Evidence-Based Medicine and the Changing Nature of Health Care 2007 IOM Annual Meeting Summary (2008) / Chapter Skim
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2 The Need for Better Medical Evidence
2 The Need for Better Medical Evidence
Pages 49-70
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From page 49... ...
Papers in this chapter examine the drivers of practice variations and healthcare costs and suggest the potential for an improved evidence base to improve the efficiency and effectiveness of healthcare services. The majority of U.S.
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From page 50... ...
Slowing overall healthcare cost growth without limiting access will require changes that impact the overall healthcare system and providing better evidence to inform decision making will be an important first step. Comparative effectiveness research that draws upon the emerging electronic health record and clinical registry data resources may be the only cost-effective and feasible mechanism for bringing about the evidence-base expansion needed.
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From page 51... ...
Categories of Care: Biologically Targeted Interventions Versus Care Management Strategies As we consider the relationship between evidence and clinical practice, it is worth considering two broad categories of interventions: discrete, biologically targeted interventions and care delivery strategies. Biologically targeted interventions are focused on a specific anatomic problem or disease process.
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From page 52... ...
Current Practice and the Evidence Base: Biologically Targeted Interventions The recent IOM workshop on evidence-based medicine highlighted the many limitations of the current evidence base, focusing primarily on the challenges surrounding biologically targeted therapies (IOM, 2007a)
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From page 53... ...
. When we look at common biologically targeted interventions -- both diagnostic and therapeutic -- we see dramatic variability across the United States.
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From page 54... ...
, we have long referred to these services as "supply-sensitive." One of the fundamental reasons for distinguishing care delivery strategies from the use of biologically targeted interventions is their distinct 5.0 Standardized ratio (log scale) 1.0 0.2 At least Primary Medical 10 or more Medical Inpatient ICU days one visit care visits specialist MDs (L6M)
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From page 55... ...
. Higher spending is not associated with greater use of biologically targeted interventions: whether these are treatments that all patients should receive (effective care)
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From page 56... ...
, a consistent pattern is found: the quality of care as reflected in process measures of care is worse when spending -- and the intensity of care delivery -- is greater. Among patients hospitalized with hip fractures, colon cancer, and acute myocardial infarction who were followed for up to five years, mortality rates in higher-spending regions and hospitals were no better or slightly worse than in lower-spending delivery systems (Fisher et al., 2003a)
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aHigh- and low-spending regions were defined as the U.S. Hospital Referral Regions in the highest and lowest quintiles of per capita Medicare spending as in Fisher et al.
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From page 58... ...
Patients' preferences for care vary slightly across regions, but not enough to explain the magnitude of spending differences seen. For example, Medicare beneficiaries in high-spending regions are no more likely to prefer aggressive end-of-life care than those in low-spending regions (Barnato et al., 2007; Pritchard et al., 1998)
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From page 59... ...
Although the need for evidence may appear overwhelming, an important opportunity lies in recognizing that the information systems and analytic approaches required to improve the evidence base for biologically targeted interventions and for improving care delivery are fundamentally the same (Table 2-2)
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From page 60... ...
population and our ability to pay for the new biologically targeted interventions that are under development will clearly depend not only on the costs of the interventions but also on the costs of delivering those interventions. Academic medicine -- and the federal agencies that provide research support -- have largely focused on improving our understanding of disease biology, while ignoring the need to understand and address the dramatic variations in care delivery among academic medical centers (Wennberg et al., 1987)
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From page 61... ...
Mary's Center Hospital Hospital Foundation Hospital) Provision of discrete, biologically targeted evidencebased interventions Composite quality 81.5 84.3 85.9 89.2 90.4 score on measures of inpatient technical quality Spending and care delivery for patients with serious chronic illness during last 6 months of life Medicare spending 50,522 43,363 40,181 28,077 26,330 Physician visits 52.1 29.8 42.2 32.2 23.9 Hospital days 19.2 17.1 17.7 14.6 12.9 Intensive care days 11.4 4.3 2.8 3.5 3.9 % admitted to 26.1 31.5 19.6 34.2 25.5 hospice % seeing 10 or 57.7 44.3 54.6 46.8 43.0 more physicians NOTES: Hospitals were selected for inclusion because they were ranked as the top five academic medical centers on the U.S.
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From page 62... ...
Such an effort should include a focus not only on the science of disease biology and improving the evidence to support the use of biologically targeted interventions, but also on the sciences of clinical practice and the evidence to support improvements in care delivery (Wennberg et al., 2007)
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From page 63... ...
(Even with no change in federal policy, there are reasons to believe that this simple extrapolation may overstate future cost growth in Medicare and Medicaid. CBO has recently released a long-term health outlook that presents a more sophisticated approach to projecting Medicare and Medicaid costs under current law, but a straight historical extrapolation is shown here for simplicity.)
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From page 64... ...
first approximation the central long-time fiscal challenge facing the United States. It is common to say that the sooner we act the better off we are, and just to calibrate that, Figure 2-6 shows that if we slowed healthcare costs growth from 2.5 percentage points to 1 percentage point starting in 2015 -- which would be extremely difficult if not impossible to do, but is helpful as an illustration -- the result in 2050 would be a reduction of 10 percent GDP in Medicare and Medicaid expenditures for the federal government relative to no slowing in the cost growth rate.
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From page 65... ...
. All available evidence suggests that lower cost sharing increases healthcare spending overall, and collectively we all pay a higher burden, although the evidence is somewhat mixed on the precise magnitude of the effect by which lower cost sharing raises overall spending.
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From page 66... ...
Second, there is an inherent limit to what we should expect from increased consumer cost sharing because healthcare costs are so concentrated among the very sick. For example, the top 25 percent most expensive Medicare beneficiaries account for 85 percent of total costs, and the basic fact that healthcare costs are very concentrated among a small share of the population is replicated in Medicaid and in the private healthcare system.
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From page 67... ...
There is thus a tension between using statistical techniques on panel data sets (of electronic health records, insurance claims, and other medical data) , which seems to be the only costeffective and feasible mechanism for significantly expanding the evidence base, and the inherent difficulty of separating correlation and causation in such an approach.
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From page 68... ...
In conclusion, it is plausible to me that the combination of some increased cost sharing on the consumer side and a substantially expanded comparative effectiveness effort, combined with changes in the incentive system for providers, offers the nation the most auspicious approach to capturing the apparent opportunity to reduce healthcare costs at minimal or no adverse consequences for health outcomes. The focus of this publication is thus central to addressing the nation's long-term fiscal challenge.
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From page 69... ...
The case of acute myocardial infarction. Health Affairs (Millwood)
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