Evidence-Based to Value-Based MedicinePDF
ACP J Club. 2006 May-Jun;144:A10. doi:10.7326/ACPJC-2006-144-3-A10
Evidence-based medicine (EBM) is an approach to clinical care based on the claim that the appropriateness of clinical interventions should be justified by the existence of high-quality evidence for the effectiveness of the intervention rather than on other grounds, such as the authority of the clinician, tradition, or politically motivated policy. EBM continues to have a significant impact on the development of medicine and more widely on health care practice, being a key motivating factor, for example, in the creation of the United Kingdom's National Institute for Clinical Excellence (NICE).
In Evidence-Based to Value-Based Medicine, Brown, Brown, and Sharma argue that the evidence base of EBM should be broadened to take into account the patient-perceived value of interventions. The authors contend that this will lead to a more sophisticated and accurate measure of the comparative worth of interventions to patients and to other stakeholders, thereby both improving the quality of health care and leading to significant savings through a more appropriate use of limited health care resources.
In this book, the authors set out the values-based medicine (VBM) agenda and explain how this approach might be introduced into day-to-day medical practice. Through case studies and explanation, the authors introduce ways in which health care workers can develop values-based clinical care and give advice about how best to communicate the rationale for interventions to patients and policymakers.
The VBM approach is introduced as a 3-layered pyramid. At the base of the pyramid, the foundation of VBM is provided by EBM as traditionally conceived. The middle layer of the pyramid is evidence about the patient-perceived value of the intervention. The final layer, the apex of the pyramid, is the integration of values and costs, using cost-utility analysis, to arrive at VBM itself.
The book begins with an introductory overview of the concept of VBM, followed by sections introducing the 3 levels of the pyramid. The first introduces the concept and techniques of EBM (the foundation of the pyramid). The second introduces mechanisms for assessing the values component of VBM using the twin concepts of “quality of life” and “length of life.” The final section shows health professionals and policymakers how to bring together EBM and information about quality in VBM (the top level of the pyramid).
This book is well structured and presented in a way that most health professionals will find accessible. Each chapter is interspersed with important points to consider and concludes with a summary of core concepts. The authors are evangelists for the VBM approach and do a good job of showing readers its attractions and practical utility. But, as for any approach to health care policy, it raises as many questions as it answers. First, the idea that VBM introduces value into EBM suggests, implicitly, that EBM itself is relatively value-free. VBM does introduce value considerations that are not explicit in EBM by importing previously excluded data about the extent to which patients place value on interventions. But this is not strictly speaking to introduce value into EBM, which is, like any other scientific approach, already an expression of value. Perhaps it is more accurate to argue that an EBM approach that does not take into account evidence about patient value is not in fact evidence-based.
The second set of important questions raised by the VBM approach is the role of patient choice. The book concludes by listing the key groups who stand to benefit from the VBM approach and suggests that one of these is the patients themselves. The claim is that VBM will provide patients with standardized information that enables them to make better decisions about their health care management. This raises important policy and ethical issues. For example, is it ever acceptable for patients to choose treatments other than those most highly rated by the VBM approach? If so, this implies that VBM needs, in addition to good evidence about effectiveness and information about the ways in which patients in general have valued such interventions, to be a genuinely patient-centered approach, because the values of individual patients may on occasion include considerations other than those of quality or length of life.
Evidence-Based to Value-Based Medicine is available from Amazon.com for U.S. $64.95.
Michael Parker, MA, PhD
Professor of BioethicsDirector, Ethox CentreUniversity of Oxford
Oxford, England, UK