In American medicine today, “variation” has become a dirty word. Variation in the treatment of a medical condition is associated with wastefulness, lack of evidence and even capricious care. To minimize variation, insurers and medical specialty societies have banded together to produce a dizzying array of treatment guidelines for everything from asthma to diabetes, from urinary incontinence to gout.
At some level, this makes sense. Some types of variation are unwarranted, even deadly.
But the effort to homogenize health care presumes that we always know which treatments are best and should be applied uniformly. Unfortunately, this is not the case. The evidence for most treatments in medicine remains weak. In the absence of good evidence recommending one treatment over another, trying to stamp out variation in care is irrational.
Don’t Homogenize Health Care
by Sandeep Jauhar
http://www.nytimes.com/2014/12/11/opinion/dont-homogenize-health-care.html
Guidelines presume we doctors always know the best treatment. We don’t.
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After spending nearly two decades in medicine, I am still amazed by how spare the evidence is on which we doctors base our medical decisions. Treatment guidelines, often accompanied by a de facto mandate, are frequently reversed.
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In American medicine today, “variation” has become a dirty word. Variation in the treatment of a medical condition is associated with wastefulness, lack of evidence and even capricious care. To minimize variation, insurers and medical specialty societies have banded together to produce a dizzying array of treatment guidelines for everything from asthma to diabetes, from urinary incontinence to gout.
At some level, this makes sense. Some types of variation are unwarranted, even deadly. For example, we know that ACE inhibitor drugs improve quality of life and survival in heart-failure patients, but only two-thirds of American physicians prescribe these drugs to such patients. A study by the National Committee for Quality Assurance, a nonprofit organization focused on health care, reported that 57,000 Americans die each year because the care they get is not based on the best available evidence.
But the effort to homogenize health care presumes that we always know which treatments are best and should be applied uniformly. Unfortunately, this is not the case. The evidence for most treatments in medicine remains weak. In the absence of good evidence recommending one treatment over another, trying to stamp out variation in care is irrational.
Even in my field, cardiology, a paragon of evidence-based medicine, most treatment recommendations are based on expert opinions, not randomized controlled trials. Rarely is there one best option.
Patient preferences have to be taken into consideration, too. Medical decisions necessarily involve value judgments, and who better to make those decisions than the patient? If a fashion model doesn’t want curative surgery because it will scar her face, that may make sense in the context of her priorities. As a doctor, I may not agree with her, but I have to try to understand her reasoning and abide by her decision.
The weaker a treatment recommendation, the more patient preferences should enter into medical decision making, and the more variation you should expect to see. This is a basic conflict in modern medicine: treatment uniformity, which aims to optimize population health, versus treatment variation, which aims to respect individual choice. There is no obvious solution to this conflict, but the resolution will determine what medical care is going to look like in 10 or 20 years.
After spending nearly two decades in medicine, I am still amazed by how spare the evidence is on which we doctors base our medical decisions. Treatment guidelines, often accompanied by a de facto mandate, are frequently reversed.
Only a few years ago, for example, beta-blocker drugs were routinely recommended for almost all patients undergoing noncardiac surgery. Since then, research has shown that these drugs may significantly increase the risk of stroke at the time of surgery. I remember colleagues questioning the beta-blocker recommendation for certain patients and being admonished for not being “evidence-based.” I shudder to think how many patients were left disabled by strokes because of the blanket adoption of this standard.
What is in vogue today is often discarded tomorrow. Hormone replacement therapy for women after menopause is an example of a once widely implemented treatment that we have now largely abandoned. In September, in response to new research, the American College of Cardiology revoked a major recommendation on heart-attack treatment. “Science is not static but rather constantly evolving,” said its president, Patrick T. O’Gara, in explaining the decision.
Of course, he is right. We don’t know how or when medical science is going to change. But we can lower the dangers associated with these reversals if we encourage doctors and patients to use their own judgment when following the guidelines.
Not surprisingly, guidelines and checklists are unpopular among most American physicians. Instead of being allowed to deliver “patient-centered” care, many physicians feel they are being co-opted by regulations. Some feel pressured to prescribe “mandated” treatment, even to frail older adults who may not benefit. Guidelines are supposed to assist and advise. But all too often, recommended care in certain situations becomes mandated care in all situations.
We have to get smarter about how we try to improve medical care. I believe the next phase of quality improvement will be a move away from homogenizing care and toward personalizing it, perhaps with the help of genomic research. Neither the old approach, in which seemingly every patient was treated differently, nor the new one, where we try to treat them all the same, has worked well. Medicine needs another way.