Tuesday, May 12, 2009

EBM sixteen years later---is it time to drag doctors, kicking and screaming, into compliance?

Evidence based medicine (EBM) was “launched” in 1992. The ensuing years have seen the design and appraisal of research become more systematic and disciplined. Moreover, the internet has revolutionized information retrieval. Has EBM matured in that time? Despite remarkable advances, practice variability remains high and the uptake of best evidence is disappointing---alarmingly low, in fact.

Boosters of Comparative Effectiveness Research (CER with CAPITAL letters, mind you) promote it as a means of aligning practice with best evidence. But if doctors are ignoring the research they already have in spades will government largesse to fund even more research help? It won’t unless, some argue, it’s coupled with bureaucratic muscle to compel doctors to adhere to some uniform standard. That concern, raised by many skeptics, has been ridiculed by the CER enthusiasts. Jerry Avorn wrote in his recent NEJM perspective piece:

As the stimulus bill was being debated in January and February, the opposition to CER found its voice in commentators who claimed that these studies will inevitably lead to government domination of the doctor–patient relationship, "cookbook medicine," and

On January 23, Representative Tom Price (R-GA), a physician, sent out an "alert" through the Republican Study Committee, falsely warning that the CER legislation would create "a permanent government rationing board prescribing care instead of doctors and patients." The true intent of the CER provision, Price warned, was "to enable the government to ration care" (emphases in original).
He went on---

The assault took on a more Orwellian tone 10 days later when Betsy McCaughey, a former lieutenant governor of New York, linked funding for CER with the stimulus bill's provisions supporting the use of electronic medical records. She warned that the inclusion of both initiatives was designed to enable electronic monitoring of individual patient-care decisions by the federal government and punishment of clinicians who fail to comply with imminent rationing guidelines.4 The radio talk-show host Rush Limbaugh then disseminated this message to millions of listeners, warning that once the stimulus bill "computerizes everybody's health record," a new federal bureaucracy "will monitor treatments to make sure your doctor is doing what the federal government deems appropriate."5

This avalanche of nonfacts did not succeed in derailing the stimulus bill or its CER funding.

So Avorn, along with other advocates for the government program of CER, portrays the skeptics’ argument as a ridiculous straw man.

But some boosters, like Bob Wachter, are more honest about the true agenda. Note his recent post entitled Are We Mature Enough to Make Use of Comparative Effectiveness Research? Drawing on Britain’s National Health Service agency NICE as an example of how CER might be used he states:

To me, NICE’s experience shows that rationing based on cost-effectiveness can be done, but we can count on it being about ten times harder in the United States (with our fragmented healthcare system, our sensationalist media, our hypertrophied legal system, and our tradition of individual benefit trumping the Good of the Commons) than it has been in the UK.

If that’s not a plain enough statement of the agenda read on to the end of the post:

We simply must find ways to drive the system to produce the highest quality, safest care at the lowest cost, and we need to drag the self-interested laggards along, kicking and screaming if need be. Comparative effectiveness research is the scientific scaffolding for this revolution, so bring it on.

Those self-interested laggards he’s talking about, they’re us. He asserts:

As much as we like to blame the politicos, the drug and device companies, and the MBAs, the AHCPR fiasco demonstrated that physicians are every bit as capable of self-interested venality as any other group.

That’s Bob’s view. What about the government policy makers who have promoted CER? Bob notes that White House budget director
Peter Orszag, who helped push the $1.1 billion program into existence, is a Dartmouth Atlas aficionado. The Dartmouth Atlas project is frequently trotted out and used as ammo for those advocating more government control of health care. As Dr. Rich recently pointed out Orszag has been evasive about the agenda:

The ambiguity of CER (as compared to cer) was made clear recently when Peter Orszag testified on behalf of the administration before the Senate Finance Committee. When queried by skeptical Republicans on the ultimate goal of the proposed CER board, Mr. Orszag was evasive. Specifically, when asked by Senator Kyle (R-Arizona) whether the CER board would be empowered to make decisions on which medical services will be reimbursed, Mr. Orszag finally replied, “Not at this point,” a reply which
did not alleviate the suspicions of the minority party.

That’s Orszag in public. His statements in the Congressional Budget Office paper on CER are more telling and make it abundantly clear that government sponsored CER is likely to be agenda-driven “research” as I noted here.

But back to Bob’s post---mark his words well: …and we need to drag the self-interested laggards along, kicking and screaming if need be. Comparative effectiveness research is the scientific scaffolding for this revolution, so bring it on.

Telling indeed. How can that approach possibly work? It rubs me the wrong way because I’m libertarian (well, libertarian as far as my Christian faith will allow me to be, as Stephen Mansfield recently put it).

Is the self-interested venality of physicians, as Bob calls it, the major barrier? Well, we physicians are conflicted, but EBM mavens Sharon Straus and Brian Haynes, writing recently in CMAJ, take a different view of the problem. They start with the premise that physicians want to practice according to best evidence but are beset with access barriers. Let’s examine the history of those barriers.

In the early days of EBM if you wanted to search for best evidence you might have found yourself in the archives of the paper library thumbing through the Index Medicus. A search on a single clinical question might have taken an entire weekend. Not very conducive to decision making at the point of care. The first web browser wasn’t launched until the year after EBM was launched, and it was considerable time after that before the web was ready for prime time. Until then if you wanted to be wired you had to put considerable work into it, as I found out from personal experience. (BTW: although Al Gore didn’t invent the Internet he was instrumental in helping get funding for development of the first browser).

After the Internet matured and PubMed came along EBM teaching outlined several steps: Formulate a concise clinical question, translate it into a set of search terms, conduct the search (usually in PubMed), cull the results, then critically appraise the relevant articles. Finally, integrate the answer thus found with clinical judgment and patient preferences. Although PubMed enabled searching at lightning speed compared to the paper library the process, as I noted early in my blogging career, was still prohibitively time consuming.

That’s what Straus and Haynes address. An editorial on EBM in a recent issue of American Family Physician said:

There is a rich body of literature advising physicians on how to ask and answer questions. Too often, though, it has encouraged physicians to focus on PubMed searches and the original research literature, a time–consuming and sometimes frustrating process. This is not unlike trying to encourage people to use e–mail and the Internet by teaching them how to write Javascript code, or encouraging people to bake bread but forcing them to grow their own wheat. Hardly a recipe for success!

Exaggerated but apt. The answer, the editorial suggests, lies in “secondary sources.” Because these sources have already done the steps of primary searching, culling and critical appraisal they offer short cuts to clinicians. Straus and Haynes note that these sources are a work in progress and that we have a ways to go in reducing the barriers to evidence uptake. Embedding information sources into electronic medical records offers hope of more effective use. The best of the best academic medical centers have learned how to embed them into their entire electronic infrastructure without being intrusive. The motto at Vanderbilt, where a model system is in place, is “tools, not rules.”

So which is the more constructive philosophy? More and better tools or dragging doctors into compliance “kicking and screaming”? You know my vote. Furthermore, as someone recently said, (sorry, I’ve misplaced the primary source for proper attribution) I do not want a panel of government policy makers writing the next edition of Harrison’s.

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