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I am betting on EBM too because it is foundational to good healthcare, provides standardization and a clear trail. It is much fairer than other concepts I have encountered. I consider myself fortunate to have found this field and especially this group. It seems to me that as working by evidence becomes the way of health care other things that are sliding like needless expense will be more clearly identified ( for instance since when is a $4.00 elastic bandage worth $360.00 in a USA emergency room and a shot of Toradol worth the same?) I agree with Ben and I am particularly interested in the decision making aspects and relative biases. Neil Maskery and colleagues have some excellent papers on this area. I believe there is a lot that can be done and this group has some of the greatest minds in healthcare working on this. An area I really appreciated and respected concerning the paper Ben and Ash collaborated on was that they showed working from 2 continents and a public as well as a private healthcare system that the areas of concern transcend differences . Amy From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Djulbegovic, Benjamin Sent: 22 May 2011 10:09 AM To: [log in to unmask] Subject: Re: insolvable uncertainty and shared decision making I think that many people are betting on EBM ( or, at least hoping that EBM will come to the rescue- hence, importance of the debate such as this): yes, the resources are finite, but if 30% of all what we do is waste, then perhaps by focusing on eliminating these wasteful and inappropriately administered health care interventions, the situation can possibly be improved? A recent article in NEJM estimates that by improving quality (I.e. reducing waste by 20%), in the US alone we could save $640 billions that then can be used for other societal needs. For long time, I thought that the "waste premise" is a reasonable one. However, for the reasons explained in our JAMA piece, I doubt this premise can guide our policies (which is not to say that we should not eliminate waste when we spot it). Ultimately, the question falls back on the importance of understanding of implications of human judgements (decisions made under uncertainty) for health policies. ben On May 22, 2011, at 6:17 AM, "Rakesh Biswas" <[log in to unmask]> wrote: From: Terry Burridge <[log in to unmask]> Date: Sun, May 22, 2011 at 3:36 PM Subject: Re: insolvable uncertainty and shared decision making But how does a government/ PCT / Community decide how to spend it's money? And how do we as voters determine how much of our GNP goes on Aid; how much on armaments; how much on health etc? In the UK we vote once every four years or so. And then have to sit back whilst said government pursues whatever policies it wishes? And even when an individual patient comes with plenty of genuine evidence about the efficacy of a particular treatment, how do decisions get made over conflicting priorities? If one course of an " anti cancer" drug for one person costs £x, who decides that is money well spent? Particularly if that same sum could be used to effectively treat 30 other people? I do this exercise with my students. I invite them to decide which groups of people they will treat given a finite budget. The discussion is always interesting, touching as it inevitably must do on personal values and beliefs as much as on economics. A fascinating topic. Many thanks for raising it. Yours Terry Burridge Sent from my iPad On 22 May 2011, at 08:03, Steven Lillis <[log in to unmask]> wrote: Having lurked for years in this forum, Ash Paul's comments have finally spurred fingers to keyboard. As a clinician, researcher and being involved at governance level in funding health care, I feel Ash has clarified what is an increasing tension between the imperatives of personal health care and those of population based health care. This tension will be the focus of a very difficult conversation that governments will have with the people of many countries, where treatments will simply not be offered despite the informed consumer wanting treatment. I am a little sceptical that shared decision making or full access to clinical information represent reasonable solutions to the tension. The issue is not one of knowledge or empowering those who have historically been disempowered, the issue is access to, and ethics behind the distribution of scarce resource. Steven Lillis MBChB FRNZCGP MGP PhD On Behalf Of Rakesh Biswas Sent: Friday, 20 May 2011 3:34 a.m. To: Subject: Re: insolvable uncertainty and shared decision making Thanks Ben and Ash for this timely article on 'indication creep' in JAMA which was definitely an excellent extension of the discussion that we enjoyed in the past few months and thanks Mayer for pointing it out. On Ash's point about patient driven health care it must be recognized that health care practically can never be just patient-driven as long as there are health professionals and other stakeholders representing other equally ( if not more) vital forces that drive health care. As Maurice Bernstein from 'Bioethics International' puts it ( although i can't be sure if this was exaclty what he meant..copying it to him as well for clarification), possibly patient autonomy and 'health professional paternalism' are two sides of the same coin? What health care possibly requires is transparency in 'information flow' that can create a democratic ecosystem (which Ben seems currently resigned to accept as the only workable solution)? This may improve health outcomes in direct proportion to the heightened shared learning between all these stakeholders? :-) warm regards, rakesh On Thu, May 19, 2011 at 2:37 AM, Ash Paul <[log in to unmask]> wrote: Dear Ben and Mayer, I agree with you both that patient centred care means involving patients in shared decision-making. Infact there is a major work-stream on this topic in the NHS led by Dr Steve Laitner with Neal Maskrey from this Group having a big input into the group. As a commissioner of healthcare, I'm all for shared decision making and all for patient centred care. However, I do have qualms about patient-driven health care. Inadequately knowledgeable patients getting distorted/wrong information from the wrong sources may want healthcare but that does not automatically mean that they need it. In a finitely funded and publicly funded healthcare system like the NHS, it is very important to distinguish between healthcare needs and healthcare wants, otherwise we will end up with financial insolvency. I have written in somewhat detail about this issue in a previous email to this group. I've just been reading a financial report from the USA that at the present rate of healthcare spending, the US Medicare Hospital Fund will become bankrupt by 2024, a full 5 years earlier than originally predicted (https://www.cms.gov/ReportsTrustFunds/downloads/tr2011.pdf). Clinicians all over the world absolutely need to grasp the nettle and start spending healthcare monies rationally and with circumspect, while at the same time involving their patients in all aspects of decision-making. They are still recognised with respect by the general public as the wise stewards of healthcare resources. Because if they don't, in the face of healthcare bankruptcy, they will have politicians and faceless bureaucrats like myself telling them what to spend treatment monies on. And then they will only have themselves to blame for their fall from grace. Both Ben and I would like to express our gratitude to the members of this group, whose thoughts on these issues we have tried to distill into this JAMA article. In the article itself, we have also acknowledged the valuable contribution of this group. The JAMA article can be accessed at: http://jama.ama-assn.org/content/305/19/2005.full Regards. Ash Dr Ash Paul Medical Director NHS Bedfordshire 21 Kimbolton Road Bedford MK40 2AW Tel no: 01234897224 Email: [log in to unmask] From: "Djulbegovic, Benjamin" <[log in to unmask]> To: [log in to unmask] Sent: Wednesday, 18 May 2011, 12:38 Subject: Re: insolvable uncertainty and shared decision making Dear Mayer Thanks for reading the paper. Since, as pointed out in our article, the problems that arise from irreducible uncertainty-->inescapable errors--> unavoidable injustice belongs to a class of the problems that do not have adequate technical solutions, I indeed believe that shared decision-making (at individual AND most importantly at societal level) is probably the only way to minimize the consequences of imbalance between false positives vs. false negative decisions. It is like democracy- it is not perfect, but because we tend to understand the rules of the game ( and don't see an alternative to it), most of us embrace it. Ash may wish to add to my response best Ben On May 18, 2011, at 12:23 AM, "Mayer Brezis" <[log in to unmask]> wrote: Dear Ben: Thank you for your superb paper in the current issue of JAMA: From Efficacy to Effectiveness in the Face of Uncertainty. Indication Creep and Prevention Creep. My question to you: in the face of insolvable uncertainty, don't you think that shared decision making might be one potential solution to reduce overuse (as shown by empiric evidence – see recent BMJ discussion http://www.bmj.com/content/342/bmj.d2117.full) while respecting individual's anxious request for more – also in a more just distribution of care? Best, Mayer Mayer Brezis, MD MPH Professor of Medicine Director, Center for Clinical Quality & Safety Hadassah Hebrew University Medical Center Jerusalem, Israel Office phone 02-6777110 Cellular 050-787-4596 Fax 02-643-9730 www.hadassah.org.il/departments/quality