Using the best evidence gained from scientific studies to inform medical decision-making is called evidence-based medicine, and it is currently a hot topic in health care. Tim Ryken, MD, neurosurgeon at University of Iowa Hospitals and Clinics, talks about evidence-based cancer care:
How is evidence-based care different from current treatment practices?
It's a process that's been developed to try to level the playing field between different information sources. For example, most practice is based on what we were taught by our mentors, perhaps supplemented by text books, all generally written by single authors.
Evidence-based approach is a process whereby a particular clinical question is identified. The data—the actual scientific data that is available—is compiled by an independent group. Then judged on its merits and assigned a relative rank of importance, based on how:
- Effective the trial was
- Thorough the trial was
- Well done the study was
Then the various treatment options are graded or placed in an area of priority as to what evidence supports the best treatment for any one condition.
How does evidence-based care help physicians and patients make the best treatment choices?
The listing or the relative ranking of effectiveness of the different treatment options can be easily viewed once this process is complete. We don't always have the best studies or the best evidence available for any one particular topic, but when confronted with a particular question, if an evidence-based document has been prepared, patients, physicians, and others can look at the choices and look back at the studies and say, "Wow. This was well done, it was compiled by multiple groups in well respected institutions and had a lot of patients involved, the study design was good, etc."
You can contrast that and say, "Well, these options were also listed" and look at the studies that supported those. They may be smaller, single center studies, or sometimes even just expert opinion in literature that really doesn't have a lot of scientific basis to it. So by compiling those different choices, hopefully we're allowed to make the best choice for the best treatment based on the evidence that's available.
Can evidence-based care be a useful tool for controlling health care costs? How?
We try to focus, from the physician national group standpoint on best medical care. Hopefully we're taking cost as a secondary issue in terms patient health and outcome. So we like to view it as a teaching tool and as a mechanism of protecting the options.
But there clearly is the angle that if you have several different treatment options and the relative cost between them is examined by an outside group, then clearly there can be an application in which the two things have equivalent outcomes. The less expensive one may be more beneficial to a particular group in the health care industry. We also look at the same aspect from patient safety and complications. Maybe two treatments are equivalent in outcome, but one has a higher complication rate—that would also come out in this process—so there's an element of patient protection, as well.
Recently, you led a team of physicians in studying the current treatment of a specific kind of brain tumor. Tell us how you used evidence-based care to come to a decision on a new treatment plan for neurosurgeons.
This was a three to four year effort with about 25 other physicians who care for malignant brain tumor patients around the country in creating a document that addressed what we thought were the five major issues concerning the malignant brain tumor patient population:
- Surgery
- Radiation
- Chemotherapy
- Pathology
- Radiology
We had panels involved with each of these subjects and went through the world literature back to 1966, which is the electronic data bases, to compile the relative strength of the data addressing the best recommendations we could on each of those topics. That was put together and published online this fall. It's publicly available, which is our policy, to make sure it's accessible to anyone who would like to look at it.
Today, what difference will evidence-based care make on medical treatment plans?
The national neurosurgery group has been active in a number of areas, including:
- Spinal chord injury
- Degenerative spine surgery
- Head trauma, one of the early topics addressed
Taking the brain tumor group as an example for surgery, we've compiled the literature that supports an aggressive role for surgery in the malignant brain tumor patient. In some cases, it wasn't as strong as some of us might want. Those of us who are surgeons feel that surgery is an important issue. It's also important that we go back and look at our data and ask, "Are we really providing the service we think we are when we offer this to patients?"
I think our documentation shows that we do. It also points out where we have some weaknesses in the literature and where we need to focus our efforts for studies—both at the national level and the governmental level—to support funding to provide a mechanism to study important.
Similar issues came up in the radiation oncology section. There are techniques for radiotherapy that have been used somewhat on a trial and error basis, and there are some studies that show they simply weren't effective and should probably be avoided. We were able to make those recommendations while still protecting the option for the baseline radiotherapy for these patients, which is really a cornerstone for their treatment options.
What are the long-term goals of evidence-based medical plans?
A number of health care industry, insurance, and governmental agencies have been looking at, providing the best health care:
- At the best cost
- With the best patient safety
- With the best patient outcome
Balancing all of those things between the different groups is obviously the challenge for the years ahead. It seems clear that it's high on the agenda for the next four years, and maybe beyond that. I think that having people trained and familiar with this process so there's not an inherent resistance when somebody is confronted with a guideline. Our natural tendency is to say, as physicians, we don't want to be told what to do. We don't want to be told here's the flowchart that you must follow.
I think understanding the process and knowing how to challenge it when we think it's appropriate, is going to be an important thing for all of us as we learn about this process. I think the most important thing from the scientific and the medical care standpoint is the evidence-based approach to a particular question clearly points out where the major deficiencies in the information are. If we study something that everyone thinks they know, we always say surgery is the best for situation X. When we actually go back and ask, "Who has provided information that shows that that's a superior outcome?" and you can't find it, that shows that's an area we need to address carefully. It helps us point out the role ahead for important studies and areas of expenditure for research money. |
