Download Evidence-Based Medicine: Promises and Problems

Evidence-Based Medicine:
Promises and Problems
Victor R. Fuchs
Henry J. Kaiser Jr. Professor Emeritus
Stanford University
Nuffield Trust, London, 12 May 2003
“Evidence-based medicine
(EBM) is the integration of best
research evidence with clinical
expertise and patient values.”
David Sackett et al.
Evidence-Based Medicine
2nd edition, 2000, p. 1
Reasons for Expansion of EBM
The Demand for EBM
The complexity of modern medicine
The high cost of modern medicine
The Supply of EBM
Innovations that reduce the cost of acquiring,
storing, processing, and retrieving information
Methodological and substantive advances in
mathematics, statistics, and the behavioral
sciences that have applications to medical care
The Promises of EBM
• More effective, safer medical
interventions resulting in better health
outcomes for patients
• Greater uniformity in the quality of care
• A slower rate of growth of expenditures
for medical care
“best research evidence”
What does “best” mean?
Why only the “best”?
Can the best be the enemy of the good?
What kind of evidence is excluded by the
adjective “research”?
“clinical expertise”
EBM does not eliminate the need for:
Noting signs and symptoms
Taking a good history
Interpreting results of tests
Thinking analytically
Physician reasoning
“It is neither necessary nor desirable to
make every physician a decision analyst,
but a reasonable objective would be to
give physicians enough experience in
quantitative reasoning that they will
know how to solve simple problems
themselves, when and how to consult an
analyst, and how to interpret the advice.”
David Eddy, NEJM, 1982
“patient values”
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Risk aversion
Time preference
Living arrangements
Working arrangements
Medical care vs. other goods and
services
• Income?
“All medical care that is effective
should be free to all”
A.L. Cochrane, Effectiveness and
Efficiency: Random Reflections on
Health Services, 1972
Is this possible in 2003?
“Although the average beliefs in a
community are appropriate for
deciding, for example, whether
chemotherapy or surgery should be paid
for with public funds, decisions for
individual patients must reflect their
own personal beliefs and preferences.”
Sackett, et al., EBM, 2nd ed., p. 180
EBM and Expenditures on
Medical Care
Will EBM act as a brake on expenditures?
Yes. It will reduce utilization of ineffective
care.
Yes. It will show that some relatively
inexpensive interventions are as effective as
more costly alternatives.
No. It will show that some interventions are
more effective than any alternative, albeit at
great cost relative to their benefit.
For EBM to realize its potential, it is necessary
to integrate it with cost-benefit analysis.
Summary
• EBM is a great advance over informal, nonquantitative approaches to clinical decisions.
• The complexity and high cost of modern
medicine make EBM necessary. Innovations
outside of medicine make it feasible.
• EBM should result in more effective, more
uniform, and more efficient medical care.
• EBM is an adjunct, not a substitute for
physicians who can diagnose accurately, access
evidence efficiently, and think analytically.
• The integration of EBM with cost-benefit
analysis poses a major challenge for health
policy.