Inappropriate use of medical services (both underuse and overuse) by physicians is rampant, affecting millions of patients. We know that because some of the nation's leading healthcare quality and safety experts reviewed several large-scale national studies and presented their findings to the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, which was formed during President Bill Clinton's administration.
The commission released a report in March, 1998, that stated: "Exhaustive research documents the fact that today, in America, there is no guarantee that any individual will receive high-quality care for any particular health problem. The healthcare industry is plagued with overutilization of services, underutilization of services and errors in healthcare practice." The central problem, as the Rand study had revealed, is clinicians' failure to follow evidence-based best practice guidelines that exist and have been proven to enhance the quality of healthcare delivery.
The commission's report acknowledged that physicians may have difficulty keeping up with an explosive growth in medical research, noting that the number of published randomized, controlled trials had increased from an average of 509 annually between 1975 and 1980 to 8,636 annually from 1993 through 1997. That's just for randomized, controlled trials. Several other types of studies considerably increase the number of annual research articles that physicians must keep up with to be current on scientific research findings. Plus, that was more than ten years ago; the numbers grow more rapidly each year.
From these data, the report concluded that a troubling gap exists between best practices and actual practices and that the likelihood that any particular patient will get the best care possible varies considerably. Translation: physicians aren't following the evidence.
Hospitals are on the hook as well and show wide gaps in their delivery of recommended care. The Leapfrog Group is a consortium of large employers that reports and compares hospital quality-performance data to help companies make healthcare purchasing decisions. (Full disclosure: Sanjaya Kumar is president and CEO of Quantros, the company that hosts the Leapfrog Group's Hospital Safety Survey.) The group tracks more than 1,200 U.S. hospitals that voluntarily report how well they adhere to a variety of evidence-based quality measures that are endorsed by the National Quality Forum (NQF) or are consistent with those of The Joint Commission and the Federal Centers for Medicare & Medicaid Services.
Results from the Leapfrog Group's 2009 hospital survey show that just over half of hospitals meet Leapfrog's quality standard for heart-bypass surgery; under half meet its standard for heart angioplasty; and under half of hospitals meet Leapfrog's quality standards for six common procedures, including high-risk surgery, heart-valve replacement and high-risk deliveries, even though nationally accepted scientific guidelines for these procedures exist and have been proven to save lives.
It's disturbingly clear from these studies that too many physicians and hospitals are not applying known, evidence-based and available guidelines for quality practice. Physicians are either ignoring or unaware of much better ways to treat their patients.
Knowing the right thing only one-fifth of the time
Failing to follow existing guidelines is only part of what makes so much of medical practice "unscientific." Another key reason is that there are so few solid, actionable scientific guidelines to begin with, and those that are available cover a relatively small slice of clinical care.
Part of the problem is that science, technology and culture are all moving targets. Today's dogma is tomorrow's folly, and vice versa. Many examples show that what physicians once accepted as truth has been totally debunked. Twenty years ago, for instance, physicians believed that lytic therapy for post-myocardial infarction would prolong a heart attack. The therapy involves clot-busting medication given to heart-attack patients. Today it is standard practice. Angioplasty and intracoronarylysis of clots are other examples. Years ago, surgery for benign prostatic hypertrophy (enlarged prostate) was one of the top DRGs (illnesses billed by hospitals) under Medicare. Today, we do far fewer of these procedures because of new drugs.
The public has little idea that physicians are playing a sophisticated guessing game every single day. That is a scary thought. We hope that one day we'll look back, for example, on cancer chemotherapy the same way we look back at the use of leeches, cupping and bloodletting.
Another part of the problem is that clinical knowledge generated by randomized, controlled trials takes far longer to reach the front lines of medical care than most people realize. Turning basic scientific discoveries into innovative therapies—from "laboratory bench to bedside"—takes up to 17 years. Existing scientific literature is being added to and undergoing overhaul every two years, which adds to the knowledge gap at the bedside.
Time lag notwithstanding, thousands of research articles are published every year, which presents a different challenge to delivering care based on the strongest evidence. Physicians can't always keep up with the volume of knowledge to be reviewed and put into practice, and those who don't provide poorer quality care. Medical advances occur frequently, and detailed knowledge quickly goes out of date.
Here's a counterintuitive consequence: the more years of practice experience a physician has, the more out-of-date his or her practice patterns may be. Research has documented this phenomenon of decreasing quality of clinical performance with increasing years in practice. Although we generally assume that the knowledge and skills that physicians accumulate during years of practice lead to superior clinical abilities, those physicians may paradoxically be less likely to provide what the latest scientific evidence says is appropriate care! It's all about the evidence and keeping up with it.
But just how comprehensive is the available scientific evidence for effective clinical practices? It is slimmer than most people think. Slice a pie into five pieces, and remove one piece. That slice represents the roughly 20 percent of clinical-care practices for which solid randomized, controlled trial evidence exists. The remaining four-fifths represent medical care delivered based upon a combination of less reliable studies, unsystematic observation, informed guesswork and conformity to prevailing treatments and procedures used by most other clinicians in a local community.
To illustrate how little scientific evidence often exists to justify well-established medical treatments, David Eddy researched the scientific evidence underlying a standard and widely used glaucoma treatment designed to lower pressure in the eyeball. He searched published medical reports back to 1906 and could not find one randomized, controlled trial of the treatment. That was despite decade after decade of confident statements about it in textbooks and medical journals, statements which Eddy found had simply been handed down from generation to generation. The kicker was that the treatment was harmful to patients, actually causing more cases of blindness rather than fewer.
Similar evidence deficits exist for other common medical practices, including colorectal screening with regular fecal-occult-blood tests and sigmoidoscopy; annual chest x-rays; surgery for enlarged prostates; bone-marrow transplants for breast cancer; and common approaches to pain control, depression, immunizations, cancer screening, alcohol and drug abuse, smoking and functional disabilities. The problem is rampant across medicine; a huge amount of what physicians do lacks a solid base of scientific evidence.