Whither Goes Evidence-Based Medicine?
Discussions that focus on health care costs have created a specialized vocabulary, such as comparative effectiveness research. The concept undergirding this field may be defined as "the conduct and synthesis of research comparing the benefits and harms of different interventions and strategies to prevent, diagnose, treat, and monitor health conditions in 'real world' settings."1 In essence, comparative effectiveness research generates evidence optimizing how we—in the "real world"—treat diseases, minimize complications, and steward our health care dollars. Bottom line: if treatments are documented to be efficacious, safe, and economical, as a result of observational studies or other research, they should be adopted. So how are we doing with data that should guide therapeutic decisions?
EVIDENCE VS EXPERIENCE
The results of a recent observational study are not optimistic.2 This study focused on the hospital treatment of exacerbations of chronic obstructive pulmonary disease (COPD). Included in the study were about 80,000 hospitalizations for COPD in 400 hospitals.
COPD is a great place to look at therapy because it is associated with high morbidity, prevalence, and costs. It affects 12 million to 24 million persons in the United States, is responsible for 500,000 hospitalizations and costs $32 billion a year, and may become the third leading cause of death in this decade.1
Some things were known already. For instance, systemic corticosteroids should be used in the treatment of hospitalized patients with exacerbations. Available guidelines suggest that the route of corticosteroid administration be oral and not higher-dose parenteral.1 Real-world medicine seems to ignore these guidelines and favors high-dose intravenous corticosteroids (an average of 600 mg/d of prednisone equivalents), on average, 92% of the time.
High-dose parenteral administration costs payers about $500 more per COPD exacerbation that requires hospitalization. The study also demonstrated that low-dose oral corticosteroids do not lead to worse outcomes. In fact, risk of treatment failure, length of stay, and costs were all lower in the oral corticosteroid group. Is there a problem here? I think so.
THE HIGH COST OF RELYING ON EXPERIENCE
The editorialist urged caution "when advocating a change in clinical practice based on observational research, and, given that current practice overwhelmingly favors high-dose intravenous corticosteroids, facilitating change will be daunting."1 But what if corticosteroid administration for COPD exacerbations is the "tip of an iceberg"? How many common and expensive treatments are used because of experience in contrast to evidence? A decade or so ago, it was the "magic" 10 g/dL hemoglobin level before surgery. That experiential target wasted money and blood products—all the while increasing infections, length of stay, and costs.
Although the term "low-hanging fruit" has been used so much it has become trivialized, real money can be saved by applying evidence to the management of redundant diseases frequenting primary care. Avoidance of guidelines because they are "cookbook" is no longer an adequate excuse—especially when we are doing things incorrectly and expensively while adding to potential complications.
1. Krishnan JA, Mularski RA. Acting on comparative effectiveness research in COPD. JAMA. 2010;303:2409-2410.
2. Lindenauer PK, Pekow PS, Lahti MC, et al. Association of corticosteroid dose and route of administration with risk of treatment failure in acute exacerbation of chronic obstructive pulmonary disease. JAMA. 2010;303:2359-2367.