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Rational use of health technology

Yot Teerawattananon M.D., Ph.D.

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mResidents

to learn every fact and detail in order to take responsibility for a patients’ life

Goal: to store encyclopedia in mind!

Bedside teaching - data, hypotheses, confirmation

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Fresh-and-blood decision making

pattern-recognition-reflects an immediacy of perception without any conscious analysis

Medical decision making—objective and rational process?

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mAttitude and Emotion

êćøćÜìĊę1 ĒÿéÜñúÖøąì ï ì ćÜéšćîÿč×õćóĒúąéšćîđýøþåÖĉÝĒúąÿĆÜÙö×ĂÜðŦâĀćì ćÜÿč×õćóÝĉêìĊęöĊêŠĂñĎšðśü÷ǰĒúąâćêĉĀøČĂñĎšéĎĒú

ñúÖøąìï êŠĂñĎšðśü÷ êŠĂâćêĉĀøČĂñĎšéĎĒú

éšćîÿč×õćó

đÿĊ÷ßĊüĉêđøĘüÖüŠćðøąßćÖøìĆęüĕð: ÖćøýċÖþćĔîĂđöøĉÖćóïĂć÷č×Ć÷đÞúĊę÷ĒêÖêŠćÜÖĆîëċÜǰ25ðŘ(11)ǰǰàċęÜĔîñĎšðśü÷Ýĉêđüß×ĆĚîøčîĒøÜøšĂ÷úą 30-40 đÿĊ÷ßĊüĉêÝćÖÖćøÛŠćêĆüêć÷ĒúąÖćøïćéđÝĘïĒúą øšĂ÷úąǰ60-70 đÿĊ÷ßĊüĉêÝćÖēøÙìćÜÖć÷ǰǰ

ðŦâĀćÖćøđÝĘïðśü÷ìćÜéšćîøŠćÜÖć÷ǰđߊî ǰñĎšéĎĒúñĎšðśü÷ÿöĂÜđÿČęĂöĂćÝđÖĉéõćüąĕ×öĆîĔîđúČĂéÿĎÜǰõćüąîĚĞćêćúĔîđúČĂéÿĎÜǰøüöìĆĚÜöĊñúÖøąì ïêŠĂøąï ï õĎöĉÙčšöÖĆî (22)

öĊēøÙìćÜÖć÷öćÖÖüŠćðøąßćÖøìĆęüĕð: öĊēøÙøŠüöìćÜÖć÷(12-14) (CHD, MI, stroke, COPD Ēúąǰmetabolic syndrome) àċęÜðŦÝÝĆ÷đÿĊę÷ÜìĊęđóĉęö×ċĚî (23)đÖĉéÝćÖÖćøĂ÷ĎŠĔîÿĉęÜĒüéúšĂöìĊęĕöŠéĊĒúąÖćøĕöŠéĎĒúêîđĂÜǰìĊęđÖĉéÝćÖĂćÖćø×ĂÜēøÙǰđߊî ǰÖćø×ćéĒøÜÝĎÜĔÝǰĒúąÙüćöñĉéðÖêĉĔîÙüćöÙĉé

ðŦâĀćÖćøđÝĘïðśü÷ìćÜéšćîÝĉêĔÝ(24-27)ǰđߊî ǰõćüąđÙøĊ÷éǰüĉêÖÖĆÜüúĒúąàċöđýøšćǰàċęÜđÖĉéÝćÖĀúć÷ÿćđĀêčǰđߊî ǰÙüćöøĎšÿċÖĂĆïĂć÷êŠĂĂćÖćø×ĂÜñĎšðśü÷ǰÖćøìĊęêšĂÜðøĆïđðúĊę÷î ï ì ï ćì×ĂÜêîđĂÜĔĀšÿĂéÙúšĂÜÖĆïÙüćöđÝĘïðśü÷×ĂÜñĎšðśü÷ǰÙüćöøĎšÿċÖñĉé ÙüćöñĉéĀüĆÜǰÖćøÿĎâđÿĊ÷ÙüćöòŦîĒúąÙüćöÙćéĀüĆÜìĊęöĊêŠĂêĆüñĎšðśü÷ǰ

ĕéšøĆïÖćøïøĉÖćøìćÜÖćøĒóì÷ŤìĊęéšĂ÷ÖüŠćðøąßćÖøìĆęüĕð:ǰÝćÖìĆýîÙêĉì ćÜúï ǰÖćøêĆĚÜךĂøĆÜđÖĊ÷Ý×ĂÜñĎšĔĀšïøĉÖćøìĊęüŠćñĎšðśü÷ÝĉêđüßéĎĒú÷ćÖǰđÿĊ÷đüúćǰÿČęĂÿćøĕöŠđךćĔÝ(28)ǰöĆÖĕöŠøŠüööČĂĔîÖćøøĆÖþćĒúąÙüćöđßČęĂìĊęüŠćĂćÖćøêŠćÜėǰìĊęđÖĉé×ċĚîÖĆïñĎšðśü÷îŠćÝąđÖĉéÝćÖĂćÖćøìćÜÝĉê(15, 16)

ðŦâĀćÙüćöÿĆöóĆî íŤì ćÜđóýÖĆïÙĎŠÙøĂÜ(29, 30)ǰÖćøýċÖþćĔîÙĎŠÿćöĊõøø÷ć×ĂÜñĎšðśü÷ÿöĂÜđÿČęĂöóïüŠćöĊðŦâĀćđóýÿĆöóĆî íŤĒúąîĞćĕðÿĎŠõćüąàċöđýøšćĔî ìĊęÿčé

e.g. negative feeling towards psychiatric patients

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mMedical errors

Technical errors Cognitive errors—mistakes in thinking from emotions influencing perceptions and judgments, actions and reactions

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mOpinion leaders

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Testosterone replacement therapy

Klinefelter syndrome Pituitary apoplexy

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Repetitive strategy used in HPV vaccine for men!

An experience of decrease libido? Enjoy life less? Irritable, less efficient at work? Falling asleep after dinner?

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Screening questions for andropause

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Off-label use of medicines

Intravitreal bevacizumab (Avastin) vs. ranibizumab (Lucentis) for Rx of age-related macular degeneration

Cisplatin for Rx of lung cancer Problem arises when the marketing is ahead of the medicines!

NIH concluded andropause had no scientific support

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mRoutine preoperative

chest x ray 70% done in the US 10% abnormal

findings 1.3% unanticipated

abnormality after a thorough history and physical exam

0.1% changed management

Source: Munro J, Booth A, Nicholl J. Routine preoperative testing: a systematic review of the evidence. Health Technology Assessment 1997: Vol 1.: No 12 11

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m NICE clinical guidance on routine preoperative tests for elective surgery (2003)

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mPercentage of otherwise healthy individuals examined preoperatively by x-ray, ECG, and laboratory testing before and after the SBU report. Also presented is the percentage of patients admitted on the day of the surgery at the time of the two studies.

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%

1989, before the SBU report

1994, after the SBU report

Source: Måns Rosén, The Swedish Council on Health Technology Assessment INHAT annual meeting 2010, Dublin

These practices resulted in savings in the range of 24 million euros annually!

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mThe case of electronic fetal

monitoring (EFM)

Rapid diffusion into health care during 1970s

Claims of substantial benefits in terms of fetal deaths and injuries

Results from 12 trials (37,000 women) s howed no significant difference in overal

l perinatal death rate, cerebral palsy but increase in caesarean sections and instr umental vaginal birth

- - Data for subgroups of low risk, high risk, preterm pregnancies were consistent wi

th overall results

Source: Alfirevic Z, Devane D, Gyte GML. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews 2006, Issue 3.

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WHO you see is What you get

Technologies used in diagnosing chronic back pain which is the only

one with real effectiveness? Physical examination Mobility/muscle tests X-ray MRI CT-scanning Neurophysiologic tests Electromyograms (EMGs)

Facet blocks Stress radiography Discography Nerve root infiltration Bone scintigraphy Termography Ultrasound Serology test

15Source: Neck and Back Pain: The Scientific Evidence of Causes, Diagnosis, a

nd TreatmentEdited by Alf L . Nachemson and Egon Jonsson . Philadelphia, Lippincott Williams & Wilkins, 2000 .

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Communication strategy of pharmaceutical companies through health professional

Publication strategy• To sponsor minimal research/favorable

comments by academic researchers• Monitoring-answer the questions of research

Medical education and communication Strategy• Professional meetings-supporting off-label use

Doughnuts for the doctors• Psychology of gift-giving–obligate to give back

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mFinal remarks

Plenty of known unknown and unknown unknows in health sciences: there is almost no absolutely truth

Need to keep up-to-date information and be evidence-based in making decisions

Scarcity of resources: need to be sensible in spending health resources

“We, in fact, pay ourselves all health care bills” 17

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m“ There are known knowns. These are things we know that we know. There are known unknowns. That is to say, there are things that we now know we don’t know. But there are also unknown unknowns. These are things we do not know we don’t know.”

The former US Defense Secretary Donald Rumsfeld

February 12, 2002

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