HPH NOW, Mar 30, 2007, Improved Delivery of Existing Medical Treatments May Save More Lives than Breakthroughs, Suggests Surgeon

Atul Gawande

More lives would likely be saved in the coming decade by improving the delivery of medical treatments already in use than by relying on scientific breakthroughs from bench research, according to Atul Gawande, a surgeon at HMS and Brigham and Women's Hospital and assistant professor in the HSPH Department of Health Policy and Management.

"Research on our health system can save more lives than research on the human genome, stem cell therapy, cancer vaccines, and all the other things you hear about on the news,'' conjectured Gawande, who spoke on March 13 in Snyder Auditorium at an event co-sponsored by the student organization HSPH Health Policy Forum.

"Yes, the enterprise of Harvard is discovery, but we also now recognize that while we've made enormous numbers of discoveries that are increasing the life expectancy for the average person, we are not delivering on them in far too many instances,'' said Gawande. "This is certainly true in the developing world, but it's also true at home.''

Gawande, who wrote the award-winning book Complications: A Surgeon's Notes on an Imperfect Science in 2003, has written a new book on taking better advantage of known medical treatments. The upcoming book, Better: A Surgeon's Notes on Performance, will be published on April 3.

Gawande said that the book arose from his attempts at trying to figure out, as a young doctor, how he could be a better physician. "I realized that the answer is the same as the answer to the question of 'How do we get better as a whole in medicine?' It has to be by thinking about how we close the gap between what we can do and what we actually do,'' he said.

The effectiveness of health care delivery can be charted as a bell curve - there are a handful of doctors, or hospitals, that deliver very poor outcomes, a handful that produce remarkably good results, and the majority in the middle, producing undistinguished care.

Health services research, also known as quality research or performance research, is designed to measure which doctors fall into the three ranges - and push those at the bottom into the middle and those in the middle into the top, explained Gawande.

He brought home the concept in a review of the care delivered in 117 cystic fibrosis centers in the U.S. All of the centers followed the same guidelines and offered the same treatments. However, patients in some of the centers lived to an average age of 47 years, while patients in the majority of the centers lived to an average age of just 30 years. Why?

Gawande said that doctors at the best-performing center, the Minnesota Cystic Fibrosis Center at Fairview-University Children's Hospital in Minneapolis, paid strict attention to details, such as making sure patients took all of their treatments designed to keep their lungs open. It turns out that many patients skip treatments when their lungs are functioning well, but don't always tell their doctors, he said.

Gawande wrote about the subject in an extensive article called "The Bell Curve: What happens when patients find out how good their doctors really are?" in the December 6, 2004 issue of The New Yorker. Gawande is a staff writer for the magazine.

"This is where we want to get to in the rest of medicine,'' he concluded. "This is what we do in health services research, and it is a major enterprise for public health work, too - addressing universal (health care) coverage, racial disparities, and, on a worldwide level, making resources available," said Gawande, who won a MacArthur "genius" Award in 2006. "But health services research is ridiculously underfunded. The National Institutes of Health's budget is $30 billion, and we feel it's not enough. The agency that does health services research only gets $300 million. That's a sign that we have not convinced the public that our work saves lives.''

—ML