Comparative Effectiveness Research and the Learning Health Care System
The Institute of Medicine (IOM) Roundtable on Value & Science-Driven Health Care, formerly IOM Roundtable on Evidence-Based Medicine, focuses on both the near-term need for evidence on the comparative effectiveness of diagnostic and treatment options, and the long-term effort of marshaling emerging technology and expertise to create a health care system in which patient care reflects the best available evidence while accumulating new knowledge.
Preventable errors cause as many as 98,000 deaths a year. The IOM report To Err is Human: Building A Safer Health System lays out a comprehensive strategy by which government, health care providers, industry, and consumers can reduce preventable medical errors, concluding that the know-how already exists to prevent many of these mistakes.
According to a Consumers Union report, Preventable Harm, medical errors kill as many as 10,000 Californians each year and injure 140,000. These errors include a class of adverse events known as “never-events” because they can always be prevented and should never happen.
Preventing Medication Errors
Medication errors cause an estimated 7,000 deaths a year. The IOM report Preventing Medication Errors finds that medication errors are surprisingly common and costly to the nation, and outlines a comprehensive approach to decreasing the prevalence of these errors. This approach will require changes from doctors, nurses, pharmacists, and others in the health care industry, from the Food and Drug Administration (FDA) and other government agencies, from hospitals and other health-care organizations, and from patients.
Geography as Destiny
For more than 20 years, the Dartmouth Atlas Project has documented dramatic variations in how medical resources are distributed and used in the United States. Where Medicare patients live and who delivers care has a profound effect on what medical care is delivered. For example, according to the Dartmouth Atlas:
- patients in Napa were three and a half times more likely to undergo aortic or mitral valve replacement than patients in Alameda;
- patients in Palm Springs were twice as likely to have back surgery as patients in San Francisco;
- patients in Ventura were five times more likely to have a transurethral resection of the prostate (TURP) as patients in Salinas; and
- patients in Redding were twice as likely to have knee replacement surgery as patients in San Jose.
A 2008 Dartmouth Atlas White Paper, An Agenda for Change: Improving Quality and Curbing Health Care Spending, provides a brief but compelling overview of supply-sensitive care and preference-sensitive care and the impact these can have on overuse, underuse and misuse. The paper includes a comprehensive set of policy solutions.
Underuse of Preventive and Acute Care
In a national study, The Quality of Health Care Delivered to Adults in the United States, that examined the medical charts of over four thousand patients, the RAND Corporation determined that patients received only 55% of the preventive care and 54% of the acute care that evidence-based guidelines would recommend.
The National Healthcare Quality Report measures trends in effectiveness of care, patient safety, timeliness of care, patient centeredness, and efficiency of care. In 2006, only about 40 percent of adults over age 40 with diagnosed diabetes receive all three recommended services for diabetics. Such services are intended to detect complications that can cause blindness or lead to amputations. There was no significant change in these rates between 2002 and 2006.
As counterintuitive as it may sound, more care isn’t always better care. Unnecessary care can expose people to infections and medical errors. “Overuse” refers to patients receiving care that is known not to be helpful and may even be harmful.
For example, between 1993 and 2003, spending for lumbar spinal fusion rose 500 percent, despite lack of evidence supporting the effectiveness of back surgeries. Indeed, studies currently show that a combination of physical therapy and anti-inflammatory medication is often the most effective treatment, and that many patients with low-back pain will see their symptoms fade on their own within three months.
Preference-Sensitive Care, Shared Decision Making and Misuse
Shared decision making (SDM) is a collaborative process whereby patients and doctors make health-care treatment decisions together, taking into account the best scientific evidence available as well as patients’ values and preferences. SDM supports an informed, values-based choice of interventions in the case of “preference-sensitive care,” i.e. when there are two or more medically reasonable alternatives likely to produce similar outcomes. SDM helps avoid the misuse of care that happens when a patient receives a treatment they would not have wanted, had they been fully informed.
In a JAMA study that analyzed over 1,000 audiotapes of patients’ visits with physicians, it was found that few decisions met criteria for informed patient decision making.
A Health Affairs article examined research into employees’ attitudes about evidence-based medicine. They found that few consumers understood terms such as “medical evidence“ or “quality guidelines.”
The Campaign for Effective Patient Care (CEPC) believes the practice of medicine should be based on solid science and that when health care is divorced from evidence, patient outcomes are likely to suffer. In the summer of 2009, the Campaign for Effective Patient Care commissioned nationally recognized pollster Celinda Lake to survey California voters about their views on the use of science in the delivery of health care.
- 92% of respondents would require doctors to tell them about strong scientific evidence supporting a specific best treatment option; and
- 90% want to know when there is no such evidence.
Results are published in a CEPC report, Perception vs. Reality: Evidence-Based Medicine, California Voters, and the Implications for Health Care Reform.