Why Some Health Policies Don't Make Sense at the Bedside

Abstract

Cost-effectiveness analysis and other forms of decision analysis are becoming more common in the medical literature and are increasingly influential in the development of health policy. Nevertheless, many clinicians find it difficult to apply policies developed from these analyses to individual encounters with patients. We examine the assumptions behind these analyses and argue that the perspective they embody can make clinical strategies appear to be less risky in theory than they are at the bedside. We believe that this problem underlies the intuitive concern many physicians have about policy analyses and calls into question the value of these analyses in shaping clinical practice. These analyses aggregate the benefits and burdens of alternative interventions across different individual persons. Thus, overall population risk appears blunted, as it would in a diversified portfolio of stocks that react differently to financial forces or in a herd of cattle that react differently to veterinary interventions. The assumptions behind these analyses make sense if aggregate outcome is what matters, but not if one cares about each individual investment or animal. Because such aggregation tends to understate individual risk, when applied to human health policy, it may misrepresent the interests of patients and cannot be assumed to provide useful guidelines for decision making at the bedside.

Risk communication in consultations about hormone therapy in the menopause: concordance in risk assessment and framing due to the context

“…The different perspectives of a policy-maker and an individual directly concerned by the situation might also be one of several explanations for the observed discrepancy between medical decisions made by physicians for groups and individual patients 25,26 . The discrepancy has given rise to the often questioned distinction between "objective" (sometimes referred to as "scientific") risk and "subjective" (or perceived) risk 27 .…”

Willingness to pay for diagnostic certainty

“…8 Mushlin et al's study of magnetic resonance imaging for patients with equivocal neurologic findings demonstrates that preferences regarding diagnostic certainty can determine whether an intervention is cost-effective for a particular patient. 9 Conversely, our study indicates that including the value of diagnostic certainty for PUD did not change cost-effectiveness rankings of management strategies even for individuals who placed the highest value on certainty.…”

The VALUE Framework: Training Residents to Provide Value-Based Care for their Patients

“…6,9 However, physicians and trainees alike have long struggled with applying policies developed for populations to their assessment and care of individual patients. 12 The VALUE Framework…”

“…Medical utility refers to the desirability of a health outcome. 12 It can reflect the patient's preferences before and after an intervention. The amount of utility obtained from conducting an intervention should be considered for each individual patient.…”