george a. diamond, md, facc sanjay kaul, md, facc division of cardiology cedars-sinai medical center...
TRANSCRIPT
George A. Diamond, MD, FACCGeorge A. Diamond, MD, FACCSanjay Kaul, MD, FACCSanjay Kaul, MD, FACC
Division of CardiologyDivision of CardiologyCedars-Sinai Medical Center and Geffen School of Medicine at UCLACedars-Sinai Medical Center and Geffen School of Medicine at UCLA
Los Angeles, CaliforniaLos Angeles, California
Lost in Translation
From Clinical Trial Evidence to Practice
Guidelines
The following presentation is rated
PGPG BLUNT LANGUAGENAKED TRUTH
LLLL
NNNN
PEDANTIC GIBBERISH
JOSEPH R. Di PALMAJOSEPH R. Di PALMA
From Evidence to GuidelineLost in Translation
1967
JOSEPH R. Di PALMAJOSEPH R. Di PALMA
From Evidence to GuidelineLost in Translation
1967
1.1. Buy an ECG machine.Buy an ECG machine.
2.2. Use it as often as you can!Use it as often as you can!
Di Palma’s Laws
From Evidence to GuidelineLost in Translation
1967
From Evidence to GuidelineLost in Translation
CARDIOLOGYCirca 1967
From Evidence to GuidelineLost in Translation
CognitiveFirewall
Exoskeleton
StentDeploymentProsthesis
RadiationShield
NeuralTransceiver
HolographicImagingSystem
GuidelineSupports
StonePlatform
LoinGirds
CARDIOLOGYCirca 2009
From Evidence to GuidelineLost in Translation
Bill
ions
of
Dol
lars
2500
2000
1500
1000
500
0 1967 2009
46 5
2220
475
Health care
CV care
29532
Cardiovascular disease
Perinatal disease
Injuries
Cancer
COPD
HIV/AIDS
Other causes
Change in Life Expectancy(yrs)
N Engl J Med 2003;349:868N Engl J Med 2007;356:2388
-1 0 1 2 3 4 5
• 54% Risk factors• 40% Treatment
• 3.5% CABG• 1.5% PCI
• 6% Unexplained
From Evidence to GuidelineLost in Translation
G. B. SHAW
“Having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking, we go on to give a surgeon a pecuniary interest in cutting off your leg.”
The Doctor’s Dilemma, 1911
From Evidence to GuidelineLost in Translation
“Right now, doctors, a lot of times, are forced to make decisions based on the fee payment schedule that's out there. So if…your child has a bad sore throat…the doctor may look at the reimbursement system and say to himself, ‘You know what? I make a lot more moneyif I take this kid's tonsils out.’”
BARACK OBAMA
From Evidence to GuidelineLost in Translation
July 22, 2009
“Right now, if a physician helps a diabetic lose weight, modify diet, monitors their medications in a timely fashion, they might get reimbursed a pittance. But if that same diabetic ends up getting their foot amputated, that's $30,000, $40,000, $50,000 immediately the surgeon is reimbursed.”
BARACK OBAMA
From Evidence to GuidelineLost in Translation
August 12, 2009
“Health insurance
companies and their
executives have reaped
windfall profits from a
broken system.”
From Evidence to GuidelineLost in Translation
BARACK OBAMAJuly 22, 2009
-20
-10
0
10
20
Per
cent
Pro
fit
Forbes, 2009
From Evidence to GuidelineLost in Translation
BARACK OBAMA Industry Ranking
HEALTH INSURANCE
2.2%
The Complete Lives System
Hastings Center Rep 1996;26:12
“[Healthcare] services that promote the continuation of the polity – those that ensure healthy future generations, practical reasoning skills, and full participation in public deliberations – are to be socially guaranteed as basic. Conversely, services to individuals who are irreversibly prevented from being or becoming participating citizens are not basic and should not be guaranteed.”
EZEKIEL J. EMANUEL
From Evidence to GuidelineLost in Translation
0 10 20 30 40 50 60 70
Age
Prob
abilit
y of
Rec
eivin
g an
Inte
rven
tion
Lancet 2009;373:423
The Complete Lives System
From Evidence to GuidelineLost in Translation
EZEKIEL J. EMANUEL
“Any health care funding plan that is just, equitable, civilized and humane must – must – redistribute wealth from the richer among us to the poorer and the less fortunate. Excellent health care is by definition re-distributional.”
DONALD BERWICK
From Evidence to GuidelineLost in Translation
July 1, 2008
“I cannot say that I vehemently support or oppose any of the provisions in the proposed health care reform legislation. I am prepared to leave the details to others, and pray that they know what they are doing.”
J Am Coll Cardiol 2009;21:1991
TONY DeMARIA
From Evidence to GuidelineLost in Translation
ACC/AHA “Useful and Effective”
FDAFDA “Safety and Efficacy”“Safety and Efficacy”
CMSCMS “Reasonable and Necessary”“Reasonable and Necessary”
PayersPayers “Usual and Customary”“Usual and Customary”
CourtsCourts “Prudent and Cautious”“Prudent and Cautious”
Regulatory Standards
From Evidence to GuidelineLost in Translation
From Evidence to GuidelineLost in Translation
• Empirical evidence trumps expert opinion
• Clinical importance trumps statistical significance
• Individual outcomes trump population averages
• Professional principles trump regulatory standards
We hold these truths to be self-evident…
From Evidence to GuidelineLost in Translation
1. Establish the scientific evidence• Assess quality and quantity
• Publish meta-analytic summaries
From Evidence to GuidelineLost in Translation
1. Establish the scientific evidence
2. Elucidate the clinical context
• Weighted composite outcomes
• Minimum clinically important difference
From Evidence to GuidelineLost in Translation
1. Establish the scientific evidence
2. Elucidate the clinical context
3. Encourage optimal processes of care
• Performance measures
• Reimbursement incentives
From Evidence to GuidelineLost in Translation
Guideline Management
Clinical Care
