EVIDENCE-BASED MEDICINE:
BRIDGING THE GAP
ROGER WISEMAN
LIBERTY HEALTH HOLDINGS
DICHOTOMY
• Autonomous doctor/patient relationship promoted
uncompromisingly
• Funders focus on FAIRNESS and EQUITY in the
allocation of healthcare resources
• Equitable access with a view to achieving optimal
clinical outcomes for patient AND population.
FALSE DICHOTOMY?
• Doctor/Patient Autonomy and Equitable Allocation are
NOT mutually exclusive
• Evidence Based Medicine principles presents an
alternative position
EVIDENCE BASED MEDICINE
• DEFINITION:
− Integration of the best available evidence from systematic
research with clinical expertise and patient values*
*Sackett, et. al., BMJ, 1996, 312: 71 - 72
EVIDENCE BASED MEDICINE
• PURPOSE OF EBM WAS TO:
− provide stronger scientific foundation for clinical work, and
− achieve consistency, effectiveness, quality and safety in
medical care.
• FROM A HEALTH FINANCING PERSPECTIVE:
− An opportunity to form a foundation for the provision of fair
and equitable distribution of limited healthcare resources.
EVIDENCE BASED MEDICINE
• DEFINITION:
− Integration of the best available evidence from systematic
research with clinical expertise and patient values*
*Sackett, et. al., BMJ, 1996, 312: 71 - 72
EVIDENCE BASED MEDICINE
• DEFINITION:
− Integration of the best available evidence from systematic
research with clinical expertise and patient values*
*Sackett, et. al., BMJ, 1996, 312: 71 - 72
A MOVEMENT IN CRISIS?
• 20 years later – the original problems have not been
resolved as intended. Particularly:
− The hidden hand of vested interest,
and
− Evidence bias
*Greenhalgh et. al., BMJ 2014; 348: g 3725
A MOVEMENT IN CRISIS?
• The hidden hand of vested interest
A MOVEMENT IN CRISIS?
EVIDENCE BIAS
A MOVEMENT IN CRISIS?
EVIDENCE BIAS – Withholding data
• Resource wastage
• Harm
A MOVEMENT IN CRISIS?
EVIDENCE BIAS – Resource wastage
A MOVEMENT IN CRISIS?
EVIDENCE BIAS – Resource wastage
“Tamiflu® shortens symptoms of influenza by half a day, but
there is no good evidence … that it reduces admissions to
hospital or complications…” *Press Release: The Cochrane Collaboration. 10 April 2014
A MOVEMENT IN CRISIS?
Tamiflu Stockpiles
• US = $ 1.3 billion
• UK = £ 0.5 billion
A MOVEMENT IN CRISIS?
EVIDENCE BIAS – Harm
Published 24 July 2014
A MOVEMENT IN CRISIS?
Marcia Angell, former NEJM editor-in-chief:
“…conflicts of interest and biases exist in virtually every field
of medicine, particularly those that rely heavily on drugs or
devices. It is simply no longer possible to believe much of the
clinical research that is published, or to rely on the judgment
of trusted physicians or authoritative medical guidelines. I
take no pleasure in this conclusion, which I reached slowly
and reluctantly over my two decades as an editor of The New
England Journal of Medicine.”
*Angell, M. 2009. Drug Companies & Doctors: A Story of Corruption. The New York Review of Books.
A MOVEMENT IN CRISIS?
• Become EBM “Fatigued”
− Explosion of information – CPDs, online access, journals –
don’t know who or what to trust
• Distorted the EBM brand
• Overemphasis of algorithmic/cook book approach
to patient care
A MOVEMENT IN CRISIS?
• In South Africa
− A multitude of EBM/clinical governance processes
− All looking at the same data
− Often come up with different conclusions and interpretations
of the data
• In some instances, access is simply managed by benefit
limits and the data is ignored
AUTHENTIC EBM
• The funding landscape in South Africa is changing
therefore there is an imperative to allocate resources
transparently and equitably.
• True evidence based medicine is central to this
attainment as we need to know*:
− Which interventions work
− Which don’t
− Which are harmful
*Chinnock, et. al., PLoS Med 2005; 2: e 107
An Example in Oncology
• Benefit structures promote exceptionalism
• Highly emotional diseases processes – often terminal.
• Simply fosters an inequity in resource allocation:
− Problem for clinical governance
− Must do due diligence
An Example in Oncology
• Is there any reason to interrogate the data differently?
Trastuzumab as adjuvant therapy for localised HER2
positive breast cancer
vs.
Adalimumab for RA and Crohn’s
disease
CONCLUSION
• EBM is central to fair and equitable resource
distribution
• Rid ourselves of exceptionalism
• Reapply our minds in terms of the way EBM is applied
and prioritise the ethical care of patients
• EBM should form the foundation of effective and
transparent clinical governance processes.
THANK YOU
ACKNOWLEDGMENTS:
MY LIBERTY HEALTH COLLEAGUES