- Email: [email protected]
Times, They Are a-Changing
EURURO-5422; No. of Pages 2 EUROPEAN UROLOGY XXX (2013) XXX–XXX
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial Referring to the article published on pp. x–y of this issue
Times, They Are a-Changing Peter C. Albertsen * University of Connecticut Health Center, Farmington, CT, USA
Powerful economic forces are threatening the foundations of modern health care. Most western societies can no longer afford all the care that we physicians advocate. Recommended treatments are being questioned and limits are being placed on our ability to order diagnostic studies and treatments. We are at a critical inflection point where individual professional autonomy is giving way to multispecialty teams that include allied professionals, epidemiologists, public health officials, and government administrators. The paternalistic attitude of traditional physician knows best medicine is ceding authority to evidence-based medicine that prizes clinical research and patient-reported outcomes and experiences. These changes are occurring on both sides of the Atlantic Ocean but are evolving along different pathways and at different speeds. The goals, however, are remarkably similar. Most European countries have adopted universal health care systems. The United States provides universal health care to citizens aged 65 yr, but for younger patients relies on a private, fee-for-service system that is increasingly out of reach for many citizens. Each society is grappling with the same issues of how much health care and what types of health care should be universally provided. The United Kingdom embraced outcomes research following a House of Lords committee report in 1988 [1]. The National Health Service Research and Development Programme determined that systematic reviews of research evidence must precede any new research funding. The program favored research on effectiveness (how well a health care intervention works in practice) over efficacy (does a health care intervention work or not). The Health Technology Assessment program was established in 1993 to promote patient-centered outcomes and cost-effectiveness research [2]. The directors encouraged pragmatic rather
than explanatory studies. These efforts subsequently led to the establishment of the National Screening Committee in 1996 and the National Institute for Health Care Excellence (NICE) in 1999. Health services research in the United States can be traced back to the pioneering work of John Wennberg, a research epidemiologist at the Geisel School of Medicine at Dartmouth College. In the 1970s, he noted wide variations in the delivery of health care services in the United States and correlated this variation not with the prevalence of disease but with the availability of health care resources. His original paper was rejected by traditional medical journals and was eventually published in Science [3]. Through Wennberg’s lobbying efforts, the Agency for Health Care Policy and Research was established and a research model known as Patient Outcome Research Teams (PORTs) was organized. A PORT was composed of a multidisciplinary team of researchers and doctors who evaluated conflicting evidence of effectiveness that existed for many common treatments and tests. The PORTs also pursued another research mission that was unusual at the time: They asked patients how they felt about their symptoms and whether they experienced any side effects from different treatments. One of their primary efforts surrounded the appropriate treatment of prostate diseases. Unfortunately, the findings of these research efforts were not well received by the practicing community. A Markov model of prostate cancer treatment effectiveness, for example, was thoroughly dismissed at the time of its publication [4]. Physicians in other fields were equally upset by the challenge to their authority. Spine surgeons in the United States were particularly incensed by the PORT recommendations and lobbied Congress to eliminate the agency. A much smaller Agency for Healthcare Research and Quality emerged in 1995, but the ideas embodied by the
DOI of original article: http://dx.doi.org/10.1016/j.eururo.2013.10.017. * 263 Farmington Avenue, Farmington, CT 06070, USA. Tel. +1 860 679 3676; Fax: +1 860 679 1318. E-mail address: [email protected]. 0302-2838/$ – see back matter # 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.eururo.2013.11.043
Please cite this article in press as: Albertsen PC. Times, They Are a-Changing. Eur Urol (2013), http://dx.doi.org/10.1016/ j.eururo.2013.11.043
EURURO-5422; No. of Pages 2 2
EUROPEAN UROLOGY XXX (2013) XXX–XXX
original PORTs lived on. These ideas emerged in 2009 as part of the American Recovery and Reinvestment Act that established the Patient-centered Outcomes Research Institute. The recently enacted Affordable Care Act, frequently referred to as Obamacare, relies heavily on these ideas, encouraging physicians to do a better job helping their patients understand their treatment choices. Governments, acting as agents for patients in our society, are demanding more data concerning the clinical impact of treatment. The article by Efficace et al. in this month’s issue of European Urology reflects these new demands [5]. To inventory the quality of data available to health services researchers, the authors conducted a systematic literature review of randomized clinical trials of prostate cancer to determine how many captured data concerning patientreported outcomes. Since 2004, the quality of the medical literature has improved. Patient symptoms are now included in more than half of the clinical studies on prostate cancer. Methodologies have also improved. Key items such as the extent of missing data and the reasons for study-subject drop out are now routinely described. The authors believe that 20% of the current literature provides sufficient details to allow health policy makers and physicians to make critical appraisals of their findings. Physicians and health care researchers need to become familiar with these new standards and tools. Government contracts will demand that they are included in new proposals and journal editors will expect this information to be included in new manuscripts. These trends are both good
and necessary. Health policy makers, physicians, and patients need to understand how medical therapies impact life and whether treatments result in health care improvement at a reasonable cost. These trends are accelerating worldwide. Efficace et al. have provided us with a comprehensive template of what constitutes quality health-outcomes research. Our job is to pay attention to the details and include these metrics in future projects. Conflicts of interest: The author has nothing to disclose.
References [1] House of Lords Select Committee on Science and Technology. 3rd Report Priorities in Medical Research [HL 54-I, 54-II & 54-III]. London, UK: HM Stationery Office; 1988. [2] Department of Health. Research for health. London, UK: HM Stationery Office; 1993. [3] Wennberg J, Gittelsohn A. Small area variations in health care delivery. A population-based health information system can guide planning and regulatory decision making. Science 1973;182: 1102–8. [4] Fleming C, Wasson J, Albertsen PC, Barry M, the Prostate PORT. A decision analysis of alternative treatment for clinically localized prostate cancer. JAMA 1993;269:2650–8. [5] Efficace F, Feuerstein M, Fayers P, et al., EORTC Quality of Life Group (Patient Reported Outcome Measurements Over Time In ONcology-PROMOTION Project). Patient-reported outcomes in randomised controlled trials of prostate cancer: methodological quality and impact on clinical decision making. Eur Urol. In press. http://dx.doi.org/10.1016/j.eururo.2013.10.017
Please cite this article in press as: Albertsen PC. Times, They Are a-Changing. Eur Urol (2013), http://dx.doi.org/10.1016/ j.eururo.2013.11.043
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial Referring to the article published on pp. x–y of this issue
Times, They Are a-Changing Peter C. Albertsen * University of Connecticut Health Center, Farmington, CT, USA
Powerful economic forces are threatening the foundations of modern health care. Most western societies can no longer afford all the care that we physicians advocate. Recommended treatments are being questioned and limits are being placed on our ability to order diagnostic studies and treatments. We are at a critical inflection point where individual professional autonomy is giving way to multispecialty teams that include allied professionals, epidemiologists, public health officials, and government administrators. The paternalistic attitude of traditional physician knows best medicine is ceding authority to evidence-based medicine that prizes clinical research and patient-reported outcomes and experiences. These changes are occurring on both sides of the Atlantic Ocean but are evolving along different pathways and at different speeds. The goals, however, are remarkably similar. Most European countries have adopted universal health care systems. The United States provides universal health care to citizens aged 65 yr, but for younger patients relies on a private, fee-for-service system that is increasingly out of reach for many citizens. Each society is grappling with the same issues of how much health care and what types of health care should be universally provided. The United Kingdom embraced outcomes research following a House of Lords committee report in 1988 [1]. The National Health Service Research and Development Programme determined that systematic reviews of research evidence must precede any new research funding. The program favored research on effectiveness (how well a health care intervention works in practice) over efficacy (does a health care intervention work or not). The Health Technology Assessment program was established in 1993 to promote patient-centered outcomes and cost-effectiveness research [2]. The directors encouraged pragmatic rather
than explanatory studies. These efforts subsequently led to the establishment of the National Screening Committee in 1996 and the National Institute for Health Care Excellence (NICE) in 1999. Health services research in the United States can be traced back to the pioneering work of John Wennberg, a research epidemiologist at the Geisel School of Medicine at Dartmouth College. In the 1970s, he noted wide variations in the delivery of health care services in the United States and correlated this variation not with the prevalence of disease but with the availability of health care resources. His original paper was rejected by traditional medical journals and was eventually published in Science [3]. Through Wennberg’s lobbying efforts, the Agency for Health Care Policy and Research was established and a research model known as Patient Outcome Research Teams (PORTs) was organized. A PORT was composed of a multidisciplinary team of researchers and doctors who evaluated conflicting evidence of effectiveness that existed for many common treatments and tests. The PORTs also pursued another research mission that was unusual at the time: They asked patients how they felt about their symptoms and whether they experienced any side effects from different treatments. One of their primary efforts surrounded the appropriate treatment of prostate diseases. Unfortunately, the findings of these research efforts were not well received by the practicing community. A Markov model of prostate cancer treatment effectiveness, for example, was thoroughly dismissed at the time of its publication [4]. Physicians in other fields were equally upset by the challenge to their authority. Spine surgeons in the United States were particularly incensed by the PORT recommendations and lobbied Congress to eliminate the agency. A much smaller Agency for Healthcare Research and Quality emerged in 1995, but the ideas embodied by the
DOI of original article: http://dx.doi.org/10.1016/j.eururo.2013.10.017. * 263 Farmington Avenue, Farmington, CT 06070, USA. Tel. +1 860 679 3676; Fax: +1 860 679 1318. E-mail address: [email protected]. 0302-2838/$ – see back matter # 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.eururo.2013.11.043
Please cite this article in press as: Albertsen PC. Times, They Are a-Changing. Eur Urol (2013), http://dx.doi.org/10.1016/ j.eururo.2013.11.043
EURURO-5422; No. of Pages 2 2
EUROPEAN UROLOGY XXX (2013) XXX–XXX
original PORTs lived on. These ideas emerged in 2009 as part of the American Recovery and Reinvestment Act that established the Patient-centered Outcomes Research Institute. The recently enacted Affordable Care Act, frequently referred to as Obamacare, relies heavily on these ideas, encouraging physicians to do a better job helping their patients understand their treatment choices. Governments, acting as agents for patients in our society, are demanding more data concerning the clinical impact of treatment. The article by Efficace et al. in this month’s issue of European Urology reflects these new demands [5]. To inventory the quality of data available to health services researchers, the authors conducted a systematic literature review of randomized clinical trials of prostate cancer to determine how many captured data concerning patientreported outcomes. Since 2004, the quality of the medical literature has improved. Patient symptoms are now included in more than half of the clinical studies on prostate cancer. Methodologies have also improved. Key items such as the extent of missing data and the reasons for study-subject drop out are now routinely described. The authors believe that 20% of the current literature provides sufficient details to allow health policy makers and physicians to make critical appraisals of their findings. Physicians and health care researchers need to become familiar with these new standards and tools. Government contracts will demand that they are included in new proposals and journal editors will expect this information to be included in new manuscripts. These trends are both good
and necessary. Health policy makers, physicians, and patients need to understand how medical therapies impact life and whether treatments result in health care improvement at a reasonable cost. These trends are accelerating worldwide. Efficace et al. have provided us with a comprehensive template of what constitutes quality health-outcomes research. Our job is to pay attention to the details and include these metrics in future projects. Conflicts of interest: The author has nothing to disclose.
References [1] House of Lords Select Committee on Science and Technology. 3rd Report Priorities in Medical Research [HL 54-I, 54-II & 54-III]. London, UK: HM Stationery Office; 1988. [2] Department of Health. Research for health. London, UK: HM Stationery Office; 1993. [3] Wennberg J, Gittelsohn A. Small area variations in health care delivery. A population-based health information system can guide planning and regulatory decision making. Science 1973;182: 1102–8. [4] Fleming C, Wasson J, Albertsen PC, Barry M, the Prostate PORT. A decision analysis of alternative treatment for clinically localized prostate cancer. JAMA 1993;269:2650–8. [5] Efficace F, Feuerstein M, Fayers P, et al., EORTC Quality of Life Group (Patient Reported Outcome Measurements Over Time In ONcology-PROMOTION Project). Patient-reported outcomes in randomised controlled trials of prostate cancer: methodological quality and impact on clinical decision making. Eur Urol. In press. http://dx.doi.org/10.1016/j.eururo.2013.10.017
Please cite this article in press as: Albertsen PC. Times, They Are a-Changing. Eur Urol (2013), http://dx.doi.org/10.1016/ j.eururo.2013.11.043