July 1, 2005 (Vol. 25, No. 13)
The Promise and Controversy
How limited healthcare budgets can best be allocated at a time of skyrocketing costs is a question that dominates global public and private discourse. At the same time, expectations are high for good health, longevity, and access to innovative medicines and technologies.
In the face of this paradox, policymakers and private payor are seeking a rational approach for deciding which medicines to recommend to physicians and reimburse. Is evidence-based medicine (EBM) the answer?
Current projections indicate a near quadrupling of the population aged 60 and over by the year 2050. As the number of elderly grows and healthcare costs continue to rise, those on the front lines of healthcareproviders, patient advocacy groups, policymakers, and pharmaceutical and biotechnology companiesfeel a sense of growing urgency to find a systematic process for evaluating the cost/benefit of spending allocation decisions.
These trends raise scores of questions for those who allocate scarce resources, including:
What are the right measurements for EBM?
What are appropriate applications for EBM?
How can EBM guidelines be effectively implemented and enforced?
How can EBM be used to promote disease prevention and healthy behavior?
In the fall of 2004, the World Economic Forum convened a group of accomplished thought leaders to discuss these questions and the role that pharmaceutical and biotechnology companies may play in advancing the discussion and practice of EBM. This article includes viewpoints from the Forum and other insights into the use of EBM guidelines.
Evidence-based medicine is a broad concept. Healthcare stakeholders offer differing definitions and applications. This poses a challenge to those who try to measure its effectiveness, implement concrete EBM treatment guidelines, or even discuss the topic.
EBM is often described as the use of evidence and outcomes data in conjunction with individual clinical expertise in treating patients. For example, physicians employ EBM by referencing outcomes data when designing a patients treatment regimen.
This description may be expanded to include the use of data-driven clinical practice guidelines and technology appraisals, which provide formal recommendations on treatment options, similar to the voluntary guidance used in the U.K. National Health Service.
Speaking at the Forum, Myrl Weinberg, vice chair, International Alliance of Patients Organizations, defined EBM as peer-reviewed information about treatment that works versus treatment that is ineffective. She added that optimal care does not rely solely on the physicians opinion, but that a systematic mechanism to support care decisions is needed that will be more adequately measured for success.
While the use of evidence-based guidelines has increased over the past decade in some countries, its success has been mixeddue partly to physician resistance, disparate views on measurement, and the lack of appropriate financial incentives.
Robert Butler, co-chair of the Alliance for Health and the Future, believes another great challenge to effective implementation are physicians who are reticent to follow cookbook health care.
Getting beyond the cookbook is problematic. A key impediment to implementing EBM guidelines is that physicians are not willing to be continually trained and re-trained on all of the new technologies called for in-treatment guidelines. One of the ongoing challenges is that for many innovative technologies, long-term outcomes in clinical practice are not available.
Systematic implementation is further hindered by concerns that guidelines disallowing the use of an existing therapy are fraught with ethical, social, and financial ramifications.
The practice of EBM will change the behavior of all stakeholders. A more self-informed public is more likely to demand a better understanding of EBM as policymakers, private payors, and employers increase the incentives for individuals to pursue more healthy behaviors.
Butler described a future-state scenario in which EBM guidance will be important to help support a healthy life-coursea process that begins at infancy and lasts through later life stages. Maintaining a healthy life-course will involve the exchange of information and best practices among pharmacists, families, social workers, employers, and providers.
Patients may be spurred by financial incentives to change their behavior as increasing co-payments are levied by public and private payors. These financial incentives are encouraging individuals to seek out cost-effective approaches to maintaining good health. For example, patients are increasingly using technology to monitor their own health rather than going to the hospital.
Policymakers are helping to facilitate healthy behavior by providing the public with EBM guidance. One example is the U.S. Administration on Aging campaign, You Can! Steps to Healthier Aging. The campaign is based on growing evidence that even modest improvements in diet and activity can promote healthy aging.
Physicians are increasingly being asked to follow EBM guidance in caring for patients. In Australia, the government sets criteria physicians are required to meet before prescribing a medicine.
Employers may also play an increased role by establishing financial incentives for employees to adopt more healthy lifestyles at work and at home. Many companies are establishing wellness and health-promotion programs. In Canada, 45% of public employers and one-third of private employers provide health education to employees.
A multi-stakeholder approach is needed to minimize the ambiguity about the definition of EBM and the incentives that facilitate its adoption. The Forum discussion demonstrated the variety of perspectives that exist and that must be reconciled in order to successfully integrate EBM into the decision-making process.
Changing demographics, in particular the growth of the elderly population, are already forcing stakeholders to make tough cost-benefit decisions. More work on identifying appropriate incentives for EBM adoption is needed. Finding the right inducements for individuals to take responsibility for improving their own behavior is also crucial in enhancing each persons life-course while conserving costs.
EBM may be a fulcrum that will accelerate the shift toward spending on prevention versus treatmentan imperative as we look to put the brakes on spiraling healthcare costs.