Strategic Solutions, Inc.

What’s Wrong with Our Health-care System? Part I 

In the year 2000, the World Health Organization ranked the United States 38th in regard to overall health care (World Health Report 2000). Whiners predictably said it was because the WHO does not like private health insurance. Yes, that’s part of the problem. Today an estimated 50 million individuals in the United States don’t have any kind of health insurance, and that rate is growing at 2 million per year, with health premiums and costs rising at 7% per year. But that doesn’t count the 15-30 million persons who are underinsured. That problem has been stated another way: 29% of people who have health insurance are not covered for catastrophic events, drugs, or even going to see a physician when they are sick.  Health costs have risen so much that they would be at the top of list for bankruptcy filings were subprime mortgages not also in crisis. At this rate within 10-20 years, the system is likely to collapse because the few people left who still might be able to afford insurance then will be in effect subsidizing the rest of us who can’t; moreover the rest of us will be so sick that by the time we arrive in the hospital we will need 10 times more work than had we been able to afford a physician visit in the first place. 

How did things get so bad? There are 4 pieces to this puzzle: evidence-based medicine; cost-effectiveness studies; infrastructure (electronic health records, etc); and health care funding. In part I of this series, we start by looking at the contributions of evidence-based medicine (EBM). 

What is EBM? Crudely, it defines what treatments and screenings work in medicine, and how well they work. More scientifically, it attempts to “rate the evidence” concerning a given procedure or treatment in series of scales using a hierarchy of different types of clinical trials or studies. The “gold standard” has always been the randomized controlled trial (RCT). In its simplest form, in this type of study, one group of patients is randomly allocated to the control drug, treatment, or procedure—whatever that may be, while the other group is allocated top to the experimental drug, treatment, or procedure. In the best design, neither the patient nor the physicians involved in the study know which group they are in. This type of design is called “double blind.” The results are then clinically and statistically analyzed by other persons not involved in the trial itself. 

Many factors also impact how well the results of the RCT are rated. For example, small numbers (typically < 20 in either group) make it harder to detect a difference in effects between the 2 groups, what we call the “effect size.” When patients or physicians know which group they are in or treating, this lack of masking or blinding can affect the outcome through a process that is termed bias. Finally, if the trial populations are not representative of more general populations, then the results of the RCT will not be applicable to more general populations. Until fairly recently, this issue was largely ignored, but is increasingly being raised as a problem. For example, if the exclusion criteria include a long list of diseases or clinical problems--hat are termed “comorbidities”--then you can imagine we will not know whether those individuals will benefit from the trial, regardless of the results. The quality of RCTs reported in the medical literature has always varied considerably. To make up for small-number RCTs, the results are often pooled in a study called a meta-analysis, which is conducted (hopefully) by investigators with no conflicts of interest. But, as many people know, the results of many of these trials have often sparked intense debate. Why? 

As we pointed out in a previous posting on statins, millions of dollars are often spent on trials with little chance of success. It’s their money you might say, so why should we be concerned? That may be so, but you’re going to pay for the results one way or another if you end up with a prescription for the drug that was tested. And those drugs can be very expensive. I’m not saying that all drug trials are like that; many are worth it, but we need to be far more selective in what trials are funded. For now, we won’t discuss problems with how RCTs are rated, but concentrate on the application of the results. Let’s use a simple treatment as an example. If you are diagnosed with a venous ulcer, the most effective treatment we know is to apply compression using a multilayer bandage. There are some contraindications to compression, primarily whether you have peripheral arterial disease, and usually a quick screening is done to know if you have that problem, too. (The test is called the ABI, and it is a ratio of the blood pressure measured at the ankle to the blood pressure at the wrist–technically the brachial artery.) So if you are diagnosed with a venous ulcer, and go visit your doctor, you would assume that 100% of the time you would be immediately prescribed compression treatment if the ABI is okay, right? Unfortunately, that’s not always the case. These were a few of the conclusions of a Canadian study carried out on venous ulcers: 

“During 1 month, 107 physicians reported having 226 patients with leg ulcers; only a few patients had had ultrasound assessment. Few physicians (16%) were confident about managing leg ulcers; 61% reported not knowing enough about wound-care products. More than 50% were unaware that compression is effective treatment for venous ulcers. Problems reported were lack of evidence-based clinical practice guidelines for leg ulcer care (82%); absence of evidence-based protocols in home-care agencies (72%); lack of access to wound-care products (69%) and wound-care centres (66%); and poor communication among health care workers (60%).” This and many other studies show that our overworked physicians don’t always know what to do. So what is the answer? 

Evidence-based clinical practice guidelines (CPGs) were developed precisely to help educate physicians and medical specialists. They started emerging in the mid nineties and have been growing more prolific every day, as one can see on the Agency for Healthcare Research and Quality (AHRQ) web pages. The problem is that not all health-care personnel are aware of them, although this number is generally rising. The other issue is that many treatments and practices have not been tested with RCTs or other kinds of clinical trials, and until they are, these treatments will remain unverified at best.  Medicare is getting in on the act too, and has a number of P4P (pay for performance) programs that are aimed at health-care providers. Essentially these programs, if they are all implemented nationwide, will force providers to comply with CPGs or lose payments; health-care providers that do well will be rewarded for their effort. How much money Medicare’s approach will save in the long run is unknown, and there are a lot of wrinkles to iron out, but it’s a good start even if it’s not perfect, because patients will get better more scientifically based treatment. The application of evidence-based medicine does promise to save lives, and help ensure that patients get the best treatment, but the major factor missing is how cost-effective treatments are. This is the subject of Part II. 

This entry was posted on Tuesday, February 12th, 2008 at 10:53 pm and is filed under General health-care. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.