If we can't even agree that it is unwise to avoid spending money on BOTH
treatments that are proven to be useless AND treatments whose benefit is
unproven (I was, of course, aware of the distinction), then there is
little hope indeed that healthcare prices will eventually drop.
While some treatments that are harmful/useless/unproven ON AVERAGE have a
benefit for some subgroup or individual, this must be backed up by
evidence. Claiming that 'my patient is different' without evidence, in the
face of average results suggesting otherwise is akin to claiming that
averages are irrelevant. And anyone who claims that averages are
irrelevant is committed to the view that playing Russian Roulette with 5
blanks and one real bullet is the same as playing with 5 real bullets and
one blank.
--
Jeremy Howick PhD, Msc, PGCert, DipSoc, BA
MRC/ESRC Postdoctoral Fellow
Centre for Evidence-Based Medicine
University of Oxford
Oxford OX3 7LF
United Kingdom
www.cebm.net
www.primarycare.ox.ac.uk/dept_staff/jeremy-howick/
eu.wiley.com/WileyCDA/WileyTitle/productCd-140519667X,descCd-authorInfo.htm
l
www.ucl.ac.uk/sts/staff/howick
On 19/07/2011 18:02, "Joshua Fenton" <[log in to unmask]> wrote:
>To cut waste or overuse, it seems that we need better and more data on
>what
>is or is not ³proven to be useless.² Recently the Good Stewardship Group
>published Top 5 lists of commonly prescribed but ineffective interventions
>in primary care (see:
>http://archinte.ama-assn.org/cgi/content/short/archinternmed.2011.231).
>
>These are useful reminders, but I found it somewhat deflating that the
>evidence-base does not allow much longer lists to be generated. While I
>believe much of what is done each day in primary care is of dubious
>effectiveness, the argument can always be made that for this particular
>patient, an expensive test or treatment is a reasonable choice.
>
>Perhaps we need organized medicine to resurrect and embrace a new form of
>the RAND appropriateness methodology, in which specialities individually
>and collectively specify means to insure wise use of big-ticket tests or
>treatments. The methodology might generate top 20 lists of sometimes
>useful tests or treatments that are commonly used inappropriately within a
>specialty, and point out common situations of inappropriate use. The same
>groups could identify the crucial evidence holes that researchers need to
>fill.
>
>_____________________________________
>Joshua J. Fenton, MD, MPH
>Associate Editor, Evidence-based Medicine (EBM)
>Assistant Professor
>Department of Family and Community Medicine
>University of California, Davis
>4860 Y Street, Suite 2300
>Sacramento, CA 95817
>(916) 734-3164, Fax (916) 734-5641
>[log in to unmask]
>
>
>
>> G'day! I like the terminology of "proven to be useless", because it
>> reduces the danger of throwing babies out with bathwater (interventions
>> where the issue is an absence of evidence, not evidence of absence of
>> effect). Evidence of absence of effect is unfortunately not required it
>> seems for many people to brand things useless. Often it seems to me that
>> the equation can be "intervention I don't believe in + no evidence of
>> effect = useless", instead of "likely to be harmful + no evidence of
>> benefit" or "evidence of no benefit". (No comment on vertebroplasty
>>here
>> just the general point.)
>>
>> Hilda
>>
>> From: Jeremy Howick
>> <[log in to unmask]<mailto:[log in to unmask]>>
>> Reply-To: Jeremy Howick
>> <[log in to unmask]<mailto:[log in to unmask]>>
>> Date: Tue, 19 Jul 2011 11:33:27 -0400
>> To:
>>
>"[log in to unmask]<mailto:EVIDENCE-BASED-HEALTH@JISCMAI
>L.AC.UK>"
>>
><[log in to unmask]<mailto:EVIDENCE-BASED-HEALTH@JISCMAI
>L.AC.UK>>
>> Subject: Re: AW: solution to health care cost crisis: technical
>> vs.philosphical..
>>
>> Dear All,
>>
>> I have very much enjoyed reading these useful contributions. Paul
>>Glasziou
>> showed us all up by stating what should be obvious to all of us what
>> everyone signed up to this list should be fighting for: CUT OUT
>>TREATMENTS
>> THAT HAVE PROVEN TO BE USELESS. It merits restating:
>>
>> "We might do this by doing less useless things (cutting waste). For
>> example, vertebroplasty for osteoporotic fractures was costing the US
>> about $1Billion per year, but the two RCTs that used a sham control
>>showed
>> no benefit. This is just one of a very long list. We could also cut
>>costs
>> by doing the same things better - which quality improvement aims to do
>>Š.
>> Another example is Peter Pronovosts' work to reduce central line
>> infections, which saved lives and money (from less ICU time)."
>>
>> Best wishes,
>>
>> Jeremy
>>
>> --
>>
>> Jeremy Howick PhD, MSc, PGCert, DipSoc, BA
>> MRC/ESRC Postdoctoral Fellow
>> Centre for Evidence-Based Medicine
>> University of Oxford
>> Oxford OX3 7LF
>> United Kingdom
>> www.cebm.net
>> www.primarycare.ox.ac.uk/dept_staff/jeremy-howick/
>>
>>eu.wiley.com/WileyCDA/WileyTitle/productCd-140519667X,descCd-authorInfo.h
>>tml
>>
>
>
>____________________________________________
>Joshua J. Fenton, MD, MPH
>Assistant Professor
>Department of Family and Community Medicine
>University of California, Davis
>4860 Y Street, Suite 2300
>Sacramento, CA 95817
>Phone (916)734-3164; Fax (916)734-5641
>[log in to unmask]
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