Winter/Spring 2008 Vol. 8 No. 1
The Road to Effective Health Care
A New Approach to Determining
The plethora of technologies and services available to diagnose and treat illnesses can boggle the mind. For example, if you have high cholesterol, you might be prescribed any one of more than a dozen medications. Which are the most effective? Do they work the same for all people? Which should insurance plans cover? Are any nonpharmaceutical therapies more effective?
The idea of consumer-directed health plans -- in which individuals "shop" for their choice of providers and services -- has been gaining popularity recently, and people equipped with good information may indeed have the power to improve the quality of their care. But even the most sophisticated health care consumers struggle to gather reliable information about which treatments are appropriate for their conditions and circumstances. The amount of medical data is staggering, and research sometimes produces contradictory results.
In fact, many decisions by health professionals and patients involve as much guesswork as hard data, a reality demonstrated by variations in how practitioners treat the same conditions and which therapies and services insurance plans cover. The situation gets more complicated every year as dozens of new drugs, devices, and other technologies enter the marketplace.
Efforts are under way to try to make sense of all the data. Several organizations conduct research to compare the effectiveness of different health care products and services and generate evidence on what works and when. But lack of coordination has led to duplication of effort, the creation of competing guidelines for how to diagnose and treat ailments, and uncertainty about which study results and guidelines are the most reliable and objective.
The situation begs for the establishment of a single entity with the authority and resources to help end the confusion, says a new report from the Institute of Medicine. The report provides a blueprint for a national program to prioritize which clinical services should be evaluated and to conduct systematic reviews of the evidence. This program would also be responsible for developing and promoting rigorous standards for clinical practice guidelines, which could help reduce the use of questionable services and better target therapies to patients most likely to benefit.
The report proposes that the secretary of the U.S. Department of Health and Human Services establish this program under the direction of Congress, which must see that the program is given the authority, expertise, and funding necessary to do the job.
It is also imperative that the new program be established in a way that ensures transparency, objectivity, and scientific rigor, so that stakeholders and the public regard it as an authoritative and trustworthy resource. Most people, including many health professionals, lack the scientific training necessary to evaluate and interpret by themselves the findings from hundreds of new research studies published every year. Moreover, some question how biased previous evidence reviews are, given that a significant proportion has been financed by manufacturers or vendors.
To help ensure objectivity and accountability, the report recommends that an independent, free-standing committee be created to advise the program on determining which evidence reviews merit priority and that an advisory board be established to provide broad oversight of the new program. The committee and board should include representatives of a range of stakeholders, including the organizations that develop clinical practice guidelines, patient groups, health professionals, and insurers, but advisory board members should be selected in a way that minimizes conflicts of interest. -- Christine Stencel
Knowing What Works in Health Care: A Roadmap for the Nation. Committee on Reviewing Evidence to Identify Highly Effective Clinical Services, Board on Health Care Services, Institute of Medicine (2008, approx. 280 pp.; ISBN 0-309-11356-3; available from the National Academies Press, tel. 1-800-624-6242; $39.95 plus $4.50 shipping for single copies).
The committee was chaired by Barbara J. McNeil, Ridley Watts Professor and head, department of health care policy, Harvard School of Medicine, and professor of radiology, Brigham and Women's Hospital, Boston. The study was funded by the Robert Wood Johnson Foundation.