Information Mastery:
A Practical Approach to Evidence-Based Care
Course Directors:
Allen Shaughnessy, PharmD, MMedEd
David Slawson, MD
Tufts Health Care Institute
Tufts University School of Medicine
November 10-12, 2011
Boston, Massachusetts
Information Mastery:
A Practical Approach to Evidence-Based Care
Using “Medical Poetry” to Reduce Health
Disparities
The True Mission of Information
Mastery: Using “Medical Poetry” to
Reform Health Care
David C. Slawson
Allen F. Shaughnessy
“It’s one thing to say that we have evidence
that something works. It’s far more
important to know how well it works.”
David M. Eddy
Marwick C. JAMA 1997;278:531-2.
What are we spending?
Gross National Product
• 1940 - 5%
• 1990 - 11%
• 1998 - 14%
• 2000+ - 20%?, 25%?
How high are we willing to let it go? What
are the costs?
Newsflash: What are we spending?
“Over the past 30 years, US healthcare
expenditures have grown 2.8% per annum
faster, on average, than the rest of the economy.
If this differential continues for another 30 years,
health care expenditures will absorb 30% of the
gross domestic product – a proportion that
exceeds that of current government spending
for all purposes combined.”
- NEJM October 23, 2008
Health Care vs. Inflation

An item that cost $100 in 1945 will cost $1233
in 2030. (3%)

Health care expenditure of $100 in 1945 will
cost $141,000 in 2030. (6%)
October 6, 2010
Health Care vs. Inflation
$16,100
$14,100
$12,100
$10,100
Inflation @ 3%/year
$8,100
$6,100
$4,100
$2,100
$100
1945
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
2020
2025
2030
Health Care vs. Inflation
$16,100
$14,100
$12,100
$10,100
Inflation @ 3%/year
$8,100
Healthcare @ 6%/year
$6,100
$4,100
$2,100
$100
1945
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
2020
2025
2030
Health Care vs Inflation


Given % of total revenue in US for federal
budget and % for health care in 2010, with
current rate of growth health care, % will
exceed entire federal budget in 2030.
Unsustainable! Only 20 years!
How do we rate?
Recent WHO ratings:




Costs: We’re #1!
Overall Quality: 12th out of 13, based on 16
health indicators
BUT!!!: 25% of our population ranks way
below the rest
Who’s #1 overall?
The National Academy of Sciences. Insuring America’s Health: Principles and
Recommendations (2004). The National Academies Press. www.nap.edu
Copyright restrictions may apply.
How to effect change?
Using a “scalpel” or a “hatchet”

Value = Quality
Cost

Quality vs. cost: Can we increase one and decrease
the other?

No attempt to control excess will be successful unless
we address physicians’ decisions regarding
management.
Focus on Quality
Underuse, Overuse, and Misuse
“If we fix overuse or misuse problems, we
improve quality and reduce costs at the same
time. Overuse is ubiquitous in American
medicine . . .”
M. Chassin
Marwick C. JAMA 1997;278:531-2.
Overuse

Safely eliminate at least 20% of what we
currently do.

Practicing Evidence-Based/Outcomes-Based
Medicine can be the “scalpel”
Overuse


Money saved by not inappropriately performing Pap
smears on women who have had a hysterectomy for
benign reasons would pay for the cost of screening
the 17 million people in the US who are currently
underscreened (10 million/year unnecessary Pap
smears).
Additional savings from unnecessary yearly Pap
smears in women with consecutively normal smears.
•
•
Saraiya M et al. J Womens Health and Gend Based Med 2002;11(2):103-9
Sirovich BE et al. JAMA 2004;291:2990-93
Misuse: Antihypertensive Drug Use


JNC V (1993) Recommendations vs. actual practice
Survey of 35,000 retail pharmacies (62% of US) for 1992
and 1995:
CCBs ACEI BB* Diuretics*
1992
33% 25% 18%
16%
1995
38% 33% 11%
8%
* Recommended by JNC V guidelines
Misuse: Antihypertensive Drug Use

Diuretics should be 1st choice for most patients
•
•
•
Solid POEM performance, including quality of life
Even with type 2 diabetes, asymptomatic LVH, high CVD risk
Benicar Example
The Seventh Report of the Joint National Committee on Prevention, Detection, and
Evaluation, and Treatment of High Blood Pressure. US Department of Health and
Human Services, May 2003
Calcium Channel Blockers

Costs: One month CCB = one year of HCTZ
• 2 million prescriptions in 2001 in one large NE state, 40%
•

inappropriate (most for CCBs)
Potential to decrease costs by 1.2 billion/year in the US, increase
quality = incremental gain in Value
What’s wrong with this picture?
•
Is there really such a thing as a “free lunch?”
Fischer MA, Avorn J. Economic implications of evidence-based prescribing for hypertension. Can better
care cost less? JAMA 2004;291:1850-56
New Technology: Computer-Assisted PAP
Smear Screening/Thin Prep/HPV vaccine




Overall: cost effective, but what about upfront
costs?
Will increase in upfront cost actually lead to
increased deaths from cervical cancer? DOEs
vs POEMs
Sensitivity vs Specificity- costs of false +
Will HPV vaccine decrease deaths?
Why do some bristle at
containing costs?
Incorrect assumption that rationing = denying
beneficial treatment
• Morally-acceptable rationing focuses on marginally
beneficial services that people would not be willing
to pay for were it not for insurance-caused grabbing
a piece of the pie
Ubel PA, Goold S. Does bedside rationing violate patients’ best interests? An exploration of “moral
hazard.” Am J Med 1998;104:64-8.
Underuse

Do it right the first time — Evidence-Based Practice
Guidelines

Will it be enough?

Delivering higher quality care at a greater expense
may not result in greater value (V=Q/C)
Containing Costs:
Setting back the clock

Drug company profits: 4 months (increased 15.3% in
2002, while inflation increased 3.6%)

Administrative costs: 2 years

Defensive medicine: 10 months

Physician services: 16 months

Total: 4.5 years

Then what?
Containing Costs:
Only one choice will work

We must limit unnecessary services (or
deny care to more people)

Why is this idea so difficult?
Cutting Costs:
The Individual vs. Society

What is the role of the physician?
Screening Controversies
“In a field filled with uncertainty and doubt, the
difference between ‘when in doubt, do it’ and
when in doubt, stop’ could easily swing $100
billion a year”
-- “Clinical Decision Making: From Theory to Practice” David M. Eddy, 1996
CP
CP
CP
Time
Sackett DL, et al. Clinical Epidemiology. A Basic Science for Clinical Medicine. 2nd
ed. Boston: Little, Brown. 1994. 156.
Survival
Screening
Cancer Appears
Death
Lead Time
Survival
Symptoms
Lead Time Bias
Hazards of Inappropriate Early
Diagnosis (Disease Screening)

Incorrect diagnosis on healthy person
with harmful treatment rendered
• breast biopsy for false positive
mammogram (50% in 10 years)
E-mail mass distribution



Legs for Life:
Free Peripheral Artery Disease Screening
Do you have to stop and rest because your
legs hurt when you walk?
Do your aching legs keep you up at night?
Do you have sores on your legs that take a
long time to heal?
Population Effect
(necessary vs sufficient)

Must consider overall effect on population (diseasespecific vs all-cause mortality)
•
•
•
PSA: may decrease deaths from prostate CA
• Overall may harm more than help (quantity or quality of life)
Colon/breast CA- Less CA deaths, more CV deaths/year
compared with control
• 2/10,000/year fewer CA deaths
• 2/10,000/year more CVD deaths
Patient-specific vs population-based screening
• Need for personal decision analysis using utilities
• Wisdom vs knowledge vs information
Where is the Conflict?
Not between individuals, but
within each individual at different
times in their lives
The Choice
Two options:
1. Breast cancer screening for all women 50 - 65
Result: reduction of 7 deaths, cost $1.2M
2. Cover BMT for any woman < 65 who develop
metastatic disease
Result: reduction of 1 death, maybe; cost $1.5M
Who do we ask?
Why not do both?
Who do we ask?

A 50-year-old woman with metastatic breast
cancer?
Her family?

Her doctor?

The government, insurance board?
An asymptomatic 50-year-old woman?
A 20-year-old woman (or her parents)?



Why not do both?
The “Pass the Buck” approach
“We are in a tailspin: individual patients drive up
costs, which are passed on to other people,
who try to recover their ‘fair share’ by
overusing services when their turn comes
around.”
DM Eddy, MD, PhD
What is the Solution?
Recognize the problem!
•
Physicians must recognize that maximizing care from the
patient’s perspective puts them both in conflict with society
and, in the long-run, with themselves!
•
Learn about the benefits, harms, and costs of important
interventions
Solutions (continued)



Identify services that are overused or
underused and ask patients, not physicians, if
they are worth their costs
Incorporate what we learn into practice policies
and adhere to them (avoid misuse —
Responsibility)
Will this be possible with our tradition of
compassion for the individual patient?
“Sooner or later, one way or another, we will
have to make decisions about how we ration
our resources”
“A cost-containment strategy that is fully driven
by quality improvement goals has the greatest
chance of controlling costs while avoiding
rationing”
Where do we go from here?




Analyze practices at the level of specific
indications, e.g. mammography, other cancer
screening, BMD, others
Accept that resources are limited
Change our way of thinking from qualitative to
quantitative reasoning
Focus on populations rather than on
individuals
Where do we go (continued)

Help patients understand consequences

Ensure that measures used to judge value of
services lead to an increase in quality while
decreasing costs

For the individual practitioner:
“When in doubt, don’t”
Using POEMs as the Scalpel

POEMs can help eliminate waste in medicine and
improve distribution
• Antibiotic Over-demand/ Overprescribing
•
73% of adults with sore throat, over 60% macrolides
• Unnecessary screening? PSA, BMD, lung cancer, routine
OB US

We can use “poetry” to maintain or improve quality in
health care while keeping costs down
“We are inventing the unaffordable and
spending the unsustainable.”
-- Richard Lamm
Former Governor of Colorado
Using POEMs as a Scalpel:
Who Benefits?
For your social conscience:
•
•
Increased access to health care for the working poor
Resources available for other benefits to society
Using POEMs as a Scalpel:
Who Benefits?
For your wallet:
•
•
•
•
Reduction of wasteful expenditures on unnecessary/useless
services
Reduced cost of employee health care
Increased profits for shareholders
More money in YOUR pocket
Using POEMs as a Scalpel:
Who Wins?
Everybody Wins!
“I think it’s clear that future generations will marvel
at our capacity to invent and document effective
health services; let’s hope they will not marvel
equally at our failure to deliver access to these
services.”
Mark Chassin, MD
Marwick C. JAMA 1997;278:531-2.
“Science my have found a cure for most
evils, but it has found no remedy for the
worst of them all- the apathy of human
beings”
- Helen Keller (1880 – 1968)
“The only thing necessary for evil to
prevail is for good men to do
nothing”
Edmund Burke