From an excellent NPR story on the puzzling regional variations in health care; there are adjacent towns with similar populations in which some medical procedures are performed five times as often in one as in the other. And more procedures does not lead to better care:
A couple of years ago Keller and some colleagues did an elegant study of one kind of back surgery in Maine, a procedure called discectomy. Keller found communities in Maine that had high rates of this surgery, communities with low rates, and communities that were somewhere in the middle. Then he followed patients who had had surgery in those communities over a five-year period to see how they fared. Keller says the conclusion was undeniable.
"In the high rate of surgery overall, the patient outcomes were the least good of those three categories. In the middle rates, the outcomes of the patients were in the middle. And in the low-rate areas — less frequent operations per capita — the outcomes were the best."
The reason that areas with more back surgery did worse, Keller says, is that doctors in those areas were operating on people whose issues were less severe; that is, patients who might not have been good candidates for an operation. So the problems associated with the surgery probably outweighed the problems of their actual sickness. For them, more wasn't better.
2 comments:
I'm all for looking for these types of inefficiencies and addressing them... however - I've recently had my own negative experience with "evidence based medicine." I find myself periodically in the position of taking a medication to offset the negative results of another one. When I requested that we look into taking the first medication on some sort of cycle, and discontinuing it for a period of time when the side effects got large enough the answer I got was that "there was no evidence that that would work." I offered that I was a pretty smart adult, that the side effects were (easily) measurable, that a cycle was pretty low risk, and that I was more than willing to try the experiment and see if it would work in my case.
My recollection about the quality of the "evidence" in evidence-based medicine it is often pretty poor, since people are very variable. Sometimes the "30% reduction in risk" is from 3 people with an adverse effect down to 2 in a population of hundreds...
This all makes me pause when I contemplate a public health care option. It makes me pretty happy to think that it would allow the government to mandate things like vaccines, but less happy when I think about the prospect of treating people with "one size fits all" policies, based on "evidence" from a changing field, in which grants and enthusiasm must be mustered in order to do the research to find any "evidence" at all.
Actually there is no good evidence for or against a lot of things that doctors do. But where there is evidence, e.g. that most back surgery is unnecessary, shouldn't we try to act on it?
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