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Comparative Effectiveness Research: Not as obvious as you would think.

February 13, 2013

When I was in medical school the big thing in the curriculum was something called “Evidence-Based Medicine” or EBM.  Every diagnosis and treatment was getting subjected to the EBM treatment.  We’d do big long projects with time-lines and charts to track the most current literature on a specific diagnosis or set of symptoms.  We’d spend hours discussing how to evaluate research papers to determine which studies were valid.  We had to learn statistics.  We med students were sort of led to believe that doctors followed the research and kind of did what it said.

Not so much, turns out.  Three recent examples: the Preventive Services Task Force on mammograms; a recent study on mastectomy vs. lumpectomy with radiation; the New England Journal of Medicine article about blood thinners vs. interventional radiology in stroke patients.  There are a ton of others.

The mammogram finding, a robust one with a lot of data points, was either ignored or castigated as taking away women’s healthcare.  The breast cancer study suggested that lumpectomy with radiation was more effective than mastectomy in recurrence rates, to which a prominent breast surgeon responded “it’s hard to imagine…”.  Interventional radiologic procedures, such as stents and thrombectomies, are used more and more even as the study suggests the use of powerful blood thinners works just as well.  We do a whole bunch of things in medicine that either don’t have any evidence to support them or used to but don’t anymore.  Antibiotics before surgery.  Cell phone bans.  Annual physicals.  Screening EKGs.  Things that seem to make sense and seem like good things to do, so we do them, without any real evidence.

The Affordable Care Act, or ACA, will try to make a big push for EBM, which the government is calling “Comparative Effectiveness Research” or CER. The goal is to find out which procedures work best for any given condition.  This seems like something that should have already been done, don’tcha think?  The problem is that many studies examine whether a treatment works better than nothing.   And once a drug or device manufacturer can prove that something works, they can market it.  They don’t want to compare their treatment to another treatment.  And they certainly don’t want to withdraw their product because it doesn’t work as well.  Doctors also have complicated relationships with the data. We might find something that works for X disease and use it even if down the line a new treatment is found that works better, because we’re used to using the first thing.  Or we’re waiting for confirmatory studies or to see what the guy down the hall is doing.  Or the results don’t make sense or are counter-intuitive so we don’t believe them.   Or we get new toys and want to use them, regardless of whether the new toy is really better than the old one.  The robot is a good example of this. Or this treatment is better for this population but not some other population. Or a doctor might be worried about money or turf.  Mammography is a big business in this country, as are mastectomies and robotic prostatectomies.

The government has different concerns.  Money is really the prime mover in this provision of the ACA.  The reason the ACA is pushing CER is that, theoretically, it can help eliminate some of the unnecessary testing and over-treatment that raise costs.  Politically, it has been used to accuse the government of playing doctor or keeping you from your health care.  CER has already been used for years at the VA to make coverage decisions and these fears have not been played out in that arena at least.

The reason I’m talking about CER and recent studies that have been in the news is so that you the patient can understand the complexity of some of the decisions your doctor makes.  Even if he or she knows ALL the most up-to-date research, things like turf, familiarity, medico-legal concerns and assumptions also play a role. Research can only provide data.  It can’t force us to act upon that data. This is because DOCTORS ARE HUMAN and MEDICINE IS NOT AN EXACT SCIENCE.


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