Wednesday, June 22, 2011

Health Advocacy Groups, Evidence-Based Medicine & Shared Decision Making

Listen, here... EBM works!!
This-time-we-really- mean-it Congressional budget cutting.  The evaporation of cheap Chinese imports.  Riot-provoking Eurozone austerity.  Too much oil within the reach of Arab craziness.  Maybe it’s all random, but the dot-connecting Disease Management Care Blog suspects our collective economic pie is in for some downsizing.  

Unions, advocacy groups and various political and social institutions seem to agree.  Demanding more benefits and higher wages is simply a hedge against the strong possibility of some painful clawbacks.  The pie may be getting smaller, so the logical response is to stake out a bigger piece.

Columbia University’s Sheila Rothman doesn't disagree, but she sure is disappointed.  Writing in the June 22/29 issue of JAMA, Dr. Rothman misses the big picture and laments the unwillingness of “health advocacy organizations” to submit to the enlightenment of “evidence-based medicine” (EBM).
The DMCB explains. 
According to Dr. Rothman, groups like the Epilepsy Foundation of America, the National Alliance on Mental Illness, the National Coalition of Cancer Survivorship, Mental Health America, the American Cancer Society, Susan G Komen for the Cure and Autism Speaks have all opposed the use of EBM to restrict unfettered access to more testing, more treatment options and more services.  This is despite solid science that, depending on the circumstances, has repeatedly shown more testing doesn’t necessarily lead to better outcomes, generic medications work just fine and some treatments actually harm patients.  Dr. Rothman suspects the real underlying agenda is battling “cutbacks” and not representing a common good.

Fair enough, says the DMCB, but let’s do some reality checking and give the organizations as well as Dr. Rothman an evidence-based way out of this health advocacy antipathy, this medical maladjustment, this health policy pickle.
First off, there is no denying that EBM represents a rational, scientific and life-preserving approach to cutting waste from a bloated health care system.  Unfortunately, the political adroitness of selling this to a skeptical public has been as flatfooted as Republican’s voucher support program idea.  Scientists may get it, but moms of autistic children are scared of EBM.  The EBM brand is headed south faster than Greek bonds.  

Secondly, critics of EBM may have a point: no evidence of any benefit, especially if measured using averages, is not the same as evidence of no benefit, especially if a lucky few at the margins do benefit.  There’s EBM, but it is no match for American-style hope.  There’s the realpolitik, and then there is the Arab spring.
Third, advocacy groups exist to…, well, advocate.  AARP is the latest example of what happens when that is forgotten. The only way these groups will give anything up, especially in the current economic environment, is to give them something in return.  EBM is not that something.  Lecturing them about the "evidence" will get you as far as lecturing the Chinese about their currency exchange rates.     

So, what is the way out? The DMCB continues to be intrigued by the evidence-base underlying "shared decision making."  There is compelling evidence that providing user-friendly, patient-centric, clear, concise and objective information about the risks, benefits and alternatives of various treatment options not only enables consumers to choose wisely, but often leads them to forgo risky, dubious and expensive options.

Which leads the DMCB to ask: why not craft a win-win policy and political compromise with the health advocacy groups that promotes the use of SDM? 

More on this in a future post.

Image from Wikipedia  

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