When your doctor recommends a medical treatment for what ails you — say, high cholesterol, back pain, noninvasive breast cancer, prostate cancer, atherosclerosis, or even pregnancy — how do you (or your doctor) know if that treatment is your best option?
You can’t know for sure — because very little money or other resources are spent on comparing different treatment options.
That’s the message of an excellent article that appeared Sunday in the Milwaukee Journal-Sentinel by business reporter Guy Boulton. (Hat tip: HealthNewsReview.)
Writes Boulton:
Many of the treatment options that confront doctors and patients every day — from which drug to prescribe to complex regimens for chemotherapy — are not based on solid evidence.
Doctors instead must rely on weak or limited studies, expert opinion, anecdotal evidence, their own experience and judgment — and, to some degree, marketing by pharmaceutical and medical device companies ….
The result is tens of billions of dollars — and maybe much more — spent each year on treatments that are of marginal or questionable value.
I really encourage you to read the entire article to get a sense of how little we know about the effectiveness — or risks — of common medical treatments and protocols. But here are some highlights:
- “The Institute of Medicine, the health arm of the National Academy of Sciences, has estimated that fewer than half of treatments given to patients are supported by good evidence.”
- “[N]umerous studies have estimated that as much as one-third of the money spent on medical care doesn’t improve patients’ health.” One result, Boulton points out, is the wide discrepancies in the types of treatments different patients receive for the same condition. Wisconsin Medicare patients, for example, were 107 percent more likely to have an angioplasty if they lived in Milwaukee instead of La Crosse and 120 percent more likely to have heart bypass surgery if they lived in Wausau instead of Madison. As Boulton notes, “all of the patients can’t be receiving the best care.”
- “[P]art of the uncertainty [about the comparative effectiveness of various treatments] stems from the focus by health care systems on new drugs and procedures. New technology accounts for roughly half of the increase in spending — and new technology in health care almost always costs more. This focus has resulted in stunning advances in medicine in recent decades. At the same time, doctors want to stay at the forefront of their profession, and they often are quick to adopt new technologies before good evidence exists to show that they work better than existing technologies.”
- “Pharmaceutical companies put their research dollars into developing new drugs as opposed to research on how to make the best use of relatively new drugs already on the market.”
- “Cardiologists may have the best practice guidelines of any specialty. Yet a recent review of the guidelines developed by the American College of Cardiology and the American Heart Association found that relatively few recommendations were based on high quality evidence.”
- “The clinical trials needed to win federal approval for a new drug … are unlikely to detect uncommon side effects because they typically involve relatively few people and often focus on short-term outcomes. In addition, the people in research trials often are younger and healthier than the patients likely to be given the drug if it wins approval.”
As Boulton points out, part of the stimulus package passed last year by Congress allocated $1.1 billion for comparative effectiveness research, and the new health-care reform law passed earlier this year creates a nonprofit institute to fund that research.
Still, such research “often faces opposition,” Boulton reports. Drug and medical device companies (and others in the $2.5-trillion-a-year health-care industry) stand to lose a lot of money if their particular treatment is found to be of questionable value.
The Milwaukee Journal-Sentinel indicates that this article is the first in what will be an occasional “Insufficient Evidence” series. I’ll link MinnPost readers to the next installment as soon as it appears.
Thanks for writing about this very interesting piece. It’s quite amazing that the question of what works best is so low on the list of priorities in the health care system today. I’d argue it is THE central problem in the cost creep tin health care that is bankrupting the country today. We should have a Marshall Plan to figure out What Works in medicine, but I have no doubt if such an effort we attempted the howls of socialized medicine would become deafening.
We have already seen how the right jumped onto the Medicare de-fundng of virtual colonoscopy as proof of America’s decline. Somehow, the ability to have a fly through colon exam, something not possible until the middle of the 1990s, has become a right in this country. Reagan never got one, for heaven’s sake.
But I take issue with the line in this piece that extolls how “New technology…has resulted in stunning advances in medicine in recent decades.” We haven’t had a really stunning advance in medicine — something that saves thousands and thousands of lives and needless suffering — since vaccines and antibiotics. Psychiatry has been thrashing around in the dark. Cardiology is busily lowering blood lipids that have little connection to heart disease. Cancer management has improved but the lives saved seems disputable. AIDS drugs have been stunning, I’ll give them that.
One other quibble is that, while the Comparative effectiveness research initiative in the health care bill is promising, they had to include language specifically requiring that it not be used to guide payment choices! Only in America. We can thank the “death panel”slander for that, or to put a face on the problem, the terrifically embarrassing congressperson from the sixth.
When I was diagnosed with GERD some years ago, my doctor prescribed Nexium as a way to reduce my stomach’s acid production. Nexium, at about $150 per month, was then the new and improved version of Prilosec. The problem is that, as I read later, the “improvement” in effectiveness was only about 2% over that of Prilosec.
I now use over-the-counter famotidine, the generic for Pepcid, and buy it in bottles of 50 tablets for $3.99. It works as well or better than Nexium and is practically free.
Makes me wonder how many other “improved” drugs are worth what we (or our insurance companies) pay for them.