The National Academies
Institute of Medicine
January 24, 2008
Where is the wisdom we have lost in knowledge?
Where is the knowledge we have lost in information?
T. S. Eliot, The Rock (1934)
Recommendations
Building a Foundation for Knowing What Works in Health Care
Congress should direct the secretary of the U.S. Department of Health and Human Services to designate a single entity (the Program) with authority, overarching responsibility, sustained resources, and adequate capacity to ensure production of credible, unbiased information about what is known and not known about clinical effectiveness. The Program should:
* Set priorities for, fund, and manage systematic reviews of clinical effectiveness and related topics.
* Develop a common language and standards for conducting systematic reviews of the evidence and for generating clinical guidelines and recommendations.
* Prepare an annual report to Congress.
The secretary of Health and Human Services should appoint a Clinical Effectiveness Advisory Board to oversee the Program. Its membership should be constituted to minimize bias due to conflict of interest and should include representation of diverse public and private sector expertise and interests.
The Program should develop standards to minimize bias due to conflicts of interest for priority setting, evidence assessment, and recommendations development.
Setting Priorities
The Program should appoint a standing Priority Setting Advisory Committee (PSAC) to identify high priority topics for systematic reviews of clinical effectiveness.
* The priority setting process should be open, transparent, efficient, and timely.
* Priorities should reflect the potential for evidence-based practice to improve health outcomes across the life span, reduce the burden of disease and health disparities, and eliminate undesirable variation.
* Priorities should also consider economic factors, such as the costs of treatment and the economic burden of disease.
* The membership of the PSAC should include a broad mix of expertise and interests and be chosen to minimize committee bias due to conflicts of interest.
Assessing Evidence
The Program should develop evidence-based methodologic standards for systematic reviews, including a common language for characterizing the strength of evidence. The Program should fund reviewers only if they commit to and consistently meet these standards.
* The Program should invest in advancing the scientific methods underlying the conduct of systematic reviews and, when appropriate, update the standards for the reviews it funds.
The Program should assess the capacity of the research workforce to meet the Program’s needs, and, if deemed appropriate, it should expand training opportunities in systematic review and comparative effectiveness research methods.
Developing Clinical Practice Guidelines
Groups developing clinical guidelines or recommendations should use the Program’s standards, document their adherence to the standards, and make this documentation publicly available.
To minimize bias due to conflicts of interest, panels should include a balance of competing interests and diverse stakeholders, publish conflict of interest disclosures, and prohibit voting by members with material conflicts.
Providers, public and private payers, purchasers, accrediting organizations, performance measurement groups, patients, consumers, and others should preferentially use clinical recommendations developed according to the Program standards.
http://www.iom.edu/CMS/3809/34261/50718.aspx
Comment:
By Don McCanne, MD
Our mishmash that we call a health care system has two general characteristics that must be rectified. First, we provide both insufficient and excessive health care services that fall far short of the goals of high quality health care and optimal health care outcomes. Second, we waste an enormous amount of funds on poor quality, ineffective care while failing to spend enough on efficient, high quality services.
John Wennberg, Elliott Fisher and their colleagues have demonstrated the high prevalence of expensive, high-tech excesses that provide no net health care benefit. Barbara Starfield and colleagues have demonstrated that higher quality and less expensive health care is delivered by systems that reinforce their primary care infrastructures. Studies by RAND have demonstrated that those receiving the best care we have to offer are being deprived of important services that they would be receiving in a high performance system. The sad status of our health care system is exemplified by the recent report demonstrating that the United States, of nineteen OECD nations, has the worst rate of amenable mortality.
The Institute of Medicine has produced several reports that should provoke action on our part. One famous report demonstrated that 18,000 U.S. residents die each year merely because they lack health insurance. We dutifully read the report and filed it in the health policy section of our libraries. That number is now 22,000 and growing.
Let’s not do that with this report. It has long been recognized that we need to know what works in health care so that we can establish guidelines for better use of our resources. It is inconceivable that a system operating under the rules of market justice could ever erect the guideposts for such reform. For this to work for all of us, we need to shift toward using the rules of social justice.
Dispensing with the superfluous rhetoric, that simply means that we need our government to use the resources of the Department of Health and Human Services to move forward with the crucial goals described in this Institute of Medicine report.
While we’re at it, let’s provide our administrators with a modern, efficient, integrated method of financing health care that would ease the task of achieving the goals in the report. Let’s enact a single payer national health program.
