What does “more evidence based” mean?

I love evidence. I try hard to make medical decisions which reflect the best information available. Despite this, I shudder when I hear “experts” decry physicians not being evidence based. I shudder when I see presentations which only focus on performance measurement, and claim that they are presenting quality measures.

The problem with all evidence is that one must put that evidence into appropriate context. For example, lowering the hemoglobin A1c in diabetic patients decreases complications. However, we do not have evidence that trying to further lower the HgbA1c in a type II diabetic patient with a HgbA1c of 7.5, when that patient already takes two hypoglycemic drugs at maximal dosing. We do not know the evidence of the side effects of the third drug. We do not have studies which weigh the risks and benefits of this aggressive attack on HgbA1c. Yet currently adopted performance measure would penalize physicians for not achieving a target HgbA1c. If the patient started at 9.5 and achieved 7.5 with 2 drugs, then logic would tell us that the patient and physician have done an excellent job. They have greatly decreased the patient’s risk of complications.

Early in my training, a wise teacher reminded me to treat the patient, not the numbers. I love lab tests, and teach about their interpretation enthusiastically. But numbers mean nothing without understanding the patient’s context.

I dislike report cards because they include no context. True evidence based medicine should adjust for the patient’s starting point, their other conditions, their social situation and their economic situation. It sounds so scientific to admonish physicians for not heeding the evidence. What do you think?

We cannot measure quality through performance measurement. We can estimate one attribute of quality through performance measurement. Quality is a large complex construct. It includes (but is not restricted to) accurate diagnosis, appropriate use of diagnostic testing, good pharmaceutical decision making, and developing a positive patient-physician relationship.

So each time I hear pronouncements that a program has improved quality, I shudder. I shudder because these programs use partial information on quality. And we do not know whether concentrating on performance measurements help or hinder the other attributes of a quality physician.