Tag Archives: Evidence-based medicine

$50,000 cost reduction for colon cancer patients?

US Oncology today announced the publication of a study that highlights the savings potential for cancer patients when their treatment is consistent with evidence-based guidelines. Here is an excerpt:

 A study conducted by The US Oncology Network and Milliman finds that colon cancer treatment that is consistent with evidence-based guidelines (specifically Level I Pathways) has significantly lower cost while demonstrating outcomes similar to those in published literature. The study shows mean per patient cost differences of more than 30 percent, $53,000 for the treatment of adjuvant colon cancer and $60,000 for the treatment of metastatic colon cancer. The study, which compared patients whose care followed physician-developed Level I Pathways evidence-based guidelines (also known as ‘on pathway’) to other patients (‘off pathway’), was published in a special joint peer-reviewed issue of the Journal of Oncology Practice (JOP) and the American Journal of Managed Care (AJMC).

The full announcement is available here.

Evidence-based medicine and cancer treatment

A new article looks at how evidence-based medicine can help reduce the cost of cancer treatment. Here’s the situation:

The high cost of oncology is gaining a lot of attention these days. With cancer care accounting for ten percent of healthcare costs, payers are hungry to find ways to be more frugal. As oncologists, it is in our best interest, as well as the best interest of our patients, to take a proactive, leadership role in finding solutions that sustain our ability to deliver high-quality care.

OK, sounds good. How do we accomplish this? One idea:

A study by Milliman analyzing Medstat 2007 data revealed that out of those chemotherapy patients with 10 major cancer diagnoses who were identified as dying in an inpatient setting, 24% received chemotherapy within 14 days of death and 51% received chemotherapy within 30 days of death. While we cannot always predict when death will occur, pathways can help guide physicians in making decisions and treatment recommendations pertaining to whether to offer additional cycles of a treatment or move to second, third, and further lines of treatment. They can also provide practical guidance that can be helpful in end-of-life care discussions. This includes demonstrating that transitioning to hospice care can improve the patient’s and the family’s quality of life and can reduce the costs borne by the family and payers by avoiding unnecessary and ineffective chemotherapy administered within a few weeks of death.

Medmal revisited

Former White House budget chief Peter Orszag has an editorial on medical malpractice in today’s New York Times. Here is an excerpt:

The academic literature tends to play down the role of medical liability laws in driving up health care costs. Doctors themselves, however, almost universally state that malpractice statutes lead to extraneous testing and treatment.

It is also conceivable that because such laws usually focus on “customary practice” — that is, a doctor who has treated a patient the way most other doctors in the area would is considered safe from accusations of malpractice — they create a strong contagion effect among doctors. The laws, no matter how weak or stringent, may therefore explain why doctors in some parts of the country generally adopt much more intensive approaches than those in other areas do.

The traditional way to reform medical malpractice law has been to impose caps on liability — for example, by limiting punitive damages to something like $500,000. A far better strategy would be to provide safe harbor for doctors who follow evidence-based guidelines. Anyone who could demonstrate that he has followed the recommended course for treating a specific illness or condition could not be held liable.

The idea of safe harbors for doctors that use  evidence-based medicine is one of several outlined in this paper from last summer: “Retooling Medical Professional Liability,” by Chad Karls. For more on evidence-based medicine as a source of efficiency and quality improvement, see this paper.

The huddle

Evidence-based medicine requires more than just knowing what treatments are best for patients—there’s also the matter of implementing best practices in the clinical setting. Here’s an example of how that can work:

Texas Health Arlington Memorial Hospital recently earned a national award for its daily ritual of clinicians joining in a daily “huddle” to coordinate patient care. And just in time for football season.

The huddles bring together nurses, social workers, nutritionists, physical therapists, chaplains and others involved in a patient’s treatment to review the patient’s status and care plans and identify concerns early. Huddle members are briefed on the patient’s social and financial needs, family dynamics and other considerations. Each member walks away with specific tasks that, presumably, don’t include pass routes or blocking assignments.

See more in the Dallas Business Journal. This white paper expands on the topic.

“Most of the time”

A new article in the Milwaukee Journal Sentinel looks at evidence-based guidelines. Here is an excerpt:

[P]hysician societies, business groups, health insurers and consumer groups have called for more research on the effectiveness of different treatments. The results of that research should help doctors develop better guidelines – and better care for patients.

Despite the contention that it will lead to “one-size-fits all” care, comparative effectiveness research is a step removed from the guidelines themselves. The contention also ignores how guidelines are designed to be used.

“It’s a mistake to think of guidelines in black and white,” said Helen Blumen, a physician and managing editor of Milliman Care Guidelines LLC, which develops guidelines.

The words to live by, she said, are “most of the time.”

The science for developing guidelines is relatively new, and guidelines are far from perfect. The thousands that exist vary in quality and at times conflict. And a treatment that works equally well for all patients is rare.

But guidelines stillcan reduce the unnecessary variation in how doctors practice medicine and encourage them to follow what are considered best practices.

“The job of guidelines is to make it easy for physicians to do the right thing and hard to do the wrong thing,” Blumen said.

The scientific method?

Look for this interesting article in the upcoming weekend’s New York Times Magazine. The article looks at the progress of evidence-based medicine, the attempt to minimize variation in care, and specifically at Dr. Brent James from Intermountain Healthcare in Utah and Idaho. Here’s an excerpt (citing Dr. John Wennberg of the Dartmouth Atlas):

Wennberg, the Dartmouth researcher, argues that Intermountain is fundamentally different from other oft-cited models of high-quality, lower-cost care, like the Mayo Clinic and the Cleveland Clinic. These places, including Intermountain, share certain traits, like having a large number of doctors who receive fixed salaries rather than being paid piecemeal for each treatment. Partly as a result, these hospitals do fewer tests, treatments and operations than other hospitals and still get excellent results. What sets Intermountain apart, Wennberg says, is that it is also making a rigorous effort to analyze and improve bedside care.

“It’s the best model in the country of how you can actually change health care,” Wennberg told me. I heard nearly the same argument from Anthony Staines, a health scholar and hospital regulator in Switzerland who recently completed a study of some of the world’s most-admired hospitals. “Intermountain was really the only system where there was evidence of improvement in a majority of departments,” Staines said.

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