Doctors are awash in choices these days, and that's mostly a good thing. They can consider multiple new drug therapies, breakthrough tests, and promising devices at every turn.
But with so many choices, how do they pick the one that is best for your care? How do they uncover the nuanced differences among treatments that allow them to find the safest and most effective choice for you?
For example, doctors must choose among more than 30 FDA-approved drugs when they prescribe high blood pressure medications. How do they know if the newest drug on the market is the best for an individual patient?
Readers may be surprised to learn how little information doctors have to evaluate their options. The Institute of Medicine estimates that fewer than half of treatments given to patients are supported by good evidence.
Fortunately, two recent federal developments aim to fill this information gap. The stimulus bill, passed last year, included $1.1 billion for research that compares treatment options. And the new health care reform law will send more than $200 million a year, starting in 2013, to the new Patient-Centered Outcomes Research Institute for comparative effectiveness research about the procedures, drugs and devices that work best for patients.
Penn Medicine's Center for Evidence-Based Practice provides some powerful examples of how such research can become a Consumer Reports for doctors. Just as many people consult Consumer Reports to compare appliances, cars, televisions, and other products, doctors and nurses can turn to comparative effectiveness research for the pros and cons of medical choices.
In the Center's four-year history, doctors and nurses have asked us to resolve some profoundly important questions: Which skin antiseptic is the best for preventing infections from surgery? Is counseling as effective as medications for the treatment of insomnia? What's the best way to prevent deadly blood clots from forming in the legs and lungs? What is the best imaging equipment for cardiac catheterization labs? In the last case, the answer was different for two of our labs, depending on their staffing. It's a beautiful example of how local centers can synchronize their recommendations to the way medicine is really practiced, right there in real time.
When the answer is clear, recommendations can be hardwired into our electronic health record system and go right to the point of patient care at the bedside. For example, research showed the importance of calculating the dosage of blood thinner according to a patient's weight. Now, drop-down menus on bedside computers make that calculation automatically. As a result, we've had a ten percent improvement in care for patients with blood clots.
Tradition and inertia can be hard to overcome. Doctors have used betadine, that yellow-colored skin wash, to clean the skin before surgery for decades. But cardiac surgeons asked the Center to determine whether a newer skin wash - which was four times more expensive - was better at preventing infections.
The newer version turned out to be at least 25 percent more effective. Now, the default choice for our doctors is the new skin wash. While it comes at a greater cost up front, we projected savings of about $300,000 per year to the hospital by reducing infections.
In another example, doctors recently asked the Center to find out whether counseling or medication was more effective in treating insomnia. The answer was clear: six weeks of counseling was more effective than drugs. Right now, insurance companies are more likely to reimburse for medications. That might change if additional and more complex studies make a convincing case for the correlation between better sleep and health, leading to fewer claims.
Barely one-tenth of one percent of the $2.5 trillion that Americans spend annually on health care goes toward research on comparative effectiveness. Instead, we are spending billions on care that drive up costs, divert resources, and may be actually harmful. Doctors are in a tight spot: we want the latest and best care for our patients, but we can't always be sure that newer treatments are any better than older ones.
How can you, the patient, promote research that is good for your health but may happen well below your awareness? When your physician presents you with recommendations for care, ask what the research shows.
Craig A. Umscheid, MD, MSCE
Director of Penn Medicine's Center for Evidence-based Practice
July 13, 2010 04:54 PM
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Health Care's "Consumer Reports": Helping Doctors Find the Best Treatments for You