Comparative effectiveness studies may not be accepted by patients

Comparative effectiveness is a buzzword that health reformers have been using to help curb soaring medical costs.

And it makes sense. After all, why do we need to subject patients to tests and treatments that haven’t been shown to work? Some degree of standardization of medical care is necessary.

But what if patients don’t listen?

I have mentioned several times that there is a prevailing, and false, mentality among the public that more medicine always means better care. Studies have shown that more intensive health care can lead to complications, unnecessary tests, and potentially worse patient outcomes.

But for comparative effectiveness data to change practice, patients have to buy in. And, in a recent blog post from NPR’s Shots, a patient survey isn’t promising.

In 2006, researcher David Nieman found that endurance racers – a group that’s collectively addicted to ibuprofen – saw no benefit from the over-the-counter pills during the 100-mile Western States Endurance Run, he presented his findings to participants in the next year’s race. And, contrary to their beliefs, the anti-inflammatory drug actually increased swelling for this group, he told them. Would they stop using it? “No,” was the answer.

Changing medical practice and disrupting conventional wisdom is hard — for both doctors and patients. Witness the public outrage when the USPSTF modified their breast cancer screening recommendations last year.

I wrote in USA Today that comparative effectiveness data is necessary to help doctors make the best decisions. Doctors need to buy in.

And so do patients.

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  • stargirl65

    People believe what they want. I have been told by many people that they got sick because they went outside with their hair wet. Never did they consider that a virus invaded their body and that is why they are sick.

  • http://warmsocks.wordpress.com/ WarmSocks

    Maybe the runners don’t take ibu to deal with swelling. If they take it for a different reason (pain) and find it effective, the swelling is a tolerable side effect (benefits outweigh risks).

    It’s all in the presentation. Like dealing with a two-year-old, you don’t take things from people. Not if you want them happy. You trade – make them think they’re getting a better deal. Why not tray a different approach: “X works better than ibu to relieve your symptoms. Would you like to try it instead?”

  • http://bittersweetmedicine.com/ Dr Lemmon

    Here are a couple paragraphs from Sandy Szwarc about what could go wrong with comparative effectiveness studies and a link for anyone wanting more details:

    “The ramifications are clear to medical professionals . . . The availability of health interventions that aren’t determined to be optimum, effective or consistent with national priorities will die from lack of funding. We might want to believe that this plan won’t interfere with the care that our individual doctors provide and that is will merely offer “information and guidance about best practices.” But doctors, who’ve had years of experience with Pay-for-Performance measures know the reality of third-party payer clinical guidelines.

    They are concerned that their clinical judgment and knowledge about what care might be best for their individual patients, as well as consistent with the wishes of their patients, will be replaced by the determinations of a government agency. These aren’t clinical guidelines and recommendations for medical practitioners in their care of patients — instead, like other pay-for-performance measures, they will have the force of regulation and power of law in compelling compliance. Any healthcare professional whose practice fails to comply with what the government determines is effective, quality care will find himself uncompensated, as well as demoted as a “quality provider” and vulnerable to malpractice lawsuits. Doctors won’t, can’t, risk providing care outside the line — and insurers won’t cover care that isn’t government-approved — out of fear of liability or financial demise.”

    http://junkfoodscience.blogspot.com/2009/06/comparative-effective-research-what-it.html

  • Doc99

    “… Any healthcare professional whose practice fails to comply with what the government determines is effective, quality care will find himself uncompensated, as well as demoted as a “quality provider” and vulnerable to malpractice lawsuits.”

    Actually, the reverse may be true. Unless Pay for Conformance is accompanied by limited immunity, underproviding care will result in increased liability exposure.

  • SarahW

    Dr Lemmon, that sort of outcome is not to be taken lightly.

    Discretion to treat the individual in the way a physician understands is optimal for that one patient, could be compromised. This bedrock of ethical medicine would crumble to the interests of persons more interested in effective management of a herd.

  • Egghead

    A large portion of the American population has rejected science…look at the Theory of Evolution and Climate Change.

    Doctors frequently change their recommendations. For years it was recommended that low fat was best…eggs were bad…partially hydrogenated oils were safe…

    I was told by my doctor that pregnancy cured my endometriosis.

    @Those who are on the wrong end of CER results will attack the research, or cite or fund their own to refute it.

    Like all those breast centers and radiologists that decry the USPSTF mammograpy guidelines.

  • http://www.MDWhistleblower.blogspot.com Michael Kirsch, M.D.

    I am fully in favor of comparative effectiveness research (CER), but I can’t fathom how it will become accepted and implemented. Every unnecessary medical test or treatment is someone else’s income. Those who are on the wrong end of CER results will attack the research, or cite or fund their own to refute it. This will be a very tough slog, but I think it is worth the fight.

  • http://bittersweetmedicine.com/ Dr Lemmon

    I love evidence based medicine. Just read my blog. However, in medicine the answer is often “it depends.” Exceptions to the rule are very common in medicine. Any mid-level can follow an algorithm as well as a fully trained physician. Any mid-level can check off the boxes as well as a fully trained physician. To the bean counters, those physicians (providers) who deviate from the guidelines frequently will appear to be the lowest quality providers; sometimes they will be, sometimes they will not. It depends.

  • http://drjohnm.blogspot.com/ DrJohnM

    I am with you on the comparative effectiveness research. I think it will confirm what masters of the obvious already know. Examples like: ICD guidelines which recommend implants for patients with ischemic LV dysfunction, even though the expensive device won’t really improve mortality if co-morbid conditions exist.

    Maybe–but this one is a stretch–outcomes research will finally settle the issue of not stenting asymptomatic coronary lesions. My enlightened colleagues already know this, but many “squishers” do not.

    Practical data will help us. Surely, it will.

    But I have to take issue with the example of endurance athletes. I am one, and so I know this club. If endurance athletes thought bee pollen would make them ride like Lance, they would do it, regardless of the downsides.

    Grin.

    JMM

  • http://bittersweetmedicine.com DrLemmon

    JohnM,

    A little off topic, but how would an asymptomatic coronary lesion be detected anyway? Why would a cath be done in the first place?

    Definitely for some things, CER will be great, specific situations with a clear yes or no answer. But for nuanced situations in patients with multiple problems and varying physiological ages it will not work. It will be applied in those situations anyway; but skill, experience and knowledge of the particular patient would work better.

  • BD

    >>Every unnecessary medical test or treatment is someone else’s income. Those who are on the wrong end of CER results will attack the research, or cite or fund their own to refute it. This will be a very tough slog, but I think it is worth the fight.>>

    Very well said, and so true.

    I don’t think patients are entirely to blame when it’s always possible to find an “expert” selling whatever voodoo the patient believes will help his problem.

  • http://www.drjohnm.blogspot.com DrJohnM

    A middle school field trip mandates me typing on an iPhone. Reasons for finding an asymptomatic coronary lesion? Hmm. That’s a week worth of posts.

    And I agree with the notion that skill, knowledge and experience will always be the common denominator of quality care.

    One thing I have learned from serving on peer review is the value of documenting the clinical thought process, especially when deviating from the norm.

  • ChristineWithRegence

    Exactly! When we take control of our health care decisions and research the best options, we can help control costs. Check out Whatstherealcost.org for more ideas!

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