Comparative Effectiveness Research
by Tom aka Rusty Rustbelt
Comparative Effectiveness Research (CER) may have inadvertently lost credibility even before health care reform is actually launched.
CER is the darling of the government-dominated health reform movement (not a government take-over, to be clear). The use of evidence-based medicine when combined with cost-benefit analysis has the potential to save a great deal of money while better serving the patients. Many see downsides though; too rigid protocols and interference with physician judgment, or the dirty “R” word, rationing.
The U.S. Preventive Services Task Force recently released a study on various breast cancer screening modalities, recommending more limited screening protocols, particularly delaying routine mammography until age 50 (except in women with unusual risk factors).
Kah – boom!
USPSTF points out film mammography does cut mortality, with the greatest reductions in women over 50, with the best results in the age 60 – 69 cohort. Film mammography does carry a risk of false positives and the pain and inconvenience of unnecessary biopsies.
USPSTF also recommends ceasing mammography on women over 74, citing a lack of reliable evidence of reduced mortality.
There was a huge backlash from women, physicians, cancer activists and some health care associations.
USPSTF also recommends against teaching women to perform ”breast self-exam” (BSE) which has been a standard tool for decades. More backlash.
USPSTF does point out that digital and MRI mammography do not show, at this time, significant improvement over film mammography, but do have greater costs.
None of the conclusion appear to have been made on strong and startling statistics, but on think pros and cons, as one might expect from quants and scientists.
Women apparently want a little less quantitative analysis and a lot more consideration.
cross-posted at Health care think tank
This is just Comparative-Effectiveness Research, which ~~left out the issue of cost.~~
Cost-Effectiveness Research is therefore dead.
I suspect that the base problem is that most American believe more medicine is better medicine. Also they falling victim to one of the biases of Behavioral Economics fall victim to the anecdote, the one person who was saved by the exam, versus the many false positivies.
Fearful people are afraid.
Teach people to be utterly paranoid and they will do all sorts of crazy things. Shocking.
Anything less than a mammogram a day is dangerous……
Cost effectiveness is surely complex. Comparative treatments and costs in currently psychology plays out in politics aroung PTSD, for instance. We should check on experiences in Britain for instance.
What has been missing from all reports of the mammogram advisatory is the conclusion that yearly x-rays for women ages 40 to 50 will cause about the same number of cases of breast cancer as it cures. The reasoning behind seems to be that they don’t want to scare older women into stopping their regular exams.
The obvious conclusion is that the advice from such studies is not for the general public filtered through our disfunctional media but for medical professionals.
I heard NPR’s self-appointed morality lecturer go to town on this one. How terrible that anybody would take cost into account when deciding whether one woman lives or dies. Except that, unlike what is suggested by the rhetoric of the moralists comment, doctors don’t pick a woman out of a crowd and say, “time to die”.
Now, the problem that goes unadressed is that whatever resources are spent on mammographies become unavailable for other uses. In this case, the uses are very likely to be medical. So while moralists want the question to be whether we are willing for one woman to die, it really comes down to whether we increase the odds that cancer in one woman will go undetected, against decreasing the odds that somebody will suffer some other ailment and perhaps death. This is a fight over who gets the resources, not over whether we spend the resources.
It is no surprise that advocates of spending more to deal with breast cancer are unwilling to allow less resources to be spent on one aspect of breast cancer – finding it. It is no surprise that advocates have tried to stir up visions of a real woman – living and suffering an unnecessary death. Nobody that I know of has been low-minded enough to dream up a hypothetical liver cancer victim (or whatever) as a counter to the hypothetical breast cancer victim. I don’t know whether to be happy about that. But I do know that we need more quantitative analysis and less fear-mongering to make this come out right.
So far the private insurers seem to think the mammograms are cost effective.
(At a recent conference we were told that the big three cost busters are 1) neonatology 2) oncology and 3) diabetes.)
The cost of mammograms has beencoming down, the cost of treating 2nd, 3rd, and 4th stage cancers is very pricey.
“CER is the darling of the government-dominated health reform movement (not a government take-over, to be clear).”
Err, who says that the health reform movement — if it actually exists –, is dominated by government?
“The use of evidence-based medicine when combined with cost-benefit analysis has the potential to save a great deal of money while better serving the patients. Many see downsides though; too rigid protocols and interference with physician judgment, or the dirty “R” word, rationing.”
All of these are scare tactics. They are possible dangers, but that is not an argument against evidence based medicine. Besides, we already have evidence based medicine. We call it “medicine”. 😉
Interesting thing about protocols. When protocols have been shown to rival physician judgement, doctors can make use of them to improve their judgement. It is not an either/or. Medicine is both art and science. Improving the science does not diminish the art, it improves it.
PLaying with stats is another approach.
http://www.truthout.org/1125091
You will have to link to something to make this claim. I havde not ever run across it.
Besides, we already have evidence based medicine. We call it “medicine”. 😉
Dont be so sure about that Min. I work in health care and I see a lot of mythology and anecdotal stories still driving a lot of decision making. Many of the decisions are over rather trivial inexpensive matters, some……………………..not so much.
The American Recovery and Reinvestment Act of 2009 created the Federal Coordinating Council for Comparative Effectiveness Research to coordinate comparative effectiveness across the Federal government. The Council will specifically make recommendations for the $400 million allocated to the Office of the Secretary for CER.
kharris:
“But I do know that we need more quantitative analysis and less fear-mongering to make this come out right.”
This seems to be the issue right nowespecially with digital mammograms. They state that MRIs are more effective to date in detecting breast cancer. Again, more expensive.