Jerome Groopman is an oncologist who has written many articles about medicine. He has a good piece in the New York Review of Books, a generally left wing publication. He is writing about “best practices,” which are the basis for many guidelines for care.
One of the principal aims of the current health care legislation is to improve the quality of care. According to the President and his advisers, this should be done through science. The administration’s stimulus package already devoted more than a billion dollars to “comparative effectiveness research,” meaning, in the President’s words, evaluating “what works and what doesn’t” in the diagnosis and treatment of patients.
But comparative research on effectiveness is only part of the strategy to improve care. A second science has captured the imagination of policymakers in the White House: behavioral economics. This field attempts to explain pitfalls in reasoning and judgment that cause people to make apparently wrong decisions; its adherents believe in policies that protect against unsound clinical choices. But there is a schism between presidential advisers in their thinking over whether legislation should be coercive, aggressively pushing doctors and patients to do what the government defines as best, or whether it should be respectful of their own autonomy in making decisions. The President and Congress appear to be of two minds. How this difference is resolved will profoundly shape the culture of health care in America.
Best practices may be derived in two ways. One is by clinical research, usually involving randomized clinical trials. In this sort of study, two groups of patients are chosen to be as alike as possible. One group is randomly selected from the total and given a drug or other treatment under study. The other group is given a placebo. One fact to be kept in mind is that placebos are quite powerful in some situations. They will produce up to 30% measurable improvement in most diseases. This, of course, is psychological but it still works. In World War II, Henry K Beecher discovered an interesting phenomenon while treating wounded troops at the Anzio Beachhead. He found that even seriously wounded men had little pain. When he investigated this, he found that most of them had been in combat in constant fear of death. The wound was seen as an escape from that risk of death and was seen in many ways as a beneficial event. The term “Million Dollar Wound” was a common term used for a wound that was serious enough to remove the wounded man from combat but not so serious that he would die or be crippled for life.
He later studied soldiers who had been seriously injured in other settings, such as road accidents similar to civilian injuries and found that they reacted much more like the civilians than like the combat soldiers. In 1955, he published a famous book titled “The Powerful Placebo.” Those who would choose what treatment should be approved and what should be rationed would do well to keep that in mind. Furthermore, people react in many different ways to the same drug.
The other principle method of writing best practice guidelines is by “consensus.” That means a group of experts meet and discuss their opinions until the group arrives at a recommendation. This may be better than nothing but may also be influenced by the life experiences and prejudices of academics, who comprise most of these expert panels.
Groopman goes on to discuss failures in rigid guidelines and whether the Obama administration plans coercive measures to enforce guidelines that may be faulty.
Medicare specified that it was a “best practice” to tightly control blood sugar levels in critically ill patients in intensive care. That measure of quality was not only shown to be wrong but resulted in a higher likelihood of death when compared to measures allowing a more flexible treatment and higher blood sugar. Similarly, government officials directed that normal blood sugar levels should be maintained in ambulatory diabetics with cardiovascular disease. Studies in Canada and the United States showed that this “best practice” was misconceived. There were more deaths when doctors obeyed this rule than when patients received what the government had designated as subpar treatment (in which sugar levels were allowed to vary).
There are many other such failures of allegedly “best” practices. An analysis of Medicare’s recommendations for hip and knee replacement by orthopedic surgeons revealed that conforming to, or deviating from, the “quality metrics”—i.e., the supposedly superior procedure—had no effect on the rate of complications from the operation or on the clinical outcomes of cases treated. A study of patients with congestive heart failure concluded that most of the measures prescribed by federal authorities for “quality” treatment had no major impact on the disorder. In another example, government standards required that patients with renal failure who were on dialysis had to receive statin drugs to prevent stroke and heart attack; a major study published last year disproved the value of this treatment.
His conclusions are that the coercion may very well be part of the health reform bill although that bill now seems to be on hold. All the parties to these new rules, of course, disclaim any interest in reducing cost by restricting access to free choice in treatments that may not be supported by best practice guidelines. The problem is that randomized clinical trials are only possible in a small proportion of health care choices. Surgery does not lend itself to such trials for obvious reasons although a few have been done. This topic reminds us of the authoritarian tendencies of the “progressive” and the threat to free choice in healthcare.
Tags: health care
Very interesting about the wounded soldiers who felt getting wounded was beneficial, possibly even life saving.
The mental/psychological component can not be over stated when it comes to disease prevention and treatment. This is not something that can be affected easily.
It is well known that chronic pain is strongly associated with guilt and/or self punishment. This will have a great impact in the outcome of sth. like a knee replacement, or some other procedure reducing pain.