What is an evidence-based, value-based health care system?

Physician Executive, Jan-Feb, 2005 by Sheri Strite, Michael E. Stuart

The two biggest issues facing health care organizations in the United States today are the rising cost of health care and maintaining or improving the quality of the care they deliver.

It is estimated that 20-30 percent of all prescriptions, visits, procedures and hospitalizations in the United States fall into the categories of overuse, underuse (including non-use) and misuse of what the best available evidence tells us should be applied to provide quality care. (1)

With a national annual expenditure of $1.6 trillion dollars for health care, this represents waste of over $300 billion dollars annually--and often results in patient harms, including death. That means for every million dollars spent on health care in the United States more than an estimated $200,000 is likely to be wasted and is potentially causing patient harms.

The significant variation in medical practice and its impact on wasteful spending across the country are well-documented and it appears that regions with higher spending do not provide better quality of care. (2)

In fact, Medicare areas with the highest spending appear to have worse outcomes in some preventive care areas. (3) Moreover, a high incidence of underuse of evidence-based care practices has been found in high-cost regions of the country, suggesting that greater spending does not improve the use of evidence-based recommendations. (4)

Overall, it appears that adults in the United States are receiving only 55 percent of recommended preventive care, 54 percent of recommended acute care and 56 percent of chronic care recommendations. (5) There are a number of reasons for this staggering amount of inappropriate care, but "uncertainty" appears to be a major contributing factor. (6)

The probabilistic nature of health care and the lack of needed information at the time of decision making by clinicians and patients results in significant amounts of inappropriate care.

Systemic approach to quality improvement

What can you do to correct this?

Physician leaders and their administrative colleagues must provide the necessary attention and resources to evidence- and value-based quality improvement efforts to achieve improved health and health care outcomes within organizations.

An evidence- and value-based approach to quality improvement requires a systematic review and synthesis of the evidence regarding benefits, harms, risks, costs, alternatives and uncertainties of health care interventions as well as an assessment of the trade-offs between effectiveness, cost, the patient's perspective and the organization's priorities (e.g., considerations of the significant impacts of making clinical change, such as impacts on marketing, public relations and legal issues).

A systematic approach to quality improvement is based on valid, useful and usable information and brings together leadership, culture, structures, processes, skills and the tools required to improve health care and health outcomes. Historically, however, obtaining valid, useful and usable information has not been easy for most organizations.

Each week more than 10,000 articles are entered into the National Library of Medicine--many of these articles are case series, studies of poor quality or studies of inappropriate design and are likely to be misleading to readers not familiar with the basic principles for determining validity through critical appraisal.

Unfortunately, most clinicians, clinical pharmacists and others involved in health care decision-making have not received even modestly successful training in critical appraisal of the medical literature. Therefore, most health care professionals are not capable of determining the validity or usefulness of most published literature.

In a simple three-question quiz regarding the basics of critical appraisal that we have administered to hundreds of physicians and other health care professionals, we found that roughly 75 percent lacked even the most basic skills of critical appraisal--a deficit that directly and regularly adversely impacts patient care and outcomes.

A recent example of how research can be misleading concerns hormone replacement therapy (HRT) in post-menopausal women with coronary artery disease. Over the past several decades there have been numerous observational studies in which women who chose to take HRT after menopause were compared to women who chose not to take hormone replacement therapy.

These observational studies reported a 40 percent to 70 percent decreased incidence of coronary artery disease in women with pre-existing coronary heart disease--even in one of the best studies of this type. (7)

However, only well-done randomized, controlled trials allow drawing conclusions regarding cause and effect. Yet based on these observational studies, physicians recommended HRT to women at high risk for coronary events and advised them that their risks of coronary heart disease would be decreased with HRT.

When valid randomized controlled trials were performed, (8,9) it became clear that there were no cardiovascular benefits. In fact there are potential harms from taking HRT, such as the increased risks of breast cancer and Alzheimer's dementia. (10)