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Ben; I've been watching this discussion with interest. I think that the issue that you initially addressed (using a guideline to treat a problem even if you're not a specialist in the area) exemplifies concerns people have about guidelines: do they oversimplify or mandate care? Will people be practicing beyond their scope and potentially do harm? I am a fan of guidelines because they provide (hopefully) the shortest route to the most appropriate care. That care may not be provided by primary care physicians but by specialists. Judicious consultation of well-written CPGs combined with appropriates history and physical exms by all physicians would save money and time for the system and decrease patients' frustration. I see several patients a week who have had unneccessary CTs/MRIs/treatments ordered by generalists who don't recognize what they're seeing and incorrectly treat the patient for weeks or months. Perhaps they're treating many simple disorders correctly; I see the very expensive failures. Loree ________________________________ From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Djulbegovic, Benjamin Sent: Tuesday, September 01, 2009 7:25 AM To: [log in to unmask] Subject: Re: EBM and increasing requests for the use of consultants... Thanks, Neal The reason that I sent my e-mail at the first place is to gauge reaction of the international audience as I was not sure if the increase referral rate is characteristic of the US medicine or is seen everywhere...Based on your, Persante's and Rakesh response it appears that the trend is global...Since evidence is accumulating to show that leading cause of increasing costs in health care is ever increasing use of new technologies (including new drugs, procedures etc), which in turn is promoted by subspecialists, it stands to reason that increase in referrals is ultimately a key driver of health care costs? Now, if such practice is associated with better outcomes as you outlined, then there is probably nothing we can do about it? regards ben From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Maskrey Neal Sent: Tuesday, September 01, 2009 5:08 AM To: [log in to unmask] Subject: Re: EBM and increasing requests for the use of consultants... Thanks Ben. Certainly in general practice in the UK there's increasing reluctance to perform minor procedures occasionally. Low risk office procedures are performed increasingly rarely and people are referred on to e.g. dermatologists for minor skin procedures that in times past we'd have been happy to undertake ourselves. Of course, there evidence that expertise in major procedures - expertise defined as performing a high volume - is highly desirable ( Halm et al. , 2002 ). Whether it is treating AIDS, performing surgery on pancreatic cancer, oesophageal cancer or abdominal aortic aneurysms or managing paediatric cardiac problems, there is a median of 3.3 - 13 excess deaths per 100 cases attributed to low volume. Coronary artery bypass surgery, coronary angioplasty, carotid endarterectomy, other cancer surgery and orthopaedic procedures also have a volume - outcome relationship, but of smaller magnitude. Experience and practice, if not making perfect, is what we all ought to look for in a clinician performing procedures. The problem is that for these big things not every patient can see the doctor with the best outcomes. As Richard Smith has written in the past, 50% of doctors are below average. And for the less serious items which pretty much anyone ought to be able to do - the shift in recent years does indeed seem to have more to do with time pressures and perceptions about risk and litigation than outcomes. Best Neal Neal Maskrey. Director of Evidence Based Therapeutics National Prescribing Centre Ground Floor Building 2000 Vortex Court Enterprise Way Wavertree Technology Park Liverpool L13 1FB web: www.npc.co.uk<http://www.npc.co.uk/> and www.npci.org.uk<http://www.npci.org.uk> ________________________________ This e-mail and any files transmitted with it are confidential and are intended solely for the use of the individual or entity to whom they are addressed. If you are not the intended recipient or the individual responsible for delivering the e-mail to the intended recipient, please be advised that you have received this e-mail in error and that any use, dissemination, forwarding, printing, or copying of this e-mail is strictly prohibited. If you have received this e-mail in error, please immediately notify the HealthPartners Support Center by telephone at (952) 967-6600. You will be reimbursed for reasonable costs incurred in notifying us. HealthPartners R001.0