Evidence-based medicine does not mean everyone is treated the same

Health care spending and health service use vary a lot from place to place across the US. Much of this variation can’t be explained by differences across regions in how sick people are. Some of the variation in service use and spending is driven by variation in the decision making of health care providers, rather than the preferences of patients. The worst is that places that spend more don’t have better health outcomes.

So we should be able to get more value for our health care dollars by reducing unnecessary variation in care, where unnecessary means a deviation from the standard of care that is neither responsive to patient’s preferences nor justified by good evidence. And by conforming care to standards based on good evidence, we should achieve better outcomes for patients.

However, Ben Djulbegovic and Gordon Guyatt urge us to be thoughtful about how we reduce variation in care.

[A] widespread and influential school of thought has emerged contending that greater uniformity of clinical practice is desirable. Advocates maintain that by achieving uniformity in care, practice variation can be decreased, in turn leading to large cost reductions. The suggested mechanism to achieve uniformity in part involves clinician adherence to practice guidelines, which is seen as synonymous with evidence-based practice.

In their JAMA essay, they argue that in most situations we shouldn’t seek uniformity of practice, for two reasons.

First, medical decision making should be shared with patients and should reflect their values and preferences. Because patients’ values and preferences vary, decisions will often vary even when patients are in the same medical situation. There’s no contradiction between this view and the goal of reducing unnecessary variation, because variation in decisions driven by patient values is necessary variation in practice. But Djulbegovic and Guyatt are concerned that some may have lost sight of this distinction.

The second problem with seeking uniformity in health care is that we have too few clinical practice guidelines that are sufficiently trustworthy to justify standardization of care. It’s nonsensical and possibly dangerous to follow a guideline that isn’t truly evidence-based.

Djulbegovic and Guyatt therefore conclude that

Evidence-based practice rests on 3 key principles: the need for systematic summaries of the best available evidence to guide practice; standards for identifying when clinicians can be confident in evidence and when they cannot; and the recognition that values and preferences are as important as evidence in determining optimal clinical decisions. Rather than justifying a drive for uniformity of care, these principles highlight the desirability of (in most clinical situations) tailoring care to patients’ particular circumstances and their individual values and preferences.

I agree but this is discouraging. In many areas of medicine, what you learn from a good systematic summary is that the best available evidence isn’t plentiful and maybe isn’t all that good. It isn’t that no one cares about evidence. The problem is that there is so much to learn and accumulating evidence costs time and money.

Reducing unnecessary variation in care has been one of the great hopes for health care reform. If we could do it right, we could improve outcomes and save money. We may not be able to do it right, however, unless we can solve another hard problem: accelerating the rate of scientific progress in clinical medicine. Perhaps unfortunately, everything connects.


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