Evidence-based Medicine Not Well Incorporated into Clinical Practice

A recent article written in the Vox by Eric M. Patashnik, the Julis-Rabinowitz professor of public policy and a professor of political science at Brown University, and co-author of Unhealthy Politics: The Battle over Evidence-Based Medicine explains the reluctance of the American doctors in wholeheartedly adopting evidence-based medicine into their clinical practice, some points from which are highlighted below: Evidence-based medicine refers to medical practices that undergo rigorous assessments in clinical trials and other research methodologies so that their effectiveness as well as safety can be established. The adoption of practices based on evidence offers the best treatment options for patients.

During the reassessment of practices that are already approved and in clinical practice, it is sometimes found that these practices are not associated with the same benefits that they were expected to cause when they were first approved. For example:

• A study published in the New England Journal of Medicine way back in 2002 demonstrated that an orthopedic procedure called arthroscopic debridement and lavage does not help in relieving pain and improving function in patients with osteoarthritis. Similar evidences of lack of benefit were noted for the orthopedic procedures spinal fusion and subacromial decompression.
• A recent study published in the Lancet indicated that stent placement in an artery of the heart to keep it patent when done for non-emergency cases does not produce significant benefit and relief of pain when compared to a sham surgery where the stent was not used. Thus, the benefit appears to be more likely due to a placebo effect of the procedure rather than the stent itself.

What are the Benefits of Adopting Evidence-based Practices?

• Evidence-based medicine provides the best treatment options for patients in terms of effectiveness and safety.
• Evidence-based practices can bring down the cost of treatment. Several individuals receive medications and undergo costly and unnecessary tests, which do not have any proven use and may even be harmful. This results in a lot of wasteful expenditure and drains the financial resources of the individual as well as the state which could have used those resources for procedures that have proven usefulness.
• Evidence-based treatment can be used not only to underplay some treatments, but also to promote treatments that are beneficial and are not adequately used.

Then Why the Reluctance?

Despite the above benefits, it is estimated that only half the treatments in clinical practice are supported with adequate evidence. Some of the reasons suggested for the reluctance in adoption of evidence-based practices in clinical medicine include the following:

• Once a treatment is introduced and people know about it, it is suddenly difficult for doctors to convey to their patients that the treatment is no longer regarded as useful.
• Several doctors get influenced by the advertisements of pharmaceutical companies and medical device manufacturers who promote their own products, instead of heeding to evidence-based medicine. They thus end up using procedures and medications that may not be really useful for the patient.
• Some doctors prefer to go with the treatments that they have been comfortable using.
• Evidence-based practices are often based on large clinical trials, which require financing. The use of taxpayer’s money for evaluating the benefits of treatment has been questioned.

How can Evidence-based Practice be Encouraged?

As a part of the “Choosing Wisely” campaign, launched in 2012 by the American Board of Internal Medicine Foundation in partnership with Consumer Reports, medical societies are advised to develop a list of treatments that have minimal clinical benefit to patient. Unfortunately, the list did not change the ground reality, with patients still being prescribed tests like imaging tests for uncomplicated headaches, cardiac imaging for patients without a history of heart problems, and routine imaging for patients with low-back pain.

One suggested approach to extend the use of evidence-based practices is that treatments should be thoroughly evaluated before being introduced. However, such an approach could affect breakthrough treatments from reaching the market early.

Another possible way would be for insurance companies to pay for evidence-based practices, and if the patient would like to undergo any unproven procedure, they would have to pay the additional amount from their pockets.

In their book Unhealthy Politics: The Battle over Evidence-Based Medicine, based on surveys, the authors found that though people are anxious to know about the benefits and risks of treatments, they fear that the findings could result in the rationing of medical care or tie the doctor’s hands, who may not be able to prescribe a treatment even if he/she feels it could benefit a particular individual. They also found that the public has great faith in their doctors, and if doctors were to promote evidence based medicine, the public would accept it more easily. Thus, the final say in the introduction of evidence-based medicine is in the hands of the clinical practitioners.

Reference:

1. Why American doctors keep doing expensive procedures that don’t work - (https://www.vox.com/the-big-idea/2017/12/28/16823266/medical-treatments-evidence-based-expensive-cost-stents)

Source-Medindia