More On Evidence Based Medicine

In a previous post I was somewhat critical of evidence-based medicine (EBM) when it is used to make payment decisions. One of the points I was trying to make is that EBM is not a passing fad. The staying power of EBM was recently reinforced by two recent developments.

First, the Medicare Payment Advisory Commission’s (MedPAC) March 2008 Report to Congress cites their own 2005 report recommending EBM as a touchstone for comparing physicians’ practices as one way to improve quality of care and value for the Medicare program:

In the March 2005 Report to the Congress, the Commission recommended that CMS measure physicians’ resource use over time and share the results with physicians (MedPAC 2005). Physicians would then be able to assess their practice styles, evaluate whether they tend to use more resources than their peers or what evidence-based research (when available) recommends, and revise their practice styles as appropriate.(13) Moreover, when physicians are able to use this information in tandem with information on their quality of care, they will have a foundation for improving the value of care beneficiaries receive.

Private insurers increasingly measure resource use to contain costs and improve quality (MedPAC 2004b).(14) Evidence on measuring the effectiveness of resource use in containing private sector costs is mixed and varies depending on how the results are used. Providing feedback on use patterns to physicians alone has been shown to have a statistically significant, but small, downward effect on resource use (Balas et al. 1996, Schoenbaum and Murray 1992), but, when paired with additional incentives, the effect on physician behavior can be considerably larger (Eisenberg 2002).

This report also notes that dialysis care is one area most ready to make use of EBM for payment purposes:

The dialysis sector is ready for pay for performance: Evidence-based measures are available, providers can improve on these measures, data are available to risk-adjust the measures, and systems are available to collect the information. CMS already collects some clinical information—dialysis adequacy and anemia status—on providers’ claims. CMS is developing additional data infrastructure that will permit the agency to collect information about quality of care from all facilities.

Any nephrologists our their have any thoughts about this?


The second new development related to EBM is the launch of “the updated, expanded, and searchable Tufts Medical Center Cost-Effectiveness Analysis (CEA) Registry website.” According to an email from the Peter Neumann, the Director of the Center for the Evaluation of Value and Risk in Health at the Institute for Clinical Research and Health Policy Studies at Tufts Medical Center, (Peter – get a shorter title), this registry “provides public access to a comprehensive online database of cost-effectiveness ratios from the published medical literature.” And has the “mission is to identify society’s best opportunities for targeting resources to save lives and improve health and to help standardize cost-effectiveness methodology.”

What distinguishes the CEA registry from the proposal to create a Center for EBM that MedPAC made in February, is that the registry is a resource for understanding the “evidence” part of EBM without any direct ties to using this information for changing payments. A colleague recently agreed with my off-line assessment that one of the challenges is that EBM – and its cousin pay-4-performance – are almost always directed at clinical areas where there is believed to be costly overuse or misuse. Very rarely are these same potentially quality improving tools directed towards clinical situations where there is documented underuse – situations where quality could be improved, long-term cost savings achieved, but there also might be short-term cost increases. This is one of my touchstone secrets for evaluating the intentions of “quality improving” initiatives – do they target any practices where there is documented underuse?

And one other interesting observation about the CEA registry. It classifies its information into 4 categories depending upon the conclusion of the research:

  1. Increases Costs/Improves Health
  2. Increases Costs/Worsens Health
  3. Decreases Costs/Worsens Health
  4. Decreases Costs/Improves Health

Doing a quick assessment of the registry revealed an interesting landscape: There are about 27 more sources for #2 than there are for #3. (Types #1 and #4 are midway between, with 8 and 10 times as many pieces of information as #3.)

There could be several possible reasons for this lopsided distribution: There really could be a LOT more clinical practices that waste money and worsen health. Or this could be the area that healthcare payers will pay for research to be conducted. Or researchers know that these types of findings will bring more research funding from payers.

I believe that the second of these scenarios is the most likely since payers are primarily concerned about reducing care that increases costs and worsens health. However, I also believe that these ratios don’t reflect the full picture of clinical care, and that there are many clinical practices that if used more would improve health – whether they increase or decrease costs….. of course that calculation often depends upon what time-frame and scope of society is considered, which leads back to the old question “costs to whom?”

What do you think?

One thought on “More On Evidence Based Medicine

  1. It has been pretty apparent for some time that EBM is a tool of managed health care and more particularly intended to blunt the impact of any universal health care policy that may be crafted over the next 4 years. EBM can be an enormous barrier to care because in the hands of insurers it assumes that the evidence is all in and that if the research hasn’t been done, then treatment can be denied or delayed until the research is generated. David Eddy once said that whoever controls the guidelines, controls medicine. He also said that “[i]n a field filled with uncertainty and doubt, the difference between ‘when in doubt, do it’ and when in doubt, stop’ could easily swing $100 billion a year”. (“Clinical Decision Making: From Theory to Practice” David M. Eddy, 1996.) The use of EBM to centralize medical decision-making, suppress clinical discretion, and reduce costs results in patients being denied care and innovation being quashed.

    The assumption that one can easily look to the “evidence” from abstract clinical trials that do not take into account the severity or course of illness in the individual as opposed to the statistical patient is fraught with danger. The bulk of medicine today is practiced in the gray zone of uncertainty, without the benefit of clinical trials. EBM is used by insurer to deny care, but even worse, is being used to preclude the use of other treatment options even when the patient is willing to pay for them. It is time for American to wake up and reclaim the medical ethical compass from insurers (including Medicare).


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