In Search of Appropriate Evidence
The ongoing conundrum of what is high quality evidence and when is it applicable to an individual patient’s situation always gets my attention. I was just at the doctor’s office where I discussed the never-ending debate about annual mammograms before or after age 50 (I’m an annual girl, for sure). Then, I read Lisa Rosenbaum’s excellent piece in the New Yorker (http://www.newyorker.com/online/blogs/elements/2013/10/the-most-slandered-treatment-in-medicine.html) addressing similar questions about appropriateness of stents in the world of cardiology. How does the patient and his/her provider know what evidence is valid (is generalizable) to the situation they confront together?
Government agencies, professional societies and even payers weigh in on “what we know from the evidence,” and this drives everything from what’s presented to us as treatment options to what is reimbursed by our health plan. The truth is that we cannot have a well-funded, well-designed, appropriately-powered answer for every medical situation and combination of health history, gender, ethnicity, lifestyle and access. I support all the attention being paid to better evidence, transparency and patient inclusiveness in research. Surely these efforts will yield information that is more likely to benefit patient decision-making down the road. And yet, I’m concerned about the emphasis on “defining value” or “identifying waste” based on such evidence, when the reality (in Dr. Rosenbaum’s example with stents) is that the percentage of inappropriate use may be far less than such studies reveal.
Ultimately, value should be based on the patient outcomes — did they get better? were more procedures or hospitalizations required that might have been avoided with earlier/more aggressive/different treatment? did the patient’s quality of life improve? Our health system tries to put all the calculations of comparative effectiveness, appropriateness and value into a neat box that can “fix” practice and arrest spending growth. We know, in reality, that appropriateness of care is determined one on one between the patient and the treating provider. For my part, I want a doctor who is well-versed in the latest research, but who is willing to discuss how the evidence may or may not apply to me and who listens to my preferences for outcomes. And, I hope for a system of care that supports that interaction and our ability to decide on a course of treatment that is right for me.