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Wednesday, June 30, 2010

Mencken was right

A funny thing happened on the way to improving our health care system. Sometimes the simple and the obvious is not so simple and obvious. In an interesting piece in the Health Affairs blog:

Is The Impact of Comparative Effectiveness Reports Being Evaluated?

June 30th, 2010 
"It is clear to all informed persons that the nation needs better evidence of what works in health care, and this has propelled comparative effectiveness research (CER) policy developments of late.  However, for a number of—mainly political—reasons, recent Federal legislation separates the process of evidence generation and evidence synthesis from policy processes, e.g. Medicare coverage or clinical guideline development.  With no direct link to health policy processes, the question occurs: is the evidence used in health policy decisions, and if so, how and what difference does it make? "  

OK- let's cut to the chase...The conclusions of the study were:

"In this study we were unable to document a single instance where the impact of a traditional evidence review was evaluated and made publicly available.  Additionally, no known systematic effort has been made to document whether such evaluations have occurred; thus this study can serve as a call for such efforts to take place."

I am not at all hostile to investment in comparative effectiveness research. My problem is how this information may be deployed to use heavy handed top down approaches to attempt to change behavior en mass.This will be done and efforts to measure actual impact with be late in coming if at all. This particular phenomena is not unique to medicine. It is basically the modus operandi of various regulatory entities which bedevil or professional lives. The ACGME creates reams of rules regulating the training environments for new physicians and have yet to put in place any program to identify their efforts have yielded an improved product. Fewer deaths with limited resident work hours? No empirical evidence whatsoever. Let's reduce hours further. Create impossible to measure competencies and impose them on training programs without a lick of evidence they serve anyone but the regulators purposes.

 In the wake of the Enron Scandal the Sarbanes-Oxley rules created am entirely new universe of financial regulations which was followed by even bigger financial scandals. Response??? More regulation without any methods to define effect. Calamity results in response without the tools to assess whether the response actually addresses the calamity in any way shape or form.  

My own take on this is for the most part people have no idea how things work. We are often not interested in fixing anything. We are more interesting in responding since it makes us feel good and it is easy for us to convince ourselves that we both understand and are empowered. H.L Mencken summarized this well when he wrote:
"For every complex problem there is an answer that is clear, simple, and wrong."

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