‘Evidence-based’, ‘Cost-Effective’ and ‘Preference-Driven’ Medicine: Decision Analysis Based Medical Decision Making is the Pre-Requisite

Abstract

Three broad movements are seeking to change the world of medicine. The proponents of 'evidence-based medicine' are mainly concerned with ensuring that strategies of proven clinical effectiveness are adopted. Health economists are mainly concerned to establish that 'cost-effectiveness' and not 'clinical effectiveness' is the criterion used in determining option selection. A variety of patient support and public interest groups, including many health economists, are mainly concerned with ensuring that patient and public preferences drive clinical and policy decisions. This paper argues that decision analysis based medical decision making (DABMDM) constitutes the pre-requisite for the widespread introduction of the main principles embodied in evidence-based medicine, cost-effective medicine and preference-driven medicine; that, in the light of current modes of practice, seeking to promote these principles without a prior or simultaneous move to DABMDM is equivalent to asking the cart to move without the horse; and that in fact DABMDM subsumes and enjoins the valuable aspects of all three. Particular attention is paid to differentiating between DABMDM and EBM, by way of analysis of various expositions of EBM and examination of two recent empirical studies. EBM, as so far expounded, reflects a problem-solving attitude that results in a heavy concentration on RCTs and meta-analyses, rather than a broad decision making focus that concentrates on meeting all the requirements of a good clinical decision. The latter include: ensuring that inferences from RCTs and meta-analyses to individual patients (or patient groups) are made explicitly; paying equally serious attention to evidence on values and costs as to clinical evidence; and accepting the inadequacy of 'taking into account and bearing in mind' as a way of integrating the multiple and distinct elements of a decision.

The Policy and Politics of Policy Appraisal: Emerging Trends and New Directions

“…But appraisal most certainly does link (and should take us back) to some rather hoary debates in public policy such as decision-making (Russel and Jordan 2009), policy co-ordination (Schout and Jordan 2007), and the development and (non-)utilization of evidence in politics (Dowie 1996;Pawson 2002;Sanderson 2006). Our aim in this article is to take stock of recent research on policy appraisal, identify what has been learned and discuss remaining gaps in the literature.…”

As a matter of fact: evidence-based decision-making unplugged

“…The main challenges to the evidence-based approach have tended to centre upon the criteria for the quality of the evidence of effectiveness and in particular the designs on which studies are based, 30 the lack of consideration of issues of patient preference and cost effectiveness 31 and the default strategy where the available research fails to meet these criteria. 32 To date, little attention has been paid to the interface between health care effectiveness and the determinants of health within populations.…”

Será que ensaios clínicos aleatórios podem inspirar decisões clínicas sobre pacientes individuais?

“…A questão importante é como, e se, podemos melhorar a qualidade das evidências para que possam ser melhor aplicadas a um dado paciente. Dowie (1996) afirma que um sistema de apoio à decisão formal capaz de refletir a complexidade da tomada de decisão e encorajar o reconhecimento explícito dos valores diferentes que cada paciente vincula a diferentes resultados, ajudaria a melhorar o uso da evidência obtida pelos ensaios clínicos, e ele pode estar certo. No entanto, a essência do argumento para mim é que os ensaios clínicos aleatórios dizem respeito basicamente a intervenções médicas e não a pacientes.…”