In an ideal world, if you were a 57-year-old man suffering from a myocardial infarction, it wouldn't matter whether you lived in Miami or Missoula, because your chances of survival would be the same.
Not so in the United States today where, to a large extent, your ZIP code determines what kind of care you receive. And much of the time, that care will not reflect what has been shown to be most effective for patients — evidence-based medicine (EBM). Witness the fact that in Pennsylvania, your chance of having a mastectomy for breast cancer could triple if you moved from one part of the state to another, according to the Dartmouth Atlas of Healthcare.
Through widespread implementation of evidence-based medicine, the United States has its best chance of erasing the variations in care that currently extract such huge costs — both human and financial — from the health care system. Once medical care is firmly anchored to proven science, lives will be saved, outcomes will improve, and efficiencies will be realized.
But what will it take to put the evidence to work? To begin with, it will require continuing pressure by organizations like the Leapfrog Group and the National Business Group on Health to reform a system that is not known for changing quickly. It will also call for huge cultural and technological changes at the payer, provider, and patient levels that will:
- Force competitors to cooperate,
- Reward scientifically supported care processes through carefully thought out incentive programs, and
- Drive the adoption of technology that makes EBM possible.
State of the union
The 1999 Dartmouth Atlas of Healthcare put the issue of medical practice variation on the map, and that map was a variegated one. Using databases of medical claims from payers such as the Centers for Medicare & Medicaid Services, the atlas describes how medical resources are distributed and used in the United States. Geography is indeed destiny, as its authors famously announced, with findings that included a mastectomy rate for breast cancer in Pennsylvania that varied threefold across the state (0.8 to 2.4 per 1,000 Medicare enrollees).
Practice variation proved an equal-opportunity discriminator: Rates for a common surgery for men — transurethral prostatectomy for benign prostatic hyperplasia — ranged from 4.4 to 11.1 per 1,000 enrollees in that same state.
And when the United States compares itself to other countries, using average life span and infant mortality as yardsticks, it lags far behind other industrialized nations such as Japan, Switzerland, France, and Australia. Granted, these disparities aren't 100 percent attributable to the health care system or to U.S. physicians who at times fail to bring scientific evidence into the exam room, but the fact remains that our focus on the latest and greatest medical technologies often comes at the expense of the less glamorous pursuits that many of those countries concentrate on: preventive care and chronic disease management.
We are undoubtedly the go-to folks if you need a marrow transplantation or a complicated mitral valvuloplasty. No other health care system is better prepared to deal with urgent, complex medical issues. But if your complaint is more pedestrian, our system is far less prepared to attend to you at that same level of excellence. A 2003 New England Journal of Medicine study of over 400 indicators of quality care for 30 common conditions determined that, on average, patients received recommended care only about half the time. ("The Quality of Health Care Delivery to Adults in the United States," McGlynn, et al, New England Journal of Medicine 348:2635-2645. June 26, 2003.)
Dissecting the reasons
Why has it been difficult for many physicians to incorporate evidence-based medicine into their daily practice? Let's start with the factors outside of the physician's control. First, the amount of new medical information physicians could potentially absorb on a regular basis is staggering. Each month, there are more than 150,000 articles published in some 20,000 medical journals. Medical information is now estimated to double every 2.5 years.
Relying on practice guidelines, as opposed to the source material, isn't always the answer. A 1999 JAMA article, "Are Guidelines Following Guidelines," by Terrence M. Shaneyfelt, MD, MPH, et al, concluded that guidelines published in peer-reviewed medical literature during the past decade often did not conform well to established methodological standards. Of 279 guidelines examined, only 29.9 percent adhered to evidence identification and summary. And even when guidelines reflect the evidence that evidence becomes dated rather quickly.
Finally, while clinical research has mapped huge tracts of medical science, there are still vast territories that remain unexplored. The evidence is thick when it comes to reasons why patients should undergo surgical procedures, yet the evidence quickly thins out when it comes to how to best migrate patients from one level of care to another after they have had these surgical procedures. It is far more attractive to figure how these surgeries can change the lives of patients than to figure out the nuances of the care that then follows.
Physicians' resistance to changing the way they practice is one of the biggest barriers to EBM adoption. For years, the medical community operated under the assumption that doctors always knew best. It took much work by driven, disciplined physicians and progressive health care organizations to disprove the infallibility of physicians. Today organizations like the Leapfrog Group and Bridges to Excellence work actively to demonstrate the glaring gaps in the quality of our care. Payers have now taken up the quality mantle, using much more sophisticated analytics to make their case. Thus, the system's growing ability to quantify quality has begun chiseling away at the reluctance of many physicians to change the way they practice.
|MCO medical directors believe that most physicians do not practice evidence-based medicine |
|"Physician resistance is the major obstacle for EBM" |
% of MCO medical directors agreeing
|All plans ||64% |
|National plans ||72% |
|Local and regional plans ||59% |
|"Universal set of guidelines will be needed to implement EBM" |
% of MCO medical directors agreeing
|All plans ||89% |
|National plans ||76% |
|Local and regional plans ||93% |
|"Physician incentives will be needed to implement EBM" |
% of MCO medical directors agreeing
|All plans ||84% |
|National plans ||87% |
|Local and regional plans ||80% |
|Source: "Evidence-based medicine and managed care: Applications, challenges and opportunities" Vanderbilt Center for Evidence-based Medicine. December 2003 |
Sometimes, even when presented with the evidence, physicians will fail to revise their approach, often for understandable reasons. The use of antithrombolytic therapy for the treatment of stroke presents just such an example. Much evidence had to be published on how this approach worked and the great difference it had in the lives of stroke victims before physicians began to feel compelled to take such a bold step in treating strokes.
This single example points to a larger issue about many physicians' relationships with published clinical research: It's often complex. It's not at all uncommon for a physician to pick up the latest research study published in even the most esteemed medical journal and think, "No way. This conclusion flies in the face of everything I've experienced in my own clinical practice." And that skepticism may sometimes be completely on target. Claims of rigorous peer review aside, some studies undoubtedly wouldn't stand up to close scrutiny — in the form of a meticulous statistical analysis, for example.
But responsibility for the slow migration of research from lab bench to bedside does not all lie at the physician's doorstep. There are plenty of systemic reasons for the failure of EBM to penetrate many physicians' daily practice, beginning with the fact that until fairly recently, there were few incentives for physicians to deliver evidence-based medicine.
Historically, compensation hasn't been linked to ensuring that your diabetics are getting regular hemoglobin A1c tests, your middle-aged women receive regular Pap smears and mammograms, and other clearly proven interventions like these.
Further complicating matters is the fragmentation of patient information. Critical patient information may reside in a number of computer systems, including those of health plans, disease management programs, emergency departments at local hospitals, and home health agencies caring for patients after recent admissions. How can physicians do right by their patients, from an EBM perspective, with such fragmented information?
Making it work
So how do we overcome these obstacles and finally become world leaders in the use of evidence-based medicine?
To begin with, we need to continue rebuilding the incentive system so that physicians are properly rewarded for following the principles of sound science. That means not just creating pay-for-performance (P4P) programs, but designing ones that inspire change where it is most needed.
For instance, many P4P programs begin issuing incentives only after absolute thresholds are achieved by physicians, like prescribing beta blockers to at least 75 percent of heart attack patients. Where does that leave the physician who is currently prescribing beta blockers for just 30 percent of her eligible patients? Pretty unmotivated, I would guess. Rewarding low-performing physicians for making significant progress, even if they're still falling short of the ideal, targets those providers who most need to be engaged.
An October 2005 JAMA study ("Early Experience With Pay-for-Performance: From Concept to Practice," Rosenthal, et al. JAMA, October 12, 2005) confirmed the tendency of many programs to reward their quality stars most generously, at the expense of their lower performers. The study, which evaluated a P4P program conducted by PacifiCare, found that doctors already at the target levels received 75 percent of the bonus money.
P4P programs can also play a large role in helping physicians improve their performance on quality indicators by promoting adoption of EBM-centric technology in physicians' offices. A large part of doing something meaningful here is ensuring that reward levels are generous enough to enable even the smallest practices to license an electronic medical record system. Of course, every practice wants to do what's best for its patients. But the reality is that if there's no financial incentive to make a large investment in a technology that so far you've done OK without, you're unlikely to take the plunge.
The good news is that generous incentives are not a pipe dream. A pay-for-performance program organized by California's Integrated Healthcare Association, a consortium of medical groups, health plans, and health systems, distributed $50 million in bonuses to medical groups in 2004.
One of the challenges in taking P4P to its full potential is the lack of coordination of different payers' programs. Every plan has its own idea of the best way to measure quality. The result is a tangle of different metrics and standards that confuses and frustrates physicians. Payers can have a large hand in raising the standard of care across the health care system if they come together now and define a universal set of quality measures. This has been voiced as a shared need by 89 local, regional, and national MCO's covering over more than 90 million lives in a survey conducted by the Vanderbilt Center for Evidence-Based Medicine published in December 2003. ("Evidence-Based Medicine and Managed Care: Applications, Challenges and Opportunities.")
What role does the patient play in this brave new world of evidence-based medicine? Making the patient a partner in EBM is not just strategic, it's inevitable. As consumers are being asked to shoulder a greater and greater percentage of their health care costs, it absolutely behooves them to become more informed about what the science says.
But we have to be realistic. Even with years of schooling and practice, many physicians agonize over tough medical decisions that involve all sorts of variables. Do we expect a patient to be able to make complex medical decisions, even with a little bit of EBM under his belt?
Absolutely not. It needs to start simple with consumers, focusing primarily on preventive care. Consumers need to be able to answer basic questions like, "What types of care or screening tests do I, as a person of this age, gender, and race, need at a bare minimum on an annual or bi-annual basis?" And then the health plans need to start building incentive systems, paralleling physician pay-for-performance programs, that reward patients who play by the rules of EBM.
The next act of the EBM story is the one that brings all of the stakeholders together, eliminating the disconnects that currently plague the system. This is where the need for an interconnected health care system comes in, a future where physicians have at their fingertips a comprehensive picture of their patients' care, not just fragments. And this is where the full power of EBM can finally be realized, where the different stakeholders mutually reinforce its practice.
Here is a scene that will become commonplace in the not-too-distant future:
A woman receives a letter from her health plan reminding her that she's due for her yearly mammogram. She knows how important it is, thanks to the literature her health plan sends her annually, but she nevertheless puts off scheduling it. A week later she receives an e-mail from her physician's office, whose EMR has alerted staff that the patient is due for a mammogram. Because the physician's EMR is connected to that of the local freestanding clinic that the patient often visits, the physician's office knows she hasn't had a mammogram there either. All of this happens just as the health plan's care management system alerts the payer that a mammogram claim should be arriving soon. If, for some reason, the claim doesn't come through after a designated period of time, the health plan alerts the physician and the patient that a mammogram still needs to be done. The woman gets a mammogram anytime during this period when she logs into her personal health record via the health plan's member portal.
The curtain descends, the music rises. Evidence-based medicine has triumphed.