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Along for the Bumpy Ride? Market Responses in the New Health Care Marketplace. Eric D. Kupferberg, PhD Associate Director Trust Initiative, HSPH 28 October 2010. “. . . if you’re not part of the steamroller, you’re part of the road.” -- Stewart Brand
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Along for the Bumpy Ride?Market Responses in the New Health Care Marketplace Eric D. Kupferberg, PhD Associate Director Trust Initiative, HSPH 28 October 2010
“. . . if you’re not part of the steamroller, you’re part of the road.” -- Stewart Brand Source: Brand, The Media Lab: Inventing the Future at MIT (New York: Penguin 1988)
Mapping I-FM Syndrome • Virtual epidemic in all regions of the country • Mostly affects successful males and females • Spread by air travel and hand-to-hand contact • Carriers rarely recognize affliction • Secondary victims suffer greatly
Causal Link • Magazines featuring interviews with successful CEOs • Pithy conclusions • Strong appeal to join the next organizational revolution • Recommendations require radical restructuring and substantial money
Carrier StateExecutive Returns to Office • Delivers torn-out article to executive assistant
Secondary Victims • Senior executive requests that management team read the article and implement recommendations ASAP
Harm Magnifier • Senior executive demands to know why revolution has not already begun to reap noticeable benefits
update: 3/31/06 Chaotic IT Adoption The wide variation in physician technology adoption inhibits efforts to improve patient care David A. Shore Source: Marie Reed and Joy Grossman, Center for Studying Health System Change, Issue Brief 89, September, 2004
Barriers to HIT Adoption Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.
“A Change is Gonna Come?” • A majority of physicians fail to recommend at least one major drug up to ten years after it’s been shown to be efficacious. • A majority of physicians continue to recommend therapy up to ten years after it’s been shown to be useless. Source; Antman EM, Lau J, Kupelnick B, Mosteller F, Chalmers TC: A comparison of results of meta-analyses of randomised control trials and recommendations of clinical experts. JAMA 1992;268:240-8.
Facts are simple and facts are straightFacts are lazy and facts are lateFacts all come with points of viewFacts don't do what I want them toFacts just twist the truth aroundFacts are living turned inside outFacts are getting the best of them Facts are nothing on the face of things -- David Byrne, Cross-eyed and Painless
History of EBM:Archibald L. Cochrane (1909-1988) • Concerned with the over use of medical techniques • Published landmark Effectiveness and Efficiency (1972)
John Wennberg and theCenter for Evaluative Clinical Services • The Center for the Evaluative Clinical Sciences . . . conducts cutting edge research on critical medical and health issues with the goal of measuring, organizing, and improving the health care system. • . . . at the micro level, they hold the promise of reforming the doctor-patient relationships through shared-decision making and of improving the quality and value of clinical care.
David L. Sackett:Ascendance of Evidence-Based Medicine • EBM is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research."
What is Evidence-Based Practice?Sackett’s Short Definition • “Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” • BMJ 1996; 312: 71-2.
Is EBM Really New? • Often labeled as a “radical overhaul” or a “paradigm shift” in medicine • Yet, some advocates trace its roots to post-revolutionary France and the work of Bichat, Louis, and Magendie • Why does this “newness” or “oldness” matter? Source: Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. “Evidence based medicine: what it is and what it isn’t”. BMJ 1996;312:71-2.
Pre-EBM: Source of knowledge is the expert opinion of individual or institution Clinical skills beyond outside purview Patients are objects of treatment Post-EBM: Source of knowledge is the collective systematic review of evidence Clinical skills subject to audit Patients are part of “studies” Locus of Expert Knowledge in EBM
Criticisms of Evidence-Based Medicine • It is basically what we’ve been doing for ages • It is possible only under “ideal” conditions • It encourages “cookbook” medicine • It increases the authority of managers and insurers • Evidence from randomized trials and systematic reviews rarely works in clinical settings • It is antipathetic to patient-centered medicine
Can Providers Evaluate Evidence? • Doctors have little time to pose specific questions and search for targeted evidence • The number of journals and studies is astronomical • Providers often lack the technical skills to conduct exhaustive searchers • Studies lack standardized formats • Providers have difficulty resolving conflicting clinical evidence • Even the best evidence requires “interpretation”
update: 7/6/06 The Business Case for P4P David A. Shore Source: Jonathan Conklin and Audrey Weiss. Pay-for-Performance: Assembling the Building Blocks of a Sustainable Program, 2004 published by Thomson Medstat.
