Category Archives: awareness

Proton Beam Therapy For Prostate Cancer

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Proton Beam Therapy For Prostate Cancer

As of this writing, there is insufficient evidence to conclude that proton beam is more effective in treating prostate cancer than conventional radiation therapy; and there is no evidence of significant differences between proton therapy and radiation therapy in total serious adverse events.  Readers may be interested in a recent article where the investigators point out that patients diagnosed with prostate cancer and  living in areas where proton beam therapy is readily available are more likely to be treated with this new technology than with conventional radiation therapy. The cost of treating prostate cancer with proton beam therapy can exceed $50,000 per patient which is twice the cost of radiation therapy. Increasingly, we are seeing new technologies with staggering costs. In prostate cancer, for example, as we write this, proton centers are being built all over the country at a cost of up to $200 million.

Reference

Aaronson DS, Odisho AY, Hills N, Cress R, Carroll PR, Dudley RA, Cooperberg MR. Proton beam therapy and treatment for localized prostate cancer: if you build it, they will come. Arch Intern Med. 2012 Feb 13;172(3):280-3. PubMed PMID:22332166.

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Critical Appraisal Matters

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Critical Appraisal Matters

Mike and I make it a practice to study the evidence on the evidence.  Doing effective critical appraisal to evaluate the validity and clinical usefulness of studies makes a difference.  This page on our website may be our most important one and we have now added a 1-page fact sheet for downloading: http://www.delfini.org/delfiniFactsCriticalAppraisal.htm

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Centrum—Spinning the Vitamins?

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Centrum—Spinning the Vitamins?

Scott K. Aberegg, MD, MPH, has written an amusing and interesting blog about a recently published randomized controlled trial (RCT) on vitamins and cancer outcomes[1]. In the blog, he critiques the Physicians’ Health Study II and points out the following:

  • Aberegg wonders why, with a trial of 14,000 people, you would adjust the baseline variables.
  • The lay press reported a statistically significant 8% reduction in subjects taking Centrum multivitamins; the unadjusted Crude Log Rank p-value, however, was 0.05—not statistically significant.
  • The adjusted p-value was 0.04 for the hazard ratio which means that the 8% was a relative risk reduction.
  • His own calculations reveals an absolute risk reduction of 1.2% and, by performing a simple sensitivity analysis—by adding 5 cancers and then 10 cancers to the placebo group—the p-value changes to 0.0768 and 0.0967, demonstrating that small changes have a big impact on the p-value.

He concludes that, “…without spin, we see that multivitamins (and other supplements) create both expensive urine and expensive studies – and both just go right down the drain.”

A reminder that, if the results had indeed been clinically meaningful, then the next step would be to perform a critical appraisal to determine if the study were valid or not.

Reference

[1] http://medicalevidence.blogspot.com/2012/10/a-centrum-day-keeps-cancer-at-bay.html accessed 10/25/12.

[2] Gaziano JM et al. Multivitamins in the Prevention of Cancer in Men The Physicians’ Health Study II Randomized Controlled Trial. JAMA. 2012;308(18):doi:10.1001/jama.2012.14641.

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Interesting Comparative Effectiveness Research (CER) Case Study: “Real World Data” Hypothetical Migraine Case and Lack of PCORI Endorsement

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Interesting Comparative Effectiveness Research (CER) Case Study: “Real World Data” Hypothetical Migraine Case and Lack of PCORI Endorsement

In the October issue of Health Affairs, the journal’s editorial team created a fictional set of clinical trials and observational studies to see what various stakeholders would say about comparative effectiveness evidence of two migraine drugs.[1]

The hypothetical set-up is this:

The newest drug, Hemikrane, is an FDA-approved drug that has recently come on the market. It was reported in clinical trials to reduce both the frequency and the severity of migraine headaches. Hemikrane is taken once a week. The FDA approved Hemikrane based on two randomized, double-blind, controlled clinical trials, each of which had three arms.

  • In one arm, patients who experienced multiple migraine episodes each month took Hemikrane weekly.
  • In another arm, a comparable group of patients received a different migraine drug, Cephalal, a drug which was reported to be effective in earlier, valid studies. It is taken daily.
  • In a third arm, another equivalent group of patients received placebos.

The study was powered to find a difference between Hemikrane and placebo if there was one and if it were at least as effective as Cephalal. Each of the two randomized studies enrolled approximately 2,000 patients and lasted six months. They excluded patients with uncontrolled high blood pressure, diabetes, heart disease, or kidney dysfunction. The patients received their care in a number of academic centers and clinical trial sites. All patients submitted daily diaries, recording their migraine symptoms and any side effects.

Hypothetical Case Study Findings: The trials reported that the patients who took Hemikrane had a clinically significant reduction in the frequency, severity, and duration of headaches compared to placebo, but not to Cephalal.

The trials were not designed to evaluate the comparative safety of the drugs, but there were no safety signals from the Hemikrane patients, although a small number of patients on the drug experienced nausea.

Although the above studies reported efficacy of Hemikrane in a controlled environment with highly selected patients, they did not assess patient experience in a real-world setting. Does once weekly dosing improve adherence in the real world? The monthly cost of Hemikrane to insurers is $200, whereas Cephalal costs insurers $150 per month. (In this hypothetical example, the authors assume that copayments paid by patients are the same for all of these drugs.)

A major philanthropic organization with an interest in advancing treatments for migraine sufferers funded a collaboration among researchers at Harvard; a regional health insurance company, Trident Health; and, Hemikrane’s manufacturer, Aesculapion. The insurance company, Trident Health, provided access to a database of five million people, which included information on medication use, doctor visits, emergency department evaluations and hospitalizations. Using these records, the study identified a cohort of patients with migraine who made frequent visits to doctors or hospital emergency departments. The study compared information about patients receiving Hemikrane with two comparison groups: a group of patients who received the daily prophylactic regimen with Cephalal, and a group of patients receiving no prophylactic therapy.

The investigators attempted to confirm the original randomized trial results by assessing the frequency with which all patients in the study had migraine headaches. Because the database did not contain a diary of daily symptoms, which had been collected in the trials, the researchers substituted as a proxy the amount of medications such as codeine and sumatriptan (Imitrex) that patients had used each month for treatment of acute migraines. The group receiving Hemikrane had lower use of these symptom-oriented medications than those on Cephalal or on no prophylaxis and had fewer emergency department visits than those taking Cephalal or on no prophylaxis.

Although the medication costs were higher for patients taking Hemikrane because of its higher monthly drug cost, the overall episode-of-care costs were lower than for the comparison group taking Cephalal. As hypothesized, the medication adherence was higher in the once-weekly Hemikrane patients than in the daily Cephalal patients (80 percent and 50 percent, respectively, using the metric of medication possession ratio, which is the number of days of medication dispensed as a percentage of 365 days).

The investigators were concerned that the above findings might be due to the unique characteristics of Trident Health’s population of covered patients, regional practice patterns, copayment designs for medications, and/or the study’s analytic approach. They also worried that the results could be confounded by differences in the patients receiving Hemikrane, Cephalal, or no prophylaxis. One possibility, for example, was that patients who experienced the worst migraines might be more inclined to take or be encouraged by their doctors to take the new drug, Hemikrane, since they had failed all previously available therapies. In that case, the results for a truly matched group of patients might have shown even more pronounced benefit for Hemikrane.

To see if the findings could be replicated, the investigators contacted the pharmacy benefit management company, BestScripts, that worked withTrident Health, and asked for access to additional data. A research protocol was developed before any data were examined. Statistical adjustments were also made to balance the three groups of patients to be studied as well as possible—those taking Hemikrane, those taking Cephalal, and those not on prophylaxis—using a propensity score method (which included age, sex, number of previous migraine emergency department visits, type and extent of prior medication use and selected comorbidities to estimate the probability of a person’s being in one of the three groups) to balance the groups.

The pharmacy benefit manager, BestScripts, had access to data covering more than fifty million lives. The findings in this second, much larger, database corroborated the earlier assessment. The once-weekly prophylactic therapy with Hemikrane clearly reduced the use of medications such as codeine to relieve symptoms, as well as emergency department visits compared to the daily prophylaxis and no prophylaxis groups. Similarly, the Hemikrane group had significantly better medication adherence than the Cephalal group. In addition, BestScripts had data from a subset of employers that collected work loss information about their employees. These data showed that patients on Hemikrane were out of work for fewer days each month than patients taking Cephalal.

In a commentary, Joe Selby, executive director of the Patient-Centered Outcomes Research Institute (PCORI), and colleagues provided a list of problems with these real world studies including threats to validity. They conclude that these hypothetical studies would be unlikely to have been funded or communicated by PCORI.[2]

Below are several of the problems identified by Selby et al.

  • Selection Bias
    • Patients and clinicians may have tried the more familiar, less costly Cephalal first and switched to Hemikrane only if Cephalal failed to relieve symptoms, making the Hemikrane patients a group, who on average, would be more difficult to treat.
    • Those patients who continued using Cephalal may be a selected group who tolerate the treatment well and perceived a benefit.
    • Even if the investigators had conducted the study with only new users, it is plausible that patients prescribed Hemikrane could differ from those prescribed Cephalal. They may be of higher socioeconomic status, have better insurance coverage with lower copayments, have different physicians, or differ in other ways that could affect outcomes.
  • Performance Biases or Other Differences Between Groups is possible.
  • Details of any between-group differences found in these exploratory analyses should have been presented.

Delfini Comment

These two articles are worth reading if you are interested in the difficult area of evaluating observational studies and including them in comparative effectiveness research (CER). We would add that to know if drugs really work, valid RCTs are almost always needed. In this case we don’t know if the studies were valid, because we don’t have enough information about the risk of selection, performance, attrition and assessment bias and other potential methodological problems in the studies. Database studies and other observational studies are likely to have differences in populations, interventions, comparisons, time treated and clinical settings (e.g., prognostic variables of subjects, dosing, co-interventions, other patient choices, bias from lack of blinding) and adjusting for all of these variables and more requires many assumptions. Propensity scores do not reliably adjust for differences. Thus, the risk of bias in the evidence base is unclear.

This case illustrates the difficulty of making coverage decisions for new drugs with some potential advantages for some patients when several studies report benefit compared to placebo, but we already have established treatment agents with safety records. In addition new drugs frequently are found to cause adverse events over time.

Observational data is frequently very valuable. It can be useful in identifying populations for further study, evaluating the implementation of interventions, generating hypotheses, and identifying current condition scenarios (e.g., who, what, where in QI project work; variation, etc.). It is also useful in providing safety signals and for creating economic projections (e.g., balance sheets, models). In this hypothetical set of studies, however, we have only gray zone evidence about efficacy from both RCTs and observational studies and almost no information about safety.

Much of the October issue of Health Affairs is taken up with other readers’ comments. Those of you interested in the problems with real world data in CER activities will enjoy reading how others reacted to these hypothetical drug studies.

References

1. Dentzer S; the Editorial Team of Health Affairs. Communicating About Comparative Effectiveness Research: A Health Affairs Symposium On The Issues. Health Aff (Millwood). 2012 Oct;31(10):2183-2187. PubMed PMID: 23048094.

2. Selby JV, Fleurence R, Lauer M, Schneeweiss S. Reviewing Hypothetical Migraine Studies Using Funding Criteria From The Patient-Centered Outcomes Research Institute. Health Aff (Millwood). 2012 Oct;31(10):2193-2199. PubMed PMID: 23048096.

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The Elephant is The Evidence—Epidural Steroids

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The Elephant is The Evidence—Epidural Steroids: Edited & Updated 1/7/2013

Epidural steroids are commonly used to treat sciatica (pinched spinal nerve) or low back pain.  As of January 7, 2013 at least 40 deaths have been linked to fungal meningitis thought to be caused by contaminated epidural steroids, and 664 cases in 19 states have been identified with a clinical picture consistent with fungal infection [CDC]. Interim data show that all infected patients received injection with preservative-free methylprednisolone acetate (80mg/ml) prepared by New England Compounding Center, located in Framingham, MA. On October 3, 2012, the compounding center ceased all production and initiated recall of all methylprednisolone acetate and other drug products prepared for intrathecal administration.

Thousands of patients receive epidural steroids without significant side effects or problems every week. In this case, patients received steroids that were mixed by a “compounding pharmacy” and contamination of the medication appears to have occurred during manufacture. But let’s consider other patients who received epidural steroids from uncontaminated vials. How much risk and benefit are there with epidural steroids? The real issue is the effectiveness of epidural steroids. Yes, there are risks with epidural steroids beyond contamination—e.g., a type of headache that occurs when the dura (the sac around the spinal cord) is punctured and fluid leaks out. This causes a pressure change in the central nervous system and a headache. Bleeding is also a risk. But people with severe pain from sciatica are frequently willing to take those risks if there are likely to be benefits. But, in fact, for many patients who receive epidural steroids the likelihood of benefit is very low. For example, patients with bone problems (spinal stenosis) rather than lumbar disc disease are less likely to benefit. Patients who have had a long history of sciatica are less likely to benefit.

We don’t know how many of these patients were not likely to benefit from the epidural steroids, but if the infected patients had been advised about the unproven benefits of epidural steroids in certain cases and the known risks, some patients may have chosen to avoid the injections and possibly be alive today.  This is an example of the importance of good information as the basis for decision-making. Basing decisions on poor quality or incomplete information and intervening with unproven—yet potentially risky treatments puts millions of people at risk every week.

Let’s look at the evidence. Recently, a fairly large, well-conducted RCT published in the British Medical Journal (BMJ) reported that there is no meaningful benefit from epidural steroid injections in patients who have had long term (26 to 57 weeks) of sciatica [Iverson].  As pointed out in an editorial, epidural steroids have been used for more than 50 years to treat low back pain and sciatica and are the most common intervention in pain clinics throughout the world [Cohen]. And yet, despite their widespread use, their efficacy for the treatment of chronic sciatica remains unproven. (We should add here that many times lacking good evidence of benefit does not mean a treatment does not work.) Iverson et al conclude that, “Caudal epidural steroid or saline injections are not recommended for chronic lumbar radiculopathy [Iverson].”

Of more than 30 controlled studies evaluating epidural steroid injections, approximately half report some benefit. Systematic reviews also report conflicting results. Reasons for these discrepancies include differences in study quality, treatments, comparisons, co-interventions, study duration and patient selection. Results appear to be better for people with short term sciatica, but improvement should not be considered to be curative with epidural steroids. In this situation, it is very important that patients understand this fuzzy benefit-to-risk ratio. For many who are completely informed, the decision will be to avoid the risk.

With this recent problem of fungal meningitis from epidural steroids, it is important for patients to be informed about the world of uncertainty that surrounds risk, especially when science tells us that the evidence for benefit is not strong.  Since health care professionals frequently act as the eyes of the patient, we must seriously consider for every intervention we offer whether benefits clearly outweigh potential harms—and we must help patients understand details regarding the risks and benefits and be supportive when patients are “on the fence” about having a procedure. Remember Vioxx, arthroscopic lavage, vertebroplasy, encainide and flecainide, Darvon and countless other promising new drugs and other interventions? They seemed promising, but harms outweighed benefits for many patients.

References

1. http://www.cdc.gov/HAI/outbreaks/meningitis.html accessed 12/10/12

2.  Cohen SP. Epidural steroid injections for low back pain. BMJ. 2011 Sep 13;343:d5310. doi: 10.1136/bmj.d5310. PubMed PMID: 21914757.

3.  Iversen T, Solberg TK, Romner B, et al.   Effect of caudal epidural steroid or saline injection  in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial. BMJ. 2011 Sep 13;343:d5278. doi: 10.1136/bmj.d5278. PubMed PMID: 21914755.

 

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5 “A”s of Evidence-based Medicine & PICOTS: Using “Population, Intervention, Comparison, Outcomes, Timing, Setting” (PICOTS) In Evidence-Based Quality Improvement Work

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5 “A”s of Evidence-based Medicine & PICOTS: Using “Population, Intervention, Comparison, Outcomes, Timing, Setting” (PICOTS) In Evidence-Based Quality Improvement Work

Much of what we do when answering key clinical questions can be summarized using the 5 “A” EBM Framework—Ask, Acquire, Appraise, Apply and “A”s Again.[1] Key clinical questions create the focus for the work and, once created, drive the work or project. In other words, the 5 “A”s form a scaffolding for us to use in doing EB quality improvement work of many types.

When healthcare professionals look to the medical literature for answers to various clinical questions or when planning comparative reviews, they frequently utilize checklists which employ the mnemonics, PICO (population, intervention, comparison, outcome)[2], PICOTS (same as PICO with the addition of timing and setting) or less frequently PICOT-SD (which also includes study design.[3]  PICOTS (patient population, intervention, comparison, outcomes, timing and setting) is a checklist that can remind us of important considerations in all of the 5 “A” areas.

PICOTS in Forming Key Clinical Questions and Searching

PICOTS is a useful framework for constructing key questions, but should be applied thoughtfully, because at times all PICOTS elements are not needed to construct a useful clinical question. For example, if I am interested in the evidence regarding prevention of venous thromboembolism in hip replacement surgery, I would want to include the population and study design and perhaps key outcomes, but I would not want to limit the question to any specific interventions in case there are some useful interventions of which I am not aware. So the question might be, “What is the evidence that thromboembolism or deep vein thrombosis (DVT) prophylaxis with various agents reduces mortality and clinically significant morbidity in hip replacement surgery?” In this case, I was somewhat specific about P (the patient population—which frequently is the condition of interest—in this case, patients undergoing  hip replacement surgery), less specific about O (mortality and morbidities) and not specific about I and C.

I could be even more specific about P if I specified patients at average risk for VTE or only patients at increased risk. If I were interested in the evidence about the effect of glycemic control on important outcomes in type II diabetes, I might pose the question as, “What is the effect of tight glycemic control on various outcomes,” and type in the terms “type 2 diabetes” AND “tight glycemic control” which would not limit the search to studies reporting outcomes of which I was unaware.

Learners are frequently taught to use PICO when developing search strategies. (When actually conducting a search, we use “condition” and not “population” because the condition is more likely to activate the MeSH headings in PubMed which produces a search with key synonyms.) As illustrated above, the PICO elements chosen for the search should frequently be limited to P (the patient population or condition) and I so as to capture all outcomes that have been studied. Therefore, it is important to remember that many of your searches are best done with using only one or two elements and using SD limits such as for clinical trials in order to increase the sensitivity of your search.

PICOTS in Assessing Studies for Validity and Synthesizing Evidence

When critically appraising studies for reliability or synthesizing evidence from multiple studies, PICOTS reminds us of the areas where heterogeneity is likely to be found. PICOTS is also useful in comparing the relevance of the evidence to our population of interest (external validity) and in creating decision support for various target groups.

PICOTS in Documenting Work

Transparency can be made easier by using PICOTS when documenting our work. You will notice that many tables found in systematic reviews and meta-analyses include PICOTS elements.

References

1. Modified by Delfini Group, LLC (www.delfini.org) from Leung GM. Evidence-based practice revisited. Asia Pac J Public Health. 2001;13(2):116-21. Review. PubMed PMID: 12597509.

2. Richardson WS, Wilson MC, Nishikawa J, Hayward RS. The well-built clinical question: a key to evidence-based decisions. ACP J Club. 1995;123:A12–3.

3. Methods Guide for Effectiveness and Comparative Effectiveness Reviews. AHRQ Publication No. 10(12)-EHC063-EF. Rockville, MD: Agency for Healthcare Research and Quality. April 2012. Chapters available at: www.effectivehealthcare.ahrq.gov.

 

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A Performance Measure for Overuse? The Loosening Of Tight Control In Diabetes

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A Performance Measure for Overuse?  The Loosening Of Tight Control In Diabetes

Performance measures for tighter glycemic control appeared following the DCCT trial (Type 1 diabetes) in 1993 and the UKPDS trial (type 2 diabetes) in 1998.[1],[2] About 7 years ago groups recommended that glycohemoglobin concentrations be less than 7%, even though clear evidence of improved net outcomes was lacking.[3]

Now in an editorial in the online version of Archives of Internal Medicine, Pogach and Aron have nicely summarized details of this journey into overuse of hypoglycemic agents resulting in the problem of harms probably outweighing benefits—at least for some diabetics—in an editorial entitled, The Other Side of Quality Improvement in Diabetes for Seniors: A Proposal for an Overtreatment Glycemic Measure.[4]

The authors review the ACCORD, ADVANCE and VADT trials and remind readers that tight glycemic control did not yield cardiovascular benefits in these trials and that severe hypoglycemia occurred in the intensive treatment groups of all three trials. Of concern was the finding that ACCORD was terminated early because of increased mortality in the intensive glycemic treatment group. These trials appear to have increased concern about the risks of severe hypoglycemia in elderly patients and patients with existing cardiovascular disease, and the National Committee for Quality Assurance Healthcare Effectiveness Data and Information Set (HEDIS) modified its glycohemoglobin goal to less than 7% for persons younger than 65 years without cardiovascular disease or end-stage complications and diabetes and established a new, more relaxed goal of less than 8% for persons 65 to 74 years of age.

Kirsh and Aron took this a step further in 2011 and proposed a glycohemoglobin concentration of less than 7.0% as a threshold measure of potential overtreatment of hyperglycemia in  persons older than 65 years who are at high risk for hypoglycemia. They point out that the risk for hypoglycemia could be assessed by utilizing data from the electronic medical record regarding prescriptions for insulin and/or sulfonylurea medications and retrieving information on comorbidities such as chronic kidney disease, cognitive impairment or dementia, neurologic conditions that may interfere with a successful response to a hypoglycemic event.[5]

This commentary is worth reading and thinking about. We agree with them that the time has come to take more actions to prevent the risk of possible overtreatment in diabetes.


[1] The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Engl J Med. 1993 Sep 30;329(14):977-86. PubMed PMID: 8366922.

[2]  Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998 Sep 12;352(9131):854-65. Erratum in: Lancet 1998 Nov 7;352(9139):1558. PubMed PMID: 9742977.

 [3]  Pogach L, Aron DC. Sudden acceleration of diabetes quality measures. JAMA. 2011 Feb 16;305(7):709-10. PubMed PMID: 21325188.

[4] Published Online: September 10, 2012. doi:10.1001/archinternmed.2012.4392.

[5]  Kirsh SR, Aron DC. Choosing targets for glycaemia, blood pressure and low-density lipoprotein cholesterol in elderly individuals with diabetes mellitus. Drugs Aging. 2011 Dec 1;28(12):945-60. doi: 10.2165/11594750-000000000-00000. PubMed PMID: 22117094.

 

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Best Care at Lower Cost: The Path to Continuously Learning Health Care in America

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Best Care at Lower Cost: The Path to Continuously Learning Health Care in America

“If home building were like health care, carpenters, electricians, and plumbers each would work with different blueprints, with very little coordination.”

“If airline travel were like health care, each pilot would be free to design his or her own preflight safety check, or not to perform one at all.”

The Institute of Medicine (IOM) has just released this latest “state of our health care” report which is well worth reading. [1]  We have a long ways to go before we have a health system. The report, released September 6, 2012, concludes that our dysfunctional health care system wastes about $760 billion each year. Much of the waste is due to inefficiencies and administrative duplications, but $210 billion of the waste is due to unnecessary services (e.g., overuse, unnecessary choice of higher cost services) and $55 billion is wasted on missed primary, secondary and tertiary prevention opportunities.

Here are just a few of the interesting points and recommendations the 18 authors make:

  • The volume of the biomedical and clinical knowledge base has rapidly expanded, with research publications having risen from more than 200,000 a year in 1970 to more than 750,000 in 2010;
  • We can achieve striking improvements in safety, quality, reliability, and value through the use of systematic evidence-based process improvement methods;
  • We need digital platforms supporting real-time access to knowledge;
  • We need to  engage empowered patients;
  • We need full transparency in all we do;
  • We need improved decision support; improved patient-centered care through tools that deliver reliable, current clinical knowledge to the point of care; and, organizations’ support for, and adoption of, incentives that encourage the use of these tools.

The pre-publication issue of this IOM report is currently available free of charge at this URL.[2]


[1] Smith M, Cassell G, Ferguson B, Jones C, Redberg R; Institute of Medicine of the National Academies. Best care at lower cost: the path to continuously learning health care in America. http://iom.edu/Activities/Quality/LearningHealthCare/2012- SEP-06.aspx.

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Divulging Information to Patients With Poor Prognoses

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Divulging Information to Patients With Poor Prognoses

We have seen several instances where our colleagues’ families have been given very little prognostic information by their physicians in situations where important decisions involving benefits versus harms, quality of life and other end of life decisions must be made. In both cases when a clinician in the family presented the evidence and prognostic information, decisions were altered.

We were happy to see a review of this topic by Mack and Smith in a recent issue of the BMJ.[1] In a nutshell the authors point out that—

  • Evidence consistently shows that healthcare professionals are hesitant to divulge prognostic information due to several underlying misconceptions. Examples of misconceptions—
    • Prognostic information will make patients depressed
    • It will take away hope
    • We can’t be sure of the patient’s prognosis anyway
    • Discussions about prognosis are uncomfortable
  • Many patients are denied discussion about code status, advance medical directives, or even hospice until there are no more treatments to give  and little time left for the patient
  • Many patients lose important  time with their families and and spend more time in the hospital and in intensive care units than would be if prognostic information had been provided and different decisions had been made.

Patients and families want prognostic information which is required to make decisions that are right for them. This together with the lack of evidence that discussing prognosis causes depression, shortens life, or takes away hope and the huge problem of unnecessary interventions at the end of life creates a strong argument for honest communication about poor prognoses.

Reference

1. Mack JW, Smith TJ. Reasons why physicians do not have discussions about poor prognosis, why it matters, and what can be improved. J Clin Oncol. 2012 Aug 1;30(22):2715-7. Epub 2012 Jul 2. PubMed PMID: 22753911.

 

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