Comments on: ACP: Putting effectiveness into the health care equation: Rational or rationing?

By: A Cracking Grand Rounds! // Emergiblog

A Cracking Grand Rounds! // Emergiblog — Tue, 04 Aug 2009 11:39:35 +0000

[...] This summary was written so well I’m going to use it exactly as written: Steven Weinberger, MD, FACP, ACP Deputy Executive Vice President and Senior Vice President for Medical Education and Publishing, continues his monthly column for KevinMd.com. Check out Putting Effectiveness Into the Healthcare Equation: Rational or Rationing? [...]

By: Rezmed09

Rezmed09 — Mon, 03 Aug 2009 17:32:20 +0000

What good is comparative effectiveness if it does not protect you from lawsuits. Be honest every study has numerous exclusion criterion. Every patient is different – especially when it is “me”. This is a pipe dream. We can’t even reduce antibiotic use much without patients screaming and threatening.

By: Michael Halasy

Michael Halasy — Sat, 01 Aug 2009 04:51:52 +0000

And Comparative Effectiveness data CANNOT be simply limited to procedures, interventions, devices, and medications. It also HAS to include providers. Which is why I am about to start a CE study comparing PA’s to Physicians in the ED setting on moderately complex diagnoses. We cannot see everything, as we are NOT physicians, but we can see a lot. The question to me, is, how are we doing? Who knows, the results may not shine favorably upon us.

By: Happy Hospitalist

Happy Hospitalist — Fri, 31 Jul 2009 20:47:14 +0000

This is one of the best essays I have read in a long time.

By: jimeyers

jimeyers — Fri, 31 Jul 2009 17:50:09 +0000

Dr Kirsch is right on. E.D. Physicians are well trained to know the difference between signs and symptoms requiring urgent evaluation and those better left to the internist or other specialist for workup. Knowing when to be thoughtfully patient and when patience is dangerous is part of the job. Steve a shotgun approach buries you with information you don’t need and haven’t the time to thouoghtfully consider. This approach will reslult in more patient dissatisfaction and lawyer inquiries, not less.

By: Michael Kirsch, M.D.

Michael Kirsch, M.D. — Fri, 31 Jul 2009 15:58:56 +0000

Steve,
I completely understand your point of view and the pressures that you face. Nevertheless, the ‘ER approach’ is not good medicine. There should not be a need to address all medical issues in a single visit. We don’t do this in the office. Ideally, ER pt should have a reasonable evaluation and should then follow up with an outside physician to reassess the patient and continue the evaluation, if needed. Many of the pt’s ER complaints will have resolved by then. I suspect that we agree on this philosophically, although real world pressures are interfering with medical judgment.

By: steve H

steve H — Fri, 31 Jul 2009 10:05:28 +0000

Dr Kirsch

please understand that from an ER point of view, this is the first, last and only time we will be seeing the patient. ALL their complaints must be addressed, no matter how insignificant. In my residency, we were told to treat and test every patient as if we were the only one who would ever see them, because most dont follow up, and most are noncompliant.

This does lead to a great deal of testing, million dollar workups, etc, and yes it is costly, however, the best piece of advice I ever received while in training is this ‘it is better for you to spend your patients money on testing than for them to spend yours for malpractice, real or imagined’.

Nobody has said how comparative effectiveness fits into my world, and until I get penalized for testing and ruling out the zebra, or until tort reform comes through, my practice will not change.

By: Pankaj Karan,MD

Pankaj Karan,MD — Fri, 31 Jul 2009 03:33:40 +0000

I love you article and I understand and agree with what you are saying.Problem is that that kind of braing sucking scientific arguements would fail in face of common ignorant uneducated people and unfortunately we have many of them who just want everyting but do not want to pay.I bet they cannot do the same thing when they are buying car or flatscreens TV etc.
Medical coommunity need to practice evidence based medicined and comparative strudies is one of the tool which will help us to better understand why we should use one ,not other because that is better for patient. An educated and smart pts with reasonably good IQ would want that but a moron would want whatever they think is right and has nothing to do with data or study: ME,me,meeeeee and some of the comments reflect that.

By: Michael Kirsch, M.D.

Michael Kirsch, M.D. — Fri, 31 Jul 2009 00:12:18 +0000

My ‘low hanging fruit’ metaphor meant there is a plethora of wasteful practices that could be eliminated without have to perform comparative effectiveness research. I am not referring to medical gray areas where thoughtful and knowledgable practitioners can disagree. I would target the buckshot style of ordering tests and consultants reflexively. The next time you are on hospital rounds, I am quite confident that the evaluation on every case we see could be curtailed without any clinical loss for the patient. I am sure that my own charts are not immune to this disease of medicomegaly.

By: jimeyers

jimeyers — Thu, 30 Jul 2009 23:06:31 +0000

Establishing the effectiveness of healthcare as a prerequisite to providing such care is perhaps a good idea in the abstract but, in practice, an impossible goal. Medicine historically has been evolutionary though plodding. Standards of practice have in the past and continue to develope over time. The current insistence on evidence based medicine cannot apply to the bulk of medical desicion making which is based upon habit, experience, logic, and science. It is not difficult to establish a statistical advantage to one medicine or treatment rather than another. It is simply a matter of designing the study, recruiting the participating hospitals and practitioners, recruiting the subjects, and then wait long enough for any result to be statisticcally significant. The will, money and time does not presently exist to find such support for even a significant proportion of medical practices. Retrospective studies are always suspect and it is hard to justify even such studies in quantiies large enough to subject to meta analysis. Reliable evidence doesn’t exist as a basis for most therapuetic decisions if reliability is defined as a 5% or less chance that the desired effect will have occurred on the basis of chance alone.

What is reasonable represents a coompromise between scientific fact and pure speculation. When accumulated experience suggests a different course habit should not stubbornly stand in the way while waiting for a degree of scientific and statistical certainty that we can not afford.

The large amount of “low hanging fruit” is simply a reflection of the extent to which thoughtful practice has been replaced by meaningless tests.