Cross design synthesis : a new strategy for medical effectiveness research : report to Congressional requesters / United States General Accounting Office.

  • United States. General Accounting Office.
Date:
[1992]
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Licence: Public Domain Mark

Credit: Cross design synthesis : a new strategy for medical effectiveness research : report to Congressional requesters / United States General Accounting Office. Source: Wellcome Collection.

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    Chapter 1 Introduction and Review of Study Designs for Evaluating Treatment Effectiveness Our nation’s “crisis of health care” has been defined mainly in terms of excessively high and ever-escalating cost, but there are also indications that, despite its high cost, the quality of health care is not optimal. The problem of quality has many manifestations, some of which point to a surprising lack of knowledge about “what works in medicine.” Indeed, more and better information is needed if the nation is to discriminate among medical interventions that are clearly beneficial for specific types of patients, those interventions that are less so, and those that do little but drive up the costs of health care and may even subject some patients to needless risk. Many new medical technologies in common use have never been rigorously evaluated (Mosteller et al., 1985). Many other treatments have been evaluated in studies that cannot be generalized across the full range of medical practice. Numerous procedures have been routinely applied to broad classes of patients—even when the benefits of these procedures are uncertain for all patients or are known only for certain kinds of cases. Electronic fetal monitoring is a case in point. This procedure was introduced for use with high-risk births in the early 1970s and, over time, came to be used routinely for normal deliveries. Sizable scientific evaluations eventually showed that, aside from high-risk cases, electronic fetal monitoring is no more effective than the earlier standard approach—which was based on intermittent use of the stethoscope (see Leveno et al., 1986). Now, the American College of Obstetricians and Gynecologists has concluded that electronic fetal monitoring provides no benefit over the stethoscope (Sandmire, 1990). Hysterectomy and drug therapy for hypertension are two other examples of procedures that, in the absence of comprehensive studies, were applied to much broader patient groups than originally intended (see Mosteller et al., 1985). These examples suggest that the lack of information about “what works in medicine” has led to the overuse of certain treatments—one source of needless increases in the cost of care. There may also be parallel instances of underutilization, although these seem more difficult to identify. To improve the quality of health care, the Congress established the Agency for Health Care Policy and Research (AHCPR) in December 1989. One way in which the new agency is to move toward improved quality of care is by conducting rigorous evaluations to produce relevant information on the effectiveness of medical interventions. But there is an increasing realization of how elusive accurate information can be. Leading experts in