, and attended all the conferences on cutting-edge findings, I might still be behind. To fill in the gaps colleagues in my medical group support one another in order to stay current." Mark Bird MD, anesthesiologist and staff physician at Kaiser Permanente, former board member at Kaiser Permanente |
According to the 2008 National Healthcare Quality Report, just 40 percent of diabetic patients received recommended preventive exams.
Many doctors do work to apply evidence that is available now. But, as well-trained as they are in medical school, it’s a challenge for doctors to keep up with the sheer number of studies published each year - 671,904 in 2008, according to MEDLINE, the National Library of Medicine database of biomedicine articles published worldwide.
The number of studies increases each year, and while some larger physician groups and other institutions have systems in place to help their doctors sort through the research, there is no system-wide approach for helping physicians and patients evaluate the relative strength and importance of new findings. Some studies are stronger than others in terms of how well they were conducted, and it is often difficult for patients and doctors to know how much credence they should give any one study.
In addition to supporting comparative effectiveness research, the Campaign for Effective Patient Care believes that we need better ways to synthesize, interpret and disseminate findings, and to incentivize their use.
6. How can aggressive care be a bad thing? Isn’t that what we all want for ourselves and our loved ones?
As counterintuitive as it sounds, more care isn’t always better care. The annual Dartmouth Atlas of Health Care study has years of data showing that patients with serious conditions who had the most tests and procedures, saw the most specialists and spent the most days in hospitals didn’t live longer or have a better quality of life than those who were treated more conservatively. Unnecessary care exposes people to infections and medical errors. The overuse of antibiotics, for example, has contributed to an alarming epidemic of antibiotic-resistant “superbugs.” Of the 110 million office-based prescriptions written annually for antibiotics and antimicrobials, 40 percent – or 44 million – are unnecessary, at an estimated cost of more than $600 million a year.
7. So is this just about cutting cost?
With 62 percent of all personal bankruptcies in the United States in 2007 driven by medical crises, consumers of all stripes (businesses, individuals, public programs like Medicaid and Medicare) shouldn’t have to waste scarce financial resources on treatments that aren’t supported by the best scientific evidence. That means stopping the dangerous overuse of ineffective care and increasing the use of more effective treatments.
8. Will evidence-based medicine lead to rationing care?
| “Evidence-based medicine means a clinical-practice approach guided by the current scientific understanding. What the present understanding of science tells us today may be different from what we find out 10 years from now, such as was the case with hormone replacement therapy. The lesson is that we need to be able to change when new evidence emerges. When new data comes before us we need to incorporate it in our practice.” Michael Zimmerman MD, Chief Medical Officer for Affinity Medical Group, representing 600 private practitioners in Alameda and Contra Costa counties |
Evidence-based medicine is about empowering doctors with the information they need to be able to offer their patients the most effective treatment for their condition. Evidence-based medicine tells us about treatments that are known to work better than other treatments. This information should be taken into account as patients and their doctors weigh their medical options. One high-profile recent example of the importance of scientific evidence in medicine is hormone replacement therapy for menopause. For years, estrogen was routinely prescribed not only as a treatment for uncomfortable hot flashes and other symptoms of menopause, but also as protection against heart disease—until a large clinical trial found in 2002 that it may actually increase the risk, at least for some women. Today, doctors and their patients are more able to weigh the risks and choose whether hormone replacement is the best treatment for certain symptoms, at certain ages or for a limited amount of time. That’s not rationing -- it’s responsible, fact-based medicine.