Tuesday, January 26, 2010

Enactment of Comparative Effectiveness Research -Libertarian Parternalism or Orszag type coercion

An excellent commentary by Dr. Jerome Groopman can be found here . It which offers a very thoughtful analysis of a number of issues related to comparative effectiveness research (CER) and what comes next.

He tells a narrative of two highly placed Obama administration players who views are seemingly widely divergent in regard to how to implement findings from clinical research; Cass Sunstein and Peter Orszag.

Sustein would "nudge" us along to do what is best for us while Orszag would implement, for example, the findings of comparative effectiveness research (CER) with " aggressive promulgation of standards and changes in financial and other incentives", the later approach finding a statutory home in the Senate health care bill but not the House bill.

Sustein and his collaborator Richard Thaler have brought to the current trendy universe of discourse and commentary the notion of "libertarian paternalism" (LP) replete with the concept of "Choice architect" and "nudging folks" to make the right decision in areas wherein their ignorance, cognitive limitations and lack of will power cloud their minds so that they do not do what in the view of the architects is the action which really is in their best interests. Basically the LP camp seems to say we ( the experts ) know what is best for you and we will in various not- really- coercive ways gently push you in the right direction. The more traditional progressive view, as exemplified by Orszag, is we know what is right and we,if necessary, will summon the force of law to make you do it.

Groopman favors the LP view and adduces persuasive evidence to the argument that a number of the so-called best practices and quality measures have been simply very bad ideas with bad consequences and I would add monuments to the hypertrophied hubris of those architects.These fiascos include the now notorious 4 hour rule for pneumonia,fountain of youth estrogen movement,very tight blood sugar control for critically ill patients, and relatively tight glucose control for ambulatory patients,statins for dialysis patients and I would add:beta blockers for almost everyone pre op.Other quality measures have been shown to have no effect one way or the other.

Goopman, in a David Hume-like argument, turns the notion of the cognitive biases that limit the non-expert humans back on the experts pointing out the obvious that they too may fall victim to the same biases, such as overconfidence, the focusing illusion and confirmation bias and that they tend to " overestimate [their] ability to analyze information, make accurate estimates and project outcomes". He even admits that he was subject to some of those foibles in what turned out to be an over-zealous push for Erythropoiesis-stimulating agents, in cancer patients.

Dr. Goopman then offers what I believe is a profound insight in regard to expert panel's "best practices".They may often fail to recognize and distinguish between those practices that can be standardized and not significantly altered by the particulars of the individual patient and those that those practices that must be altered to the individual patient. A check list to prevent infection when an IV catheter is inserted exemplifies the former and issuing a dictum that all ambulatory patients with diabetes should be treated to a given Hb AIc is an example of the latter.What blood sugar target level is optimal may vary not only between individual patients but also may vary often time with the same patient and the one size for everyone is a recipe for trouble.

To the extent they actually believe their own rhetoric both Obama and Orszag demonstrate a naive view of science and medical research. They speak of simply "finding out what works and what doesn't" seemingly ignorant of the fact that so often what we "determine" today from clinical research is contradicted tomorrow and how very difficult it can be to find out what is best or even define "best"Science offers provisional conclusions subject to refutation.

Dr. Groopman hopes that the Sunstein approach will be used- preferring nudging to coercion. Given a binary choice I would opt for nudging as well However, some have suggested that notion of libertarian paternalism is an oxymoron and some have raised a slippery slope concern see here for one discussion of those issues.Nudging might gradually morph into regular traditional coercive paternalism. I am reminded of the "third party experts" who profess to know what is best for you better than you do and Thomas Sowell's comments in that regard.See here to see and hear Sowell on that issue.

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