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Monday, January 26, 2015

Are patients pawns on the chess board of population medicine?

They would seem to  be at least so it appears to be in the presentation of the "population medicine approach" of by Dr. Harold Sox,former editor of the Annals of Internal Medicine, former president of the American College of Physicians (ACP) and former chair of the U.S. Preventive Services Task Force, offered in the November 13 ,2014 issue of  the Journal of the American Medical Association (JAMA).

Here is my thumbnail summary of what Dr. Sox wrote in describing how the population medicine approach would work.The major important diseases would be identified as would methods for their prevention. With that knowledge in hand , then funds could be transferred across patients and disease processes so that the maximal overall health benefit could be achieved.In this process it might well be that sometimes funds would be diverted away from the testing and treatment of some so that the preventive measures could be funded and then  " in a few generations" the benefit would be fully realized.He is explicit regarding the fact that in the short run some people would be harmed although he does not seem to explain why it would be only the short run as would not new preventative measures always be formulated and have funds diverted to their execution.The population medicine advocates claim the approaching of each patient strictly as a individual is "obsolete" and  are promoting a statistical medicine that claims to be capable of provided the greatest health benefit to the greatest number.Practicing physicians know how difficult it can be to recommend what might be best for the individual patient,the "populationists" glibly claim to know what is best for everyone.

In chess, pawns or for that matter any piece, might be sacrificed in executing a strategy of placing the opponent 's king in checkmate. Is it the case that individuals might be sacrificed in executing a strategy of maximizing the health of the specified population as measured by some metric such as quality adjusted life years  (QALY) per dollar spent ? After careful study and  multiple re-reads of Dr. Sox's article my answer to the question posed in this commentary's title is yes.The patients are the pawns on the chess board of population medicine.

1 comment:

W. Bond said...

In addition, if you follow through on the logic: Patient’s A, B, and C have a denial of services that they want so that D, E, F, G, H, I, and J can be treated. However – and as if often the case – if you look at the “microeconomics” of the situation, it will be far from this straightforward.

So, let’s say the service for patients A, B, and C is ICU care over the age of 75 (say some meta-analysis will find no survival benefit in the aggregate).

Meanwhile the service for D-J is a statin drug for primary prevention with a “pooled cohort” 10-year score of greater than 7.5%. Now, nearly all men over the age of 60 will meet this criteria, regardless of lipid profile and other risk factors. Even after an adequate explanation of pros and cons, patients D- J – or at least some of them - may decline said therapy.

So, one can easily imagine a situation where relatively healthy A, B, and C’s lives are needlessly endangered while they are critically ill with reversible and treatable acute illnesses (urosepsis, G.I. bleeds, etc).

At the same time patients D-J make an informed decision that they do not want their therapy. What to do with these illogical D-J? Well, we already have these wellness programs that charge employees for not meeting health goals [correction: that reward employees for meeting health goals; you’ll note the distinction without a difference]. When someone else is paying – even, indeed, if you are a net payer rather than recipient of these funds – how free are you to make this decision? One can easily imagine increasing penalties for the “non-compliant” with primary prevention recommendations, etc.

Preventative care is a positive good when freely chosen. However, will there be room for individual doctors and patients to disagree with guidelines? It’s still easier to deny than compel, but we’ll see.