Evidence-Based Medicine and the Changing Nature of Health Care: Meeting Summary

203 Pages·2008·3.39 MB·English

by  Mark B. McClellan, J. Michael McGinnis, Elizabeth G. Nabel, LeighAnne M. Olsen, Institute of Medicine

Mark B. McClellan, J. Michael McGinnis,
Elizabeth G. Nabel, and LeighAnne M. Olsen
http://avaxhome.ws/blogs/ChrisRedfield
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Suggested citation: IOM (Institute of Medicine). 2008. Evidence-based medicine and the
changing nature of health care: 2007 IOM annual meeting summary. Washington, DC: The
National Academies Press.
“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
—Goethe
Advising the Nation. Improving Health.
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Foreword
Evidence-based medicine (EBM) has been famously characterized by
David Sackett as the “conscientious, explicit, and judicious use of cur-
rent best evidence in making decisions about individual care.” The central
notion in EBM of the importance of integrating individual clinical expertise
with the best available external evidence provides a helpful framework for
providers navigating the uncertainty inherent in patient care. The selection
of EBM as a topic for the 2007 Annual Meeting of the Institute of Medicine
(IOM) signals its potential as a key driver toward greater value and effi-
ciency in medical care. Technological and scientific innovations continue to
expand the universe of medical interventions, treatments, and approaches
to care, ushering in an era rich with potential for improving the quality of
health care but also rife with increased uncertainty about what works best
for whom. That uncertainty can—and does—lead to the delivery of services
that may be unnecessary, unproven, and sometimes harmful.
This publication, Evidence-Based Medicine and the Changing Nature
of Health Care, documents the content of the 2007 IOM Annual Meeting.
In the years ahead, demographic, epidemiologic, and technologic develop-
ments will foist change on health care. Reforms will be necessary to remedy
existing shortfalls in access to care as well as to take better advantage of the
opportunities provided by innovation, information technology, and broader
stakeholder engagement.
At this time in our nation’s history, a host of health policy issues
dominate the headlines, from the safety of imported drugs to children’s
healthcare coverage. Amid the cacophony surrounding each debate, the
IOM strives to voice objective, independent, evidence-based counsel and
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vi FOREWORD
recommendations on critical questions. We know from experience that as-
cendancy and importance of healthcare access, cost, and quality challenges
are no guarantees of action. The IOM’s mission is to draw attention to
issues and options that lay the groundwork for policy. We work to engage
the field, facilitate needed discussion and debate, and develop sound policy
recommendations.
The last 2 years have seen a burgeoning interest in convening activities
at the IOM: the forums and roundtables that bring together individuals
from government, academia, business, and the public at large for collec-
tive consideration and action around common problems. The Roundtable
on Evidence-Based Medicine draws upon the many perspectives within
the healthcare field, informs the debate, and provides an opportunity for
dialogue among key stakeholders. The Roundtable’s overview publication,
The Learning Healthcare System, outlines a number of opportunities to
transform the development and use of evidence to improve health care. The
subsequent workshops and meetings in the Learning Healthcare System
series delineate research methods, assess data availability, and describe ways
to improve research on the effectiveness of healthcare delivery. The 2007
IOM Annual Meeting drew upon the Roundtable membership for planning
and execution and builds upon some of the work of the Roundtable. This
publication is the second in the Learning Healthcare System series.
I would like to offer my personal thanks to Roundtable participants,
particularly Mark McClellan, Betsy Nabel, and Michael McGinnis, for their
contributions as part of the planning committee.
Harvey V. Fineberg, M.D., Ph.D.
President, Institute of Medicine
Preface
The creative and innovative ethic of American medicine is legend and
has contributed fundamentally to the breadth, depth, and pace of advances
in our capacity for diagnosis and treatment of disease and injury. Indeed,
the number of new pharmaceuticals, biologics, medical devices, and health-
care services introduced into American healthcare settings and market-
places substantially exceeds the capacity to know the circumstances under
which a particular intervention is best applied. The consequences of this
gap between assessment capacity and available services include increasing
uncertainty about what constitutes “best care,” a steady expansion in the
national and personal cost of medical care, and a substantial growth in con-
cern and distrust among physicians and patients alike. The need is acute for
better evidence to guide the decisions of patients and their caregivers on the
approaches most appropriate to individual circumstances and preferences.
This need for a more systematic approach to evidence development
and application, as well as the prospect of new ways of meeting the need,
provides the back-drop for the discussions at the 37th Annual Meeting of
the Institute of Medicine (IOM). Entitled Evidence-Based Medicine and
the Changing Nature of Health Care, this meeting was held on October 8,
2007, and focused on the potential of evidence-based medicine to help
deliver the promise of scientific discovery and technological innovation and
provide the right care for the right patient at the right time.
The annual meeting was structured to bring together many of the na-
tion’s leading authorities on various aspects of the issues—both challenges
and opportunities—to present their perspectives and engage in discussion
with the IOM membership. Included in the presentations, and documented
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viii PREFACE
in this publication, are summaries of the rapidly changing nature of the
science base and tool chest for medical practice; the implications for the
costs, quality, and effectiveness of health care; the challenges to individual
practitioners; possible means of accelerating the necessary assessment of
the appropriateness, effectiveness, and value of medical care; and the policy
changes necessary to improve the efficiency and outcomes of the American
healthcare system.
Organization of this meeting was facilitated by the experience and com-
mitment of the IOM’s Roundtable on Evidence-Based Medicine, in which
we are participants. Convened in 2006, the IOM Roundtable is comprised
of about two dozen members representing national leadership from the
various stakeholder sectors important to progress in health care: patients
and the public, providers, service delivery organizations, health researchers,
government agencies, employers, insurers, health product manufacturers,
and information technology organizations.
The Roundtable’s vision is for a learning healthcare system that “draws
upon the best evidence to provide the care most appropriate to each patient,
emphasizes prevention and health promotion, delivers the most value, adds
to learning throughout the delivery of care, and leads to improvements in
the nation’s health.” In effect, the learning healthcare system is one which
enlists organizations, providers, and patients in driving the process of
discovery as a natural outgrowth of patient care, and ensures innovation,
quality, safety, and value in health cares. As a tangible focus for progress
towards this vision, the Roundtable has set the goal that by 2020, 90 per-
cent of clinical decisions will be supported by accurate, timely, and up-to-
date clinical information, and will reflect the best available evidence. While
ambitious, this goal ought to be achievable, given the nation’s commitment
of more that one out of every six dollars to the delivery of health care.
We are pleased to have had the opportunity to present some of the
key perspectives motivating the Roundtable’s work over the last 2 years to
the distinguished IOM membership, in serving as the planning committee
members for the Annual Meeting and as authors of this publication.1 We
would like to also acknowledge our Roundtable colleagues who served as
discussion moderators, and, in particular, the individual contributors who
donated their valuable time and insights to the scientific program through
their presentations and through their efforts to further develop the content
into the manuscripts contained in this summary.
A number of IOM staff were instrumental in the preparation and
conduct of the meeting, including Afrah Ali, Sandra Amamoo-Kakra, Bryn
1 The responsibility for the published annual meeting summary rests with the authors and
the institution. IOM forums and roundtables do not issue, review, or approve individual
documents.
PREFACE ix
Bird, Allison Brantley, Sarah Bronko, Thelma Cox, Donna Duncan, Patrick
Egan, Amy Haas, Geraldine Kennedo, Adam Rose, Autumn Rose, Sara
Sairitupa, Judith Shamir, Kristina Shulkin, and Jovett Solomon. The re-
sponsibility for assembling the volume from the meeting was carried out by
Roundtable staff under the direction of LeighAnne Olsen and included the
work of Katharine Bothner, Molly Galvin, and Daniel O’Neill. We would
also like to thank Lara Andersen, Michele de la Menardiere, and Bronwyn
Schrecker for helping to coordinate the various aspects of review, produc-
tion, and publication.
As illustrated in this publication, the challenges facing the nation’s
healthcare system are great, as is its promise. We look forward to expand-
ing the sphere of engagement and action in the field to capture the substan-
tial opportunities identified in this publication and the vision we all share
for the health and productivity of Americans.
Mark B. McClellan, M.D., Ph.D.
IOM Annual Meeting Co-Chair
Director, Engelberg Center for Health Care Reform,
Leonard D. Schaeffer Chair in Health Policy Studies
The Brookings Institution
Elizabeth G. Nabel, M.D.
IOM Annual Meeting Co-Chair
Director, National Heart, Lung, and Blood Institute
J. Michael McGinnis, M.D. M.P.P.
Executive Director, Roundtable on Evidence-Based Medicine