Evidence-Based Medicine: A Way to Decrease Waste

Efficiency and effectiveness are both qualities that all healthcare organizations should always strive for. This week, I decided to look into the blogosphere for ways in which these two qualities can be achieved. I was able to come across a couple of blogs that really inspired me. They both touch upon the importance of evidence-based medicine in reducing the amount of money wasted each year, thus improving both efficiency and effectiveness. It is quite often that we hear that the United States is one of the countries that spends the largest percentage of GDP in healthcare, yet there are always complaints about the quality not being up to par. This can be partly attributed to the amount of money wasted each year on unnecessary procedures that have no real effect on the patient's health.

The first blog I explored is called The Healthcare Blog. I specifically read a post by Maggie Mahar entitled A Blueprint for Healthcare Reform. In this post she argues that "unnecessary care doesn't just waste dollars: it can be hazardous to your health". Because of this, she stresses the idea that reduced utilization can lead to better outcomes, and supports this through the findings of Dr. John Wennberg. The other post I looked at showed a different side of the problem of evidence-based medicine: the lack of it in the United States. In a blog named Gooznews.com, Merril Goozner wrote a post titled FDA Proposes Lack-of- Evidence Based Medicine Policy. He explained that the FDA is trying to get a policy passed which would allow pharmaceutical companies to give journal articles advertising the off-label uses of the specific medicines to physicians. This would of course incentivize more studies for the other uses of the medicine, but unfortunately it would not be in a controlled and supervised manner and findings from these trials can lead to misleading information regarding the true benefit of the medicine for the off-label use. Through his article, he is able to convey the inefficiency of this policy, and the harmful effects it could have on our healthcare system.

I have attached the comments I made in regards to their arguments, and hope that you will take the time to read what these authors have to say to better understand the need for evidence-based medicine.

Comment 1 - First and foremost, I would like to thank you for this very insightful post. I myself had never read or heard any of Dr. Wennberg's work, and find it very intriguing that knowledge in this subject has been so prominent yet no one has seemed to be doing much to fix the problem of waste in our healthcare system until very recently. I would have to agree with much of what was written in the previous comments in terms of why so much money is being disposed of so carelessly. Both the fear of malpractice law suits as well as the lack of flowing knowledge between patient and physician can often lead to overusing treatments and procedures. I think that because of this it is very important that we do keep in mind this idea of evidence-based medicine, and really focus on the patient's actual needs. I found the concept of "Manifest Efficacy" to be really relevant to this issue as well. Although I had never heard the actual term, the concept of it is one that is very familiar. I think that it is very much the responsibility of the physician to be looking out for their patients because most of these people are not very knowlegdeable of what many procedures entail and thus trust their caregivers wholeheartedly, never really questioning what is being done to them, instead believing that it is what is best for their health. I believe that in order to move into a more patient based healthcare system, new ideologies that promote this type of environment need to be accepted by Healthcare organizations. An excellent example of this can be seen in the new rules established by the Institute for Healthcare Improvement. These rules re-define the way HCO's manage healthcare, and really do a great job at trying to cut down some of the waste. Some of these rules include 1) Treating health as a continuous process 2) Letting knowledge flow freely between caregiver and patient 3) Customizing Care 4) Letting the patient be the source of control and decision-making, and so forth. By living up to these types of expectations, there is a shift in the mentality of how to access the necessary care for each individual, and thus a better quality of care is provided.

In regards to the rewarding quality rather than quantity, I believe that the gradual shift towards a pay-for performance method of reimbursement might provide the necessary incentives for providing better quality of care. While this might not be the only answer, it might serve as a stepping stone for future change.

Comment 2 - Merrill, thanks so much for giving insight on this new policy that is trying to be enacted. As a policy major, I am appalled at the idea of a policy such as this one even being brought to the table. I cannot believe that anyone would really think that this would be beneficial for either physicians or patients. Not only does this pose a possible threat to patients, but it could potentially be more costly for physicians and even the pharmaceutical companies if these drugs prove to have adverse effects when using them for off-label purposes. I am curious to know if the people who would be put in these so-called clinical investigations are aware of what they are putting themselves through. Even if they did, you are correct in saying that the result of these studies could be misconstrued. Who can assure us that the proved benefits of taking a medicine are not the result of another confounding factor. It makes me very weary of where the FDA's heart really is if they are willing to propose something that could potential even take someone's life. While pharmaceutical companies might make more money rapidly, the long term effects and cost for the country cannot be measured. It is imperative that we keep the same type of test and trials that we have been doing in order to ensure knowledge of the true benefits of these drugs. I would hate to see so much money go to waste trying to recover from such a crisis that a policy like this poses.

Quaid Twins: Eye Openers to the Reality of Medical Errors

In late November 2007, the eyes of America were open to the reality of the threat of medical errors with the unfortunate experience of the Quaid twins. Dennis Quaid and his wife (pictured on the left) had put their two week old babies under the care of the staff of the Cedar Sinai Hospital, one of the most renowned hospitals in California. Little did they know that during the twins time at the hospital, they were going to be put under more danger than what they were admitted for. During one of the night shifts, the twins were administer a dosage of a blood thinner, Heparin, that was 1000 times what they needed. This put both twins into shock and they had to be transferred to the neonatal intensive care unit. There was another patient who also suffered the same problem, but their name was not disclosed. Fortunately, all three patients recovered from this medication error, and there are no signs of permanent damage. While the Quaid twins were able to survive this error, there have been other patients who have died from overdoses of Heparin. Though the Quaids are attributing this error to the pharmaceutical concepts, we must also considering the error in the delivery process administer by the hospital. It is the hospitals responsibility to ensure quality care to each patients, and thus should constantly be evaluating their performance so that errors such as these do not occur.

Even in a hospital as supreme in quality as Cedar Sinai Hospital, it is now evident that errors occur. In fact, according to the US Food and Drug Administration, 98,000 deaths a year can be accounted to medical errors. While the Quaid's are attributing this particular error to the pharmaceutical companies, it makes us wonder if there was anything the hospital could have done to prevent this error as well. Now a days, hospitals need to really begin to look at these problems internally and see what they can do to limit their liabilities without spending a surplus of money to prevent errors. For example, in the case of this overdose, perhaps if the person stocking the medicine realized that these two concentrations of the drug resembled each other, he or she could have made a sign to signal which vial was which, which would have probably been more cost efficient then they multiple days spent in the NICU and medicine to reverse the effects of Heparin.

If we look at the most frequent types of medication errors found within our hospitals, we can see that omission of a dosage is the most frequent. The bar graph on the right, provided by The Commonwealth Fund, a foundation which works to improve high performance in our health system, shows other causes as well. Improper dosage and prescription error are right below omission in frequency. All of these errors could potentially be solved, or at least reduced, by improving the systems performance of the hospital. Because more and more hospitals are realizing this concept, hospitals are moving towards a more factory based approach to reduce the number of mistakes within their practices.

One of the ways by which they are experimenting is by the use of the Six Sigma efforts, provided by General Electric. According to the Six Sigma Website, Six Sigma is a "measure of quality that strives near perfection". There are two processes by which this statistical measure can be achieved. One is called Six sigma DMAIC, which stands for define, measure, analyze, improve and control. The other one is Six Sigma DMADV which stands for define, measure, analyze, deign, and verify. Both of these methods try and achieve as little variation as possible.Through the use of these data based methodological process, companies can asses the efficiency and quality of their process, and install measure to constantly be improving and trying to achieve that Six Sigma, which would represent perfection. Many hospitals all across America are using programs such as this already. One of the hospitals that has seen results from the Six Sigma Efforts is St. Joseph Health Center in St.Louis. After implementing these processes, they were able to obtain a decrease in annual turnover as well as an increase in revenue and in emergency room admissions. By examining each part of their departments and really striving for the best, they have been able to radically turn around their hospital.

It is imperative that more hospitals look at constantly improving their system process to minimize the number of error that occur within their facilities. As hospitals, one of the main responsibilities and missions should be to save lives, not to endanger them. Errors such as the overdose of the Quaid twins are preventable and should be foreseen and accounted for. Only then will hospitals truly decrease their liabilities and become the health sanctuaries that we desire them to be.