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Figuring out what works for US health care
Editorial
Figuring out what works for US health care As virtually any American will tell you, health care in the USA varies wildly. The care one receives, and the outcomes achieved, depend on a bewildering array of factors, not least of which is whether or not one has health insurance, and, for those who are insured, what the insurance does or does not cover. Geographic variations in treatment and the training and inclinations of individual doctors are other important influences. Add to this mix the highest level of health-care spending on the planet, and the existence of multiple formularies, guidelines, and evidence, and the result is a hodgepodge of science, ideology, politics, economics, and folklore. “Decentralised” is perhaps the kindest adjective that can be applied to it. Should this melange define 21st-century medical practice? The US Institute of Medicine (IOM) does not think so. In a recent report, Knowing What Works in Health Care: A Roadmap for the Nation, the IOM looked at how evidence is used to determine effective care. It recommends that a national clinical effectiveness effort, with the unfortunately Orwellian moniker of “The Program”, be established through a Congressional directive to the US Secretary of Health and Human Services. From the outset, it is clear that there will be enormous resistance to such a centralised effort, based in part on a historic tradition of autonomy and self-determination of medical professionals in the USA. The resistance, though, should be tempered with a cold-eyed realism: the costs of health care cannot continue to escalate indefinitely. Further, consistent standards and a rational approach to treatment ought to be valued, since these will ultimately lead to better outcomes for more patients. The devil is in the details, though. How would a national programme work? The proposed organisation would be responsible for producing unbiased, credible information about what works in health care, through the development of systematic reviews, standards of evidence, and guidelines. An advisory board, with representatives from the private sector and public services, would oversee The Program and set priorities for determining evidence-based practice. The Program would establish methodological standards and a common language for evidence, as well as assess research capacity and expand training opportunities in systematic reviews and comparative methods of www.thelancet.com Vol 371 February 2, 2008
assessing effectiveness. The principles of systematic review are clearly laid out, but the report cautions that the number of US researchers qualified to do systematic reviews is unknown, and, further, that systematic reviews do not, and should not, include recommendations. The standards that would evolve from The Program’s reviews would be expected to become those preferred by professional and consumer organisations. That streamlining would be a noble, if ambitious, goal: for example, according to the report, the National Guidelines Clearinghouse lists 471 guidelines on hypertension and 276 for stroke. What is a busy clinician, never mind an interested but non-medically educated patient, to do with all this information? The current system is clearly broken. But is a new federal programme, especially one that does not make recommendations, the answer? Doubtful. Assimilating evidence, weighing the strength of randomised trials, and assigning importance to scientific conclusions are all essentially worthless activities if patients do not have access to the high-quality care that should result, and if insurers and their surrogates, lobbyists, drug companies, and others with vested commercial interests, continue to control US health care. A national organisation whose goal is to improve clinical care and outcomes must be preceded by reform of the whole health-care system. The IOM report is a worthy plan that seems unlikely to be implemented. Nevertheless, the ideas behind it are especially important now, for one reason—Nov 4. The next presidential election will likely determine the foreseeable future of the practice of medicine in the USA. Among Democratic voters, health care is reported to be the most important issue. Thus, the Democratic candidates have made health-care reform a cornerstone of their platforms. Although all have shied away from a single-payer system, the Democrats, by contrast with their Republican rivals, who generally favour more industry-friendly reform, are focused on universal coverage. Universal coverage combined with the highest-quality, evidence-based practice would be a singular and lasting achievement for the next president. As the number of contenders in the presidential race narrows, those left standing ought to put a high priority on developing a plan of thorough reform of health care, one based on evidence, one that works—and one that works for all. ■ The Lancet
The printed journal includes an image merely for illustration
See World Report page 375
For the Institute of Medicine report see http://www.iom.edu/ CMS/3809/34261/50718.aspx
359
Figuring out what works for US health care As virtually any American will tell you, health care in the USA varies wildly. The care one receives, and the outcomes achieved, depend on a bewildering array of factors, not least of which is whether or not one has health insurance, and, for those who are insured, what the insurance does or does not cover. Geographic variations in treatment and the training and inclinations of individual doctors are other important influences. Add to this mix the highest level of health-care spending on the planet, and the existence of multiple formularies, guidelines, and evidence, and the result is a hodgepodge of science, ideology, politics, economics, and folklore. “Decentralised” is perhaps the kindest adjective that can be applied to it. Should this melange define 21st-century medical practice? The US Institute of Medicine (IOM) does not think so. In a recent report, Knowing What Works in Health Care: A Roadmap for the Nation, the IOM looked at how evidence is used to determine effective care. It recommends that a national clinical effectiveness effort, with the unfortunately Orwellian moniker of “The Program”, be established through a Congressional directive to the US Secretary of Health and Human Services. From the outset, it is clear that there will be enormous resistance to such a centralised effort, based in part on a historic tradition of autonomy and self-determination of medical professionals in the USA. The resistance, though, should be tempered with a cold-eyed realism: the costs of health care cannot continue to escalate indefinitely. Further, consistent standards and a rational approach to treatment ought to be valued, since these will ultimately lead to better outcomes for more patients. The devil is in the details, though. How would a national programme work? The proposed organisation would be responsible for producing unbiased, credible information about what works in health care, through the development of systematic reviews, standards of evidence, and guidelines. An advisory board, with representatives from the private sector and public services, would oversee The Program and set priorities for determining evidence-based practice. The Program would establish methodological standards and a common language for evidence, as well as assess research capacity and expand training opportunities in systematic reviews and comparative methods of www.thelancet.com Vol 371 February 2, 2008
assessing effectiveness. The principles of systematic review are clearly laid out, but the report cautions that the number of US researchers qualified to do systematic reviews is unknown, and, further, that systematic reviews do not, and should not, include recommendations. The standards that would evolve from The Program’s reviews would be expected to become those preferred by professional and consumer organisations. That streamlining would be a noble, if ambitious, goal: for example, according to the report, the National Guidelines Clearinghouse lists 471 guidelines on hypertension and 276 for stroke. What is a busy clinician, never mind an interested but non-medically educated patient, to do with all this information? The current system is clearly broken. But is a new federal programme, especially one that does not make recommendations, the answer? Doubtful. Assimilating evidence, weighing the strength of randomised trials, and assigning importance to scientific conclusions are all essentially worthless activities if patients do not have access to the high-quality care that should result, and if insurers and their surrogates, lobbyists, drug companies, and others with vested commercial interests, continue to control US health care. A national organisation whose goal is to improve clinical care and outcomes must be preceded by reform of the whole health-care system. The IOM report is a worthy plan that seems unlikely to be implemented. Nevertheless, the ideas behind it are especially important now, for one reason—Nov 4. The next presidential election will likely determine the foreseeable future of the practice of medicine in the USA. Among Democratic voters, health care is reported to be the most important issue. Thus, the Democratic candidates have made health-care reform a cornerstone of their platforms. Although all have shied away from a single-payer system, the Democrats, by contrast with their Republican rivals, who generally favour more industry-friendly reform, are focused on universal coverage. Universal coverage combined with the highest-quality, evidence-based practice would be a singular and lasting achievement for the next president. As the number of contenders in the presidential race narrows, those left standing ought to put a high priority on developing a plan of thorough reform of health care, one based on evidence, one that works—and one that works for all. ■ The Lancet
The printed journal includes an image merely for illustration
See World Report page 375
For the Institute of Medicine report see http://www.iom.edu/ CMS/3809/34261/50718.aspx
359