The Break-Even Point: When Medical Advances Are Less Important Than Improving the Fidelity With Which They Are Delivered

Abstract

Society invests billions of dollars in the development of new drugs and technologies but comparatively little in the fi delity of health care, that is, improving systems to ensure the delivery of care to all patients in need. Using mathematical arguments and a nomogram, we demonstrate that technological advances must yield dramatic, often unrealistic increases in effi cacy to do more good than could be accomplished by improving fi delity. In 2 examples (the development of antiplatelet agents and statins), we show that enhanced effi cacy failed to achieve the health gains that would have occurred by delivering older agents to all eligible patients. Society's huge investment in technological innovations that only modestly improve effi cacy, by consuming resources needed for improved delivery of care, may cost more lives than it saves. The misalignment of priorities is driven partly by the commercial interests of industry and by the public's appetite for technological breakthroughs, but health outcomes ultimately suffer. Health, economic, and moral arguments make the case for spending less on technological advances and more on improving systems for delivering care. INTRODUCTIONA lthough modern medicine can be proud of its successes in the prevention and treatment of disease, much more can be done to alleviate morbidity and premature mortality. Two transcendent problems predominate. First, available care is not delivered well: Americans do not always obtain the interventions that would improve their health or prevent illness. By one account, Americans receive only 55% of recommended health care services.1 Gaps in delivery are even greater for the poor and for racial and ethnic minorities.2 Second, the interventions that Americans do receive have limited effi cacy in improving outcomes. More lives could be saved by developing better drugs, technologies, and procedures. In effect, society faces a choice between these 2 strategies for bettering health and must strike a prudent balance in how many resources it allocates to each endeavor. FidelityThe fi rst endeavor addresses what might be described as the fi delity of health care. Independent of the effi cacy or effectiveness of interventions, fi delity is the extent to which the system provides patients the precise interventions they need, delivered properly, precisely when they need them. Fidelity is lacking when patients cannot make known their need for care (eg, there are barriers in access or communication), when clinicians cannot recognize that an intervention is indicated (eg, there is a lack of time, knowledge, attention, or memory), and when the intervention cannot be delivered properly (eg, there is inadequate infrastructure, procedures, safety, coordination, or information). Fidelity has less to do with the properties of interventions than with the functionality of the system that delivers them. It requires systems of care (eg, practice groups, hospitals) to have intelligent designs, skilled professionals, coordinated teams, adequate resources, compe...

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