If physician decisions were based strictly on Cochrane

First, a disclosure. I am President and Board Chair of the not-for-profit Lundberg Institute in California, which is dedicated to Archie Cochrane.

What would happen if we in American healthcare actually followed the teachings of the revered Archie Cochrane? I’m sorry. You don’t know what those teachings are? … and you don’t even know who Archie Cochrane was? Oh my …

Click www.lundberginstitute.org, no registration required, and then click to Dedication. Mission, Platform, Resources, and you can learn what he and it are all about.

In 1972, Archie Cochrane of the U.K. wrote that because resources for healthcare would always be limited, they should be used for treatments that have been proven to be effective. His influential book provided strong advocacy for controlled clinical trials.

Evidence-Based Medicine (EBM), a term, best I can tell, that was first published by David Eddy in JAMA in 1990, was further defined by Sackett and colleagues of McMaster University in the BMJ as “… the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” The Cochrane Collaboration and the Cochrane Centers sprung from this inspiration.

The notion of Evidence-Informed Medicine surfaced in 2001 from Sackett’s revised statement that “Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values.”

Many studies and statements by experts say that somewhere between 25 and 40% of American medical decisions are not based on sound evidence of effectiveness. Since physician decisions drive the majority of cost of medical care, strictly applying Cochrane’s teachings would “save” the U.S. something like $700,000,000,000 to $1 trillion per year. But think about it.

Fifteen million Americans are employed in healthcare. Some four to six million would then lose their jobs, bumping the unemployment rate well into double digits.

And what would all that freed-up money be spent for? Cocaine, gasoline, gadgets, high-calorie food, taxes, porno, the Pentagon, Wall Street bonuses?

Maybe spending a lot of it on education would make sense. Or maybe medicine should just keep on spending to do its part to keep the economy going, regardless of effectiveness, as long as it is safe.

Did I say safe? Oh! But that’s another topic for another column.

George Lundberg is a MedPage Today Editor-at-Large and former editor of the Journal of the American Medical Association.

Originally published in MedPage Today. Visit MedPageToday.com for more health policy news.

Comments are moderated before they are published. Please read the comment policy.

  • http://www.BocaConciergeDoc.com Steven Reznick MD FACP

    Love your tongue in cheek approach. There is no question that treatment based on what scientific evidence demonstrates works best should be our goal. The problem is that in this society patients , newly empowered by the internet and direct to consumer advertising are free to spend more money on treatments that have no scientific backing than on treatments that do. I believe the process of promoting evidence based medicine to clinicians is as important as promoting it to the public.

  • Bill Tucker

    Being a iconoclast/contrarian by nature I love EBM–because it often disagrees with what we do (Standard of Care) every day for our Pt’s. But being a realist, I know it’s unrealistic to practice EBM in this country on any consistent basis.

  • http://fertilityfile.com IVF-MD

    Here’s one glaring fact. EBM cost-effectiveness conclusions can never profess to predict outcomes on an individual basis, only as aggregate. For example, suppose that studies show that treatment A for end-stage terminal cancer costs $500,000 per patient to administer and results in miraculous tumor regression and 20 year survival in 2% of patients. Without treatment, the disease is 99.9% fatal in 1 month. From a central-planning point of view, that’s not cost effective to implement. However, what if you want to take the opportunity to try and save your child’s life and you are willing to second-mortgage your home and burn your life savings to go after that 2% chance of hope, knowing full well that’s it’s only 2%. Would you be entitled to that right? And what if you wanted to opt out of forced taxation, ie paying your earnings into a system that would not pay for your child’s treatment based on their EBM-guided central planning? Should you then be free to pay out of pocket for the treatment instead of paying taxes? This is the fundamental moral dilemma.

  • doc99

    Link EBM & Best Practices to Liability Safe-Harbors and we’ve got a conversation.

  • http://minochahealth.typepad.com doc

    I usually find the Cochrane Database reviews to be much more reflective of the state of scientific evidence and thus reliable on any given topic. In contrast, the conclusions in numerous reviews/guidelines written by the experts in that particular field (for example cardiologist writing about cardiac issues) may (or may not) be colored by potentially conscious or subconscious bias.

Most Popular