The value of comparative effectiveness reviews is locally based

by Craig A. Umscheid, MD, MSCE

In its 2010 comparison, the Commonwealth Fund has rendered the verdict yet again: the United States leaves other nations in the dust when it comes to healthcare costs — and yet provides its residents with the worst outcomes overall. In the study, the U.S. underperformed on virtually every front in comparison to Australia, Canada, Germany, Netherlands, New Zealand, and the United Kingdom.

The new health reform law reflects one lesson its architects learned from other countries in setting aside $100 million for comparative effectiveness research. By setting out clearly the pros and cons of various treatments and procedures, such research could play an important role in helping us get better value for our healthcare dollars.

At Penn Medicine’s Center for Evidenced-Based Practice, we have experienced the value of comparative effectiveness reviews that are locally based. We research questions brought to us by doctors and nurses who are our colleagues and respond to medicine as it is practiced in our own system. We are able to use data from our own patients, which will yield results most likely to work for the population we serve. Because our results will benefit care in the very system that supports us, we can also move results quickly into practice.

In our four-year history, our doctors and nurses have asked us to resolve some profoundly important questions: Which skin antiseptic is the best for preventing infections from surgery? Is counseling as effective as medications for the treatment of insomnia? What’s the best way to prevent deadly blood clots from forming in the legs and lungs?

For decades, doctors have used betadine, that yellow-colored skin wash, to clean the skin before surgery. But cardiac surgeons asked the Center to determine whether a newer skin wash – which was four times more expensive – was better at preventing infections.

In our review of the medical literature, we found the newer version to be at least 25 percent more effective. Now, the default choice for our doctors is the new skin wash. And here’s where the value proposition comes in. While that skin wash comes at a greater cost up front, we projected savings using our own patient data of about $300,000 per year to the hospital by reducing infections.

In this case, the most effective care is the least expensive, but only in the long run – and only if you looked at the system as a whole. The pharmacy’s cost still goes up, but Penn Medicine’s costs overall go down. High levels of trust for the Center’s work help our administrators take this holistic perspective when the pharmacy is defending their budget.

Sometimes we come up with results that vary by circumstance. When we researched a question about choices among cardiac catheterization lab imaging equipment, the answer was different for two hospitals inside our own health system. For the hospital with fewer staff, a concern for patient safety created by a mobile imaging arm requiring high staffing levels trumped the benefits of the more advanced images resulting from that mobile arm.

When our research results in a clear-cut answer, Penn Medicine hardwires the recommendations into our electronic health record system, where doctors and nurses can see it right at the patient’s bedside. For example, our review of the medical literature showed the importance of calculating the dosage of blood thinner according to a patient’s weight. Now, drop-down menus on bedside computers make that calculation automatically. As a result, we’ve had a ten percent improvement in care for patients with blood clots.

All healthcare professionals now navigate a sea of burgeoning choices – each with its own champions and adversaries. How do we know if the newest drug or procedure is the best for an individual patient?

The painful, honest answer is – we often don’t. The Institute of Medicine estimates that fewer than half of treatments given to patients are supported by good evidence. We base decisions on what we learned as housestaff, what our colleagues tell us, and what we read in journals when we have time. According to AHRQ, it takes 14 years for an evidence-based practice to become routine.

The national debate over healthcare too often focuses on costs vs. outcomes. That’s a false choice. Locally based literature reviews are a valuable tool in helping us reach the goal we must: the best care for our patients at a cost the nation can afford.

Craig A. Umscheid is the Director of Penn Medicine’s Center for Evidence-based Practice.

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  • IVF-MD

    Who foots the bill for this 100 million dollars of research? What determines who gets their hands on this money? I agree that doctors should vigilantly test out the best and most cost-effective ways to achieve desired outcomes. Taking it one step further, I would ask what is the most cost-efficient way of obtaining such information?

  • Doc D

    The Commonwealth Fund’s report has been criticized for not using objective measures of quality. The assessment was based on surveys–”perceptions” of care. All these comparisons have limitations and selective data interpretation…and patients still keep streaming to the US for care.

    Also, your projected savings from the new skin wash, are just that…projected. It remains to be seen that altering a single element of a complex set of influences on infection rates will have that impact.

    I’m not against comparative effectiveness. But, it has value as an information tool, not as a regulatory guide.

    • twicker

      Quick note on the “patients streaming to the US for care:”
      Yes, patients are, indeed, coming to Johns Hopkins, Brigham & Women’s, Duke, Mayo Clinic, etc., for care. That said, they are not, under any conceivable circumstances, streaming to Central Carolina Hospital in Sanford, NC, or Heywood Hospital in Gardner, MA — or the vast, vast majority of health centers. People from other countries “stream,” to the extent that they stream, to a small number of extremely good hospitals — and then only for the particular specialists that they want to see. Most Americans do not get to see these top practitioners, any more than the average citizen in, say, India gets to eat at the finest restaurants.

      Of note: McKinsey & Co. released a report in 2008 that calculated that fewer than 60,000 people were coming to the US for healthcare in 2007 — and a great deal more Americans were going elsewhere (references here, in Forbes, discussing people coming to America (some number less than 60k, according to the overall numbers and the percentages), and then here , for an interesting discussion about Americans leaving for other locations — with even the UCLA 2001 figures suggesting that almost 500,000 people — specifically those other than Mexicans who had settled in the US — hopped the border w/Mexico for health care.)

      So – yes, some (few) people, for whom money is not an object, come to (almost exclusively) the top centers in the US for health care. And many, many more Americans, faced with either money problems or the healthcare system as experienced by normal Americans, went elsewhere.

      A wonderful endorsement of the few top hospitals with large budgets for the best people, but not exactly a ringing endorsement of our overall system.