Evidence-based medicine and your health

In a conversation with Beth Nash, M.D. of the BMJ Publishing Group, publishers of the British Medical Journal, she outlines evidence-based medicine and how it could fit into your health care decision making.

We hear a lot about “evidence-based medicine” these days. Haven’t doctors’ decisions always been based on science?

Not always. Several cases in which research overturned longstanding practices that were just assumed to work pointed to the need for a formal, evidence-based approach. For example, for years it was believed that kids should have their tonsils removed to prevent recurrent sore throats.

But when it was properly studied, it turned out that it hurt more than it helped. A newer example is the use of estrogen replacement therapy to prevent heart disease in women after menopause. It made good sense in theory. Then the clinical trials came out and showed that it did more harm than good.

Isn’t it “cookbook medicine” to base decisions solely on research?

A treatment decision is like a three-legged stool. The first leg is the clinical evidence, the second is the doctor’s expertise, and the third is the patient’s values and preferences. Doctors need to integrate their clinical expertise and their years of experience treating patients, and you in particular, into their treatment recommendations. But at the same time, they should be receptive to questions about what the research shows.

Where do the patient’s values and preferences factor in?

Values could include religious beliefs, ethics, thoughts about living wills and advance directives, and so on. Preferences involve individual sensitivities. Some people are keen to avoid drug therapy, while others find it difficult to make lifestyle changes. Some prefer not to undergo surgery because of the potential risks. A good example of a condition where patient preference comes into play is prostate cancer, where the evidence provides no clear-cut idea of what intervention is best; surgery, radiation, and watchful waiting are all reasonable options. Women with breast cancer have similar decisions to make about mastectomy vs. lumpectomy or in some cases whether to have additional radiation or chemotherapy. You learn as much as you can about the available options, then follow your gut.

Comments

[Matthew Carroll]

I recently learned about a stunning aspect of our health care system which short changes the patient and lowers the overall level of healthcare while generating big profits for doctors.

I feel the need to share this information with as many people as possible because they can avoid the problem if they have the knowledge I am sharing with them here.

The problem is that doctors are allowed to purchase durable medical equipment, in my case a walking boot, and then bill Medicare or an insurance company for that boot. The amount they receive for the boot is fixed by Medicare, and the insurance companies all pay approximately the same amount.

What this means to the patient is that if you need a walking boot or any type of DME device, the best product on the market and the worst product on the market cost you the exact same amount. So you should never accept anything less than the best. You should do research and find the best product on the market and demand that your doctor prescribe it for you.

If you do not, you will most certainly receive a low quality product since the doctors have a strong incentive to find the cheapest boot on the market and provide it to their patients in order to maximize the profit from that product.

I did some research and learned that these boots range in cost to the doctor from as low as $40 to as high as $175. The expensive boot is more comfortable, far more stable and might offer features such as range of motion and extra liners for hygiene. The reimbursement for this category of product is around $240. So, the doctor makes a profit whether he prescribes the best or the worst product on the market. But the amount of profit for the lower quality boots is significantly higher.

Since doctors fees are under constant pressure downwards, they are all looking to profits on durable medical equipment to make up the difference. So there is a lot of pressure to compromise quality care in favor of a healthier bottom line.

The result is that patients are always being given bottom of the line products instead of top of the line products without knowing that they actually have a choice.

What's even worse is that I read some studies from Europe that early weight bearing and early physical therapy after an ankle fracture leads to shorter recovery times. But, cheap walking boots are too flimsy to allow early weight-bearing while the better boots do allow early weight-bearing. So, doctors are not just making better profits from these low quality boots, they are actually keeping patients in casts longer and lengthening recovery times unnecessarily.

I am hoping to get this published on your Blog to make patients aware that they should ask their doctor if the boot they are receiving is the best one on the market and if he or his practice is making a profit from the boot. The patient would be well advised to do some research on the internet to find the best boot on the market and then request that one. Remember the doctor makes a profit no matter what boot he gives you, and the cost is the same to the patient for the best boot and for the worst boot.