David Meltzer
"The value of technology can be understood only in the social context in which it is used," said Meltzer, an associate professor in the departments of medicine and economics and in the Harris School, and the director of the Center for Health and the Social Sciences at University of Chicago.
Meltzer described how the field of cost-effectiveness analysis was launched in part 30 years ago with key work by Milton Weinstein, the Henry J. Kaiser Professor of Health Policy and Management at HSPH. The methodology was developed with the involvement of social scientists interested in measurement but moved quickly into widespread application. It is one of the main tools used by government regulators, insurers, and other institutions to shape medical decisions, resource allocation, approval of new drugs and devices, and health policy.
"There are important gains to be made by closer collaborations between social scientists interested in behavior and persons interested in technology assessment," said Meltzer, who gave examples from his own work and that of others.
Variations in personal preferences can radically change the conclusions of a cost-effectiveness analysis, he said. In a study last year, he and his colleagues reported that intensive glucose control in older patients with type 2 diabetes was harmful on average when applied unselectively across the population. However, they also found that, among older patients who agreed to intensive therapy, it was both beneficial and highly cost-effective.
In another example from another research group, Meltzer noted that PAP smears are extremely cost-effective in the women tested every three years, as now recommended, or $2,600 per life year saved. The cost-effectiveness drops dramatically for PAP smears conducted every two years. Annual PAP smears save, on average, just eight hours of life at a cost of $830,000 for every life year saved.
"Cost-effectiveness analyses of interventions often stratify cost-effectiveness by indication, yet technologies are often used non-selectively, and the actual costs and effectiveness may be strongly influenced by patterns of use," he said.
In another line of research, Meltzer applies his empirical cost-effectiveness approach to understand how doctors choose interventions, why medical practice varies across small regions not explained by patient factors, and why treatments may be used inappropriately. From the social network literature, he hypothesized that the social structure of the medical practice can profoundly affect the spread of innovations and the choice of interventions, possibly explaining mystifying geographic variations in care that have nothing to do with patients.
As an example, Meltzer described the social hierarchy of the hospital teaching team at University of Chicago, which includes the attending physician, the resident, a primary intern and a co-intern, and patients. Ten years of data show that people seek advice from persons like themselves - in specialty, gender, age, medical school, and even tendency to read journal articles.
Hoping to capitalize on those effects to promote change, he is conducting a randomized clinical trial that pairs a hospitalist with geriatricians to develop and disseminate a curriculum to improve hospital care of vulnerable elders.
Manipulations of social structure may play a role in the management of technical change, including design of practice environments and use of opinion leaders or opinion leadership teams, he said. A team is needed that reflects the diversity of the group whose practice is in need of change.
The event was co-sponsored by the Department of Health Policy and Management and the Office of the Dean.
—CCM
Copyright, 2009, President and Fellows of Harvard College
