Why Evidence-Based Medicine?

Let’s start with a few questions with answers that may surprise you:

• Can medical care sometimes do more harm than good? 
• Can a treatment for a particular medical problem be the right choice for one person and the wrong choice for another? 
• Can more testing or medical care be worse than less testing or care? In other words, is more always better? 
• Are the newest and most technologically advanced treatments always the best? 
• Are there times when it is better not to find a cancer?

Let’s take a closer look at these questions and some examples.  

Can medical care sometimes do more harm than good?

An example is use of an MRI scan to evaluate low back pain. MRI machines can produce beautiful pictures of the spine and the nerves associated with it. They show the different parts in remarkable detail. Sounds like a good idea if you want to know what is going on in your back when it hurts. The problem is that MRI scans are sometimes too good at finding abnormalities. Because all of us experience some gradual degeneration in spinal discs as we age, it is very common to find “abnormalities” even in people with no symptoms at all (up to 30 in 100 individuals).

In a research study done to see if MRIs helped in the care of people with low back pain, one-half were given an MRI early in their evaluation and the other half only if things weren’t improving with simple care. After 12 months the two groups had equal improvement in their symptoms. However, the people that had the MRI were more likely to have had surgery (even though their group did no better in the long run). Would you like to have spine surgery if it made no difference in how you recovered from your back pain? Probably not.

There are many other examples of “over-diagnosis” and unneeded treatments. It is best when considering a test or treatment to understand the risks, as well as the benefits it may have -- and potential alternatives. 

Can a treatment be right for one person and not for another? Are there times when it is good NOT to find a cancer?

Let’s take a look at prostate cancer. We have become very good at diagnosing prostate cancers, but not all of them will cause problems for the man that has it. In fact, with prostate-specific antigen (PSA) testing, about 17 percent of men will be diagnosed, but only 3 percent will die from it – most of the time it is not a lethal cancer! Even with current treatment, we can only cut the 3 percent who would die down to 2 percent. If you were able to see all prostate cancers, it is estimated that 30 percent of men in their 40's, 40 percent of men in their 50’s and so on through the ages have cancer cells in their prostates. Treatment for prostate cancer frequently results in loss of urinary control and loss of sexual function. Less frequently it results in more severe complications, including death. For some men, the risks of treatment are worth taking even if the likelihood of dying from the cancer is low, because any risk of dying from cancer is too high for them to accept  For others, the possible impacts on quality of life are severe enough to justify keepin an eye on the cancer without treating it to see whether and how it progresses. Again, there is not a right or wrong choice. It depends on how you feel about the potential consequences and how well you understand them. But for many men, it may be best not to find the cancer in the first place. 

Is less care sometimes better than more? Are the newest and most technologically advanced treatments always the best?  

It is common to assume that healthcare services consistently improve health, so why not use them generously (especially the latest and greatest technologies)? Let’s consider the most common and serious problem in the United States, the one which kills more people  than anything else: Coronary artery disease, the cause of heart attacks. Over the years, doctors have developed procedures to open narrowed and blocked arteries that supply life-giving blood to the heart muscle. If you are having a heart attack, opening the problem blood vessel with a small balloon (angioplasty) can save your life and preserve heart function. Angioplasty is also commonly used to treat chest pain (angina) caused by narrowed arteries, supplying the heart and opening blood vessels that have already caused a heart attack. Interestingly, research has clearly shown that angioplasty does nothing to prolong life or prevent heart attacks unless you are having one at the time or have particularly severe blockages. The procedure controls angina in a few more people than medication does (though most peoples’ pain is controlled with medication alone). But is invasive and can cause complications. It is also very expensive. In spite of this knowledge, most people who get angioplasty feel that it will prevent heart attacks and lengthen their life better than medication alone -- even though we know it won’t. For many people, angioplasty involves risks, discomfort and high expenses that do not improve their symptoms better than medicine alone. Nor does it improve their long-term outlook for good health.

So you see, the more you know, the better your choices will be.

Engaged Benefit Design provides incentives to learn more about treatments that may or may not be right for an individual. The amount a person pays for them is higher.  However, they may be eligible for a reward if they take the time to learn about the treatment and discuss it fully with their doctor. Other services -- those that evidence shows should always be done in particular circumstances -- are covered without any co-payment.