Evidence-Based and Cost-Effective Medicine for the Uninitiated

David B. Cooper

• Publisher: CRC Press
• Year: 2018
• eBook ISBN: 9781315348735
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

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Part I Introduction

1 The levers of decision-making in medical practice

Key points

The current paradigm of medical decision-making – labelled as ‘muddling through elegantly’ – is based on the unique knowledge of the individual physician about medical practice. It is characterized by applying patho-physiological-based enquiry to individual patients.

The method has been criticized for leading to the situation where there are large variations in medical practice. Patients sometimes receive ineffective, or poorly effective, treatment. In response to these concerns, alternative decision-making criteria have been proposed – evidence-based decision-making and cost-effective decision-making. These two methods build on the experiences of decision-makers outside health care and therefore there is some controversy about their application.

Decision-making requires a substrate to work. In the case of health care the substrate is the framework that supports health care and the viewpoint of the individuals within that framework. With this in mind, Part I seeks to review the fundamental forces shaping health care decision-making, and apply them to the development of the new decision-making paradigms.

Why does health care exist?

This is not as odd a question as it might seem at first. It is part of human nature to care; in a manner that benefits both ourselves and others. This apparently simple situation hides a paradox. Is it the role of health care to offer care to the individual, or to offer care to as many patients as possible, given scarce resources? The nature of this paradox is best explained by an example.

Table 1.1 Summary of choice faced by the health authority

Treatment	A	B
Success : treated ratio	1 : 6	1 : 4
Cost per treatment	£600	£1500
Number treated	38	12
Babies	5	3

Consider two treatments, A and B, for infertility, being considered by a health authority which has £18 000 to spend. The choice faced by the health authority is summarized in Table 1.1.

If the health authority acts in the best interest of the individual, i.e. acts to assure the most possible chance for the individual to conceive, then it would select treatment B. However, this would result in fewer babies and fewer treatments from a society viewpoint. If, in contrast, the aim of the health authority is to maximize the benefits of health care to society, then it would choose treatment A, even though it lessened the individual’s chance of conceiving.

In making decisions, therefore, the division is absolute; either an individual-based decision or a society-based decision is made. This dichotomy of decisions has been summarized as the dichotomy between the greatest good for the greatest number (often termed utilitarianism), or the greatest good for the individual (often termed libertarianism). It is very clear that whichever decision-making framework is chosen, it has a profound influence on how decisions are made. Accordingly, there is great debate about the merits of either system.

Utilitarianists postulate that the greater benefit to society must be at the centre of all welfare states and that it is the government’s right to decide the greater number to be treated (if you like, it is the role of the government to decide the social order and ranking of suffering). However, libertarians argue that suffering can only be assessed on the individual level and that the government’s role is to set the boundaries of the services provided. In practice, it is possible to design a decision-making process and indeed an entire health care system using either utilitarianism or libertarianism, but in either case the distortions of the system must be accepted.

In utilitarian-based systems the suffering of the individual is placed second to society. We have seen this situation with the case of child B,¹ where the judge’s ruling was that it was correct for the health authority to withhold treatment, given the benefit that could be obtained for others in society from the funds it would take to treat the leukaemia from which the child was suffering. Under this ethic, however, it might mean that if the majority of the population were smokers, then treatment should be offered to these individuals instead of those with rarer conditions (the so-called perverse taste paradox).

The libertarian view places benefit to the individual above that of society. It is the view taken by many general practitioners in the UK – who view their role as to secure health for the patient in front of them. The libertarian view could, if applied, mean that those who have great suffering that is self-inflicted, may take precedence over those with genetic disorders.

From this discussion it is apparent that both systems of health care have been, and are, applied. However, both have potential problems (more of which will be discussed later in this book). The new paradigms of medical decision-making have root in these two systems. Evidence-based medicine is most synonymous with the benefit for the individual patient, while decision analysis has root in utilitarian policy. However – as we will discuss later – it is not as clear-cut as the statement suggests.

Information and levers for change

For any new decision-making process to work, both information and levers are needed. In the case of health services the two are intrinsically linked. The levers for change in medical decision-making have been classified as information which provides evidence for:

• Professional change. This includes evidence for the effectiveness of procedures, the effects of guidelines and the integrity of professional values. The application of professional levers also includes the use of audit and other performance measures based on process and outcome. These levers are the aim of evidence-based medicine and, to an extent, cost-benefit associated medicine. They are difficult to apply correctly, as we will see, but are a major focus.
• Customer change. This includes the satisfaction of patients, the understanding of patients about treatments, and the acceptability of treatment to patients. This is a difficult set of levers for change to apply. It is difficult, first, to define who the customers are, and second, to define who takes responsibility. This aspect is covered in greater detail in Part IV.
• Economic levers. These include the use of financial information to shift ideas and purchasing, and the use of contracting mechanisms. In the past the strength of financial levers has been over-emphasized. The strength of financial leverage depends on the amount of free, and freeable, funding available. However, studies have shown that the amount of uncommitted moneys may be small. In this circumstance the emphasis shifts to efficiency and demand management, both of which have a heavy professional input.

The limitation of the levers we have mentioned explains why there is a focus on the use of professional levers via evidence-based medicine and cost-effective medicine. However, as we will discuss, the application of these levers is problematical without a clear definition of the purpose of medical practice.

The nature of the levers and the process of rationing

The decision-making process, together with the levers applied, enables a description of the processes in rationing. These processes are important from a philosophical and ethical viewpoint, as any one of them can be used to make a viable resource allocation system. The impact of these processes is the subject of the remainder of this book. Resource allocation systems may be:

• technocratic – where the professionals’ values and beliefs decide who benefits from he...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Preface
• Part I Introduction
• Part II Evidence-Based Medicine
• Part III Cost-Effectiveness in Medicine
• Part IV Conclusion
• Index