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Feb 25

Would you believe me if I told you only 11% of patients are receiving rigorous scientifically backed evidence based treatment (at least in the case presented below)?

For argument sake let us presuppose that your overall health is half based on you doing the correct things (making healthy lifestyle choices), and half based on your doctor doing the right thing.

It is an open argument if most of us in the developed world who have the opportunity to make the correct lifestyle choices actually choose wisely - but again for argument sake and based on most of the readers of this blog are probably mostly making the wise healthy choices what about the other half of the equation - the doctor choices of the appropriate treatment for you?

According to a recent study (Tricioci et. al., 2009, published in the well respected JAMA journal) reported in the Wall Street Journal regarding heart disease treatment the numbers do not look good. Of the 2,700 heart disease patients only 11% of the patients received treatment supported by high-quality scientific evidence. About 50% of the treatments given had limited scientific backing. From the WSJ article:

The findings from the JAMA study reflect the challenge doctors and patients face in choosing the best course of treatment for a variety of conditions. And they underscore that even though drug and device companies, government agencies and philanthropic groups have spent billions of dollars developing and testing new treatments in recent years, much of what happens in the doctor’s office or the hospital operating suite might not be based on rigorous scientific evidence.

To give you a bit of background of what is, or is not, considered good scientific evidence I quote from the WSJ article.

The American College of Cardiology and the American Heart Association have been jointly issuing guidelines to doctors on care of cardiovascular patients for more than 20 years. Recommendations based on multiple randomized clinical trials, in which patients are randomly assigned a treatment, are considered having the highest level of evidence. A single randomized study or non-randomized studies comprise the second level, while recommendations backed by expert opinion or case studies are considered having the weakest evidence. Guidelines are also ranked by whether empirical evidence or general opinion supports that a treatment is useful and effective or not.

Now I believe it isn’t the case that the doctor is necessarily doing anything wrong - the problem is the lack of adequate clinical trials testing which treatment is actually most effective compared to weaker evidence including such things as ‘expert opinion’. Opinion based on experience is valuable, but it is not science - though sadly in many cases it is the best we have.

However, things may change in the future with the new Obama administration as reported in WSJ.

This month, the Obama administration and Congress budgeted more than $1 billion of the economic stimulus package to fund research for comparing the effectiveness of different treatments in head-to-head studies aimed at providing evidence to clinicians and insurers on the best treatment strategies.

“We need those studies to make the kind of changes in health care that are being talked about — being sure we get the best possible care for our patients in the most cost-effective manner,” says Sidney Smith, a medical guidelines expert and cardiologist at University of North Carolina, Chapel Hill and senior author of the JAMA paper.

Though with the current state of the economy I wonder if this will be possible - I hope so. In most cases the the drive behind most large clinical trials are pharmaceuticals trying to get a new drug approved. From the WSJ article:

One reason for the lack of stronger evidence is that the large “megatrials” that have dominated cardiovascular research in the past decade were sponsored by drug and device companies. While those studies provide an important source of information, they are typically designed primarily to win approval for a treatment or to widen the market for a therapy already on the market, and not to guide treatment decisions, according to the JAMA study.

I am not sure what to say - it appears many times the clinical studies have not been performed and we simply do not know what is the most effective treatment for various health conditions (I will try to ignore the most ‘cost effective’ treatment discussion). Clinical trials are expensive and there are many variables you have to worry about (e.g. individual patients additional complications) and so as a society we might not be able to afford to thoroughly test what is the most effective treatment out of all the options that currently exist. One thing the above research suggest is for the patient do their best to be informed and knowledgeable (though this is not an easy task).

The second thing the above research brings to mind is you might want to pay even more attention to the half of the health equation you have more control over - you making the best daily health choices.

One Response

  1. CC Says:

    This reminds me of the last time I had the flu. My boss back then told me to go to the doctor on university campus. I went there expecting to be sent home with a few reminders such as ‘drink more water take more rest’. But then they actually took a blood test and determined that I had the type A flu. Also, what surprised me was that they asked me if I want a prescription for Tamiflu. I thought the usual way to treat a flu (a normal, not avian) was just to rest it out. But hey, I am living in the country with the highest stockpile of Tamiflu. But then shouldn’t they save it for the much awaited avian flu pandemic!?
    And a few months ago, I was urged by my coworkers to get the flu shot. Oh my, I’m a healthy 30-something…
    Is there something weird going on in this country? Why are people so paranoid? Would you call this ‘quality health care’?
    As for cardiovascular diseases, the trend of taking statins in the West has not spread here yet. I think they’re still on wheatgrass juice.

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