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OurBlook interview with Dr. Allen Weiss, president and CEO, Naples, FL, Community Hospital
 Please describe what you mean by evidence-based medicine (EBM).
AW: We need to mandate evidence-based medicine, which comprises guidelines for best practices, established by practitioners from medical outcomes research studies.
What are the pros of it?
AW: EBM would allow more predictable results for patients, because the current 40 percent variation in treatment for the same diagnosis would be reduced to near zero. For example, only 59 percent of Medicare patients with cancer receive "best practices," according to the National Quality Forum, while only 55 percent of all U.S. patients receive recommended care according to RAND Corp.
Patients do not receive recommended care as prescribed in national medical specialty guidelines about 46 percent of the time. Another 11 percent of patients received care that is not recommended and potentially harmful.
Quality of care varies considerably by medical condition. People with cataracts receive about 79 percent of recommended care. Patients with alcohol dependence receive only about 11 percent of recommended care. People with diabetes receive only 45 percent of the care they need. Fewer than half of patients with diabetes have their blood sugar levels measured on a regular basis. Thirty-two percent of patients with coronary heart disease get recommended care, and only 45 percent of patients who suffer a heart attack receive medications that could reduce their risk of death by more than 20 percent. This information is gleaned from Health Leaders Oct 2009.
What are the cons?
AW: In the past many, physicians viewed EBM as "cookbook" ... saying that each patient was unique and therefore needed a unique treatment. Certainly there are significant differences among patients but there are many more similarities. EBM would eliminate waste and ineffective treatments which, in turn, would disadvantage those involved with these processes.
Do you have a policy of using evidence-based medicine at your hospital? If so, how extensive is it and exactly how have you implemented it?
AW: We have over 150 clinical pathways which incorporate EBM. Many of these pathways are embedded in our electronic order system, which is used currently over 50 percent of the time. We anticipate the majority of orders placed in the next year to be electronic and evidence based. We have discussed the advantage of formalizing the review and reporting of the use of EBM and I expect this will be accomplished in the near future.
Would there be a significant impact on the U.S. healthcare system if it were implemented much more widely?
AW: Most experts agree there is currently 30 percent waste in the system due to misuse, overuse, underuse, defensive medicine, fraud, abuse and miscommunication. Additionally, there is an opportunity to make the malpractice system more efficient. EBM would have an immediate positive impact on all of these unfortunate processes.
Does the reform legislation now before Congress carry provisions for evidence-based medicine and if so, are they adequate? If not, what should be added?
AW: The initial proposal by President Obama included some modest funds for further development and implementation of EBM, which was called comparative effectiveness research. I believe this process is fundamental to health care reform. Unfortunately, all of the recent debates and legislative proposals have focused on insurance reform.
How does evidence-based medicine affect the legal malpractice problem that plagues healthcare providers?
AW: Evidence-based medicine would also impact costs associated with costly malpractice. According to a study in the Quarterly Journal of Economics, the malpractice system includes approximately 1 percent of direct costs (awards, legal fees, administration, etc.) and 9 percent for the indirect costs of so-called "defensive medicine." Of the 1 percent which goes to direct costs, the harmed patient only gets less than half.
EBM would help define what was and was not malpractice. If EBM was followed correctly and there was a bad outcome, that would be unfortunate but not malpractice. If EBM was not followed and there was a bad outcome, then malpractice was committed. This would simplify the system ... saving 0.5 percent direct costs ... but more importantly the 9.0 percent cost for defensive medicine would also be eliminated.
With prescribed treatment plans for various diseases, it almost sounds that there could be no deviations. Is that true, and if so, how can U.S. healthcare improve if new and different treatments can't be used?
AW: Currently, non EBM does not lead to new and different treatments. Clinical research on EBM would still be done in appropriate settings and lead to improvements in care.
Is there anything else you'd like to say about evidence-based medicine?
AW: There is more than enough money in the healthcare system to care for everyone including the 50 million uninsured and others. We just need to spend the money wisely and not wastefully. We have resistance from those who are making a living off non EBM. "Rice bowls" will be broken but we must do this or we will not remain competitive in a global economy.
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