It sometimes seems ‘obvious’ why things go wrong in practice. For example, the proportion of people with diabetes prescribed a cholesterol reducing drug is low…. because? You might have your favorite answer at the ready. Others certainly do and will climb their hobby horse with little or no encouragement. ‘Prescribers don’t accept the guidelines‘, ‘patients don’t take their medicines‘, ‘people can’t afford the drugs‘ or ‘doctors don’t monitor patients‘. The truth may encompass any or all of these.
Let’s do the maths with reference to Glasziou and Haynes.
Let’s assume 80% is true in each of the following points:
1. Doctors are aware of the guidelines.
2. Doctors accept the evidence underlying these guidelines.
3. Doctors remember to apply the guidelines when the relevant patients present.
4. It is possible to do something practical to comply with the guidelines.
5. Doctors act to prescribe the relevant treatment.
6. Doctors and patients agree on the need for that treatment.
7. Patients comply with the treatment.
If these statements are true 80% of the time then 21% of people with the relevant problem will be managed according to the guidelines (0.8x 0.8x 0.8x 0.8x 0.8x 0.8x 0.8= 0.21). Experience tells us that in many, if not most, conditions only 1 in 5 people will be managed as per research evidence.
A quick review of the literature confirms this.
1. Only 17% of patients with diabetes were screened for sexual dysfunction despite it being a common complication of this condition.
2. A primary care study has shown that despite an active education program over two years the proportion of treated patients whose blood pressure was controlled to < 160/90 mm Hg remained at only 33%.
3. When examining the referral origin of all Colorectal cancer patients diagnosed in one study only 24% had been referred on a pathway that was consistent with national guidelines.
An agile and cost effective solution could be devised for any problem in medicine if the innovator has a firm grasp of the context in which an innovation is to be deployed. Doctors therefore already have some of the necessary credentials. And also, if a solution is generated that changes the way everyone involved feels when they do the needful. These are a function of the right brain (intuition and imagination) as opposed to the left brain (logic).
Lean innovators know that an innovation will only change outcomes if that treatment is less of a threat than any alternative, and or if it increases good feelings. We also know that the actions of doctors alone are never enough to result in a particular outcome. If medicine is a partnership then so are the results. As always context is everything.
Picture by algona81