Sunday, July 10, 2011

Health Reform: Evidence-Based Medicine and the Real World

July 10, 2011- The July 7 edition of the New England Journal of Medicine just arrived. It contains two back-to-back articles that illustrate the problems of transforming medicine into an evidence-based format.

• The first is “Lessons from the Trenches – A High Functioning Primary Clinic.” Its author, Thomas Bodenheimer, MD, a well-known University of California academic, describes the workings and make-up of Clinica Family Health Services, a Denver-based primary care community health clinic. The clinic serves 40,000 patients at 4 sites. Fifty percent of these patients are uninsured; 40% are on Medicaid. Clinica aspires to be one of the first Accountable Care Organizations. Each of its locations includes three primary care practitioners, three medical assistants, a RN, a case manager, a behavioral health professional, and medical-records and front-desk staff. The clinic “has moved boldly from a doctor-based model to a team-based model.” Patients are never turned away, and most are seen on the day they call. The 4 clinics have a linking EMR, and they concentrate on assembling data that show progress. These data includes time it takes to see a primary care doctor or to meet with “the team,” entry to care during 1st trimester, number of low birth rate infants and % of Cesareans, Pap test within last 3 years, number of patients with diabetes and their glycated hemoglobin levels, and number of patients with hypertension. The goal is to improve all these measures. The basic idea is to serve patients while retaining loyal clinicians. The next step will be to reduce ER visits and hospital admissions. This step “awaits a new funding stream, which requires participation in which Clinica will share savings from reduced downstream costs.” To which I say, “ Good luck.” Many observers, including myself, say Accountable Care Organizations are DOA.

• Alison M. Stuebe, MD, an obstetrician-gynecologist at the University of North Carolina in Chapel Hill, writes the second article, “Level IV Evide3ne – Adverse Anecdote and Clinical Practice.” She confesses to being an early enthusiast of evidence-based medicine, which she defines as Gold-standard; level 1 evidence, as found in the medical literature. But, she says, “I’ve come to appreciate that under the influence of a randomized, controlled trial – not matter how well conducted or generalizable – pales in comparison with that of audible bleeding of a profound postpartum hemorrhage." In other words, in acute situations, you can often throw evidence-based medicine data out the window and act with your gut. She calls these acute situations “Level IV evidence based on adverse anecdotes.” In her words, “Adverse anecdote can transform a clinician’s practice pattern in an instant.” Whether to perform an Caesarean depends on the urgency of the clinical situation, on clinical judgment, not on data dogma.


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