Monday, 5 May 2014

The status quo bias


I like this JAMA (Volpp 2012) article because it raises the issue of the status quo and this is well-timed because just for now, we are accustomed to the debates on the introduction of new technologies or new drugs, and maybe that's why we’re now starting to evaluate the opportunity of innovation in terms of cost-efficiency or even cost-effectiveness. I’m talking about the $150,000 from the introduction of trastuzumab in metastatic cases of breast cancer per year of life gained, or the $370,000 of the use of erlotinib for advanced cancer of the pancreas cases (Weinstein 2010). But the question of the status quo is: are we wondering about the cost–effectiveness of clinical activities that are undertaken every day, or is that the status quo of having achieved a position in the portfolio of services, puts them at safety from doubts?

To illustrate the status quo, without going in-depth, I chose a couple of examples from the field of preventive activities and a couple more from the supposedly curative care activities.

Example 1 - PSA

Almost all health care assurances, both public and private, offer to men of 50 years of age, the opportunity to get an annual PSA test (Prostate Specific Antigen). It doesn’t seem to be a particularly expensive test, but now the controversy focuses on the disadvantages of early detection, because, according to experts, it’s not clear that this will bring more life to patients, but it does seem however, the resulting overtreatment can cause new problems in their daily life (incontinence, impotence). Expert groups claim to inform the men very well about all this prior to taking the test, but the assurances stubbornly continue to offer the annual PSA in its preventive portfolio without further consideration.

In case you are interested in this issue I offer the link to the U.S. National Cancer Institute.



Example 2 - Papanicolau

If the cost of annual screening for cervical cancer is compared with the biannual screening, the cost per year of life gained from the first is $800,000 with respects to the second (Weinstein 2010), and despite this disproportion being well known, many women and gynaecologists continue the current practice of annual Pap smear.

Example 3 - Long-term follow-ups

For this example, I have chosen an unusual theme for assessment: long-term follow-up of patients who have had at some point in their life any major medical or surgical procedure. It turns out that in these situations, the specialists apply some control guidelines that most of the time does not appear to have any support in the evidence. It’s customary to see in hospitals, patients with controls scheduled every six months or every year, with requests for biomarkers, PET or scans. This is the status quo of the large consumption of diagnostic technology. Are we sure that the implementation of diagnostic tests for long-term monitoring is adequate, or rather we are dealing with clear cases of overacting?

To illustrate this example a little better, I selected a quote of one of the 5 questions (the one with the number 4) that the American Society of Clinical Oncology recommends that should be asked:


Example 4 - Potentially avoidable hospitalizations

John Wennberg has amply demonstrated, (Wennberg 2010) that the availability of hospital beds in a territory is the main tracer of the amount of hospital admissions occurring, and not the clinical rigor of the criteria adopted by patients who believed that a hospital stay can bring them some added value. The point is clear: more beds, more admissions, regardless of other considerations, even the most purely clinical.

If we make an estimate with Catalan data that I happen to have handy at the moment, for potentially avoidable hospital admissions, we find very remarkable figures that I’ll refine in a moment, because nobody can overlook that no matter how good the clinical management that we apply will be,  this figure will never be zero. Well, if we imagine that the Catalan hospitals would have a number of potentially avoidable admissions as the quartile of Catalan hospitals with lowest figures (pure benchmarking), the system could avoid more than 30,000 hospital admissions per year. But in exchange, the funding model continues to pay per admission, beyond considerations of suitability (it is clear that this occurs not only in Catalonia, but everywhere).

Discussion

Today I wished to talk about an issue that affects the inner part of the business core of clinical management. And for this reason I think that the introduction of critical thinking about the most common clinical practice is necessary, because due to the large diagnostic and healing power of the resources that we have, this reflection of the status quo should prevail not only for waste of resources hypothetical questions but also for the ability that we have to cause additional problems for the sick as a result of unnecessary clinical overacting.

Bibliography

Volpp KG, Loewenstein G Asch DA. Assessing Value in Health Care Programs. JAMA, May 23/30 2012;307,20:2153-4.

Weinstein MC, Skinner JA. Comparative Effectiveness and Health Care Spending. Implications for Reform. NEJM 2010.326;5:460-5.

Wennberg JE. Tracking Medicine. Oxford University Press 2010.



Jordi Varela
Editor

1 comment:

  1. This is a great post and an important point about current practice. Much of what we do now is low value, so looking to save money in the future by choosing only high value new technology will leave us with a lot of legacy practices that offer little benefit -- but always pose at least some risk of harm. -- Shannon Brownlee, Lown Institute

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