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Medical Knowledge: Lost in Translation
Medical Knowledge: Lost in Translation
When we debate issues of health care, we frequently argue over what to cut and what to add, but infrequently reflect on what we already have that isn't being utilized. In short, there's a great deal that we lose in the translation. While most pin their hopes for a healthy future on new discoveries, many fail to utilize the current knowledge.
Dr. Claude Lenfant from the National Institutes of Health writes, "Moving the knowledge off the shelves and into practice, making it relevant and accessible to practitioners and patients, achieving a true marriage of knowledge with intuition and judgment - all this requires translation."1
But the reality is that the eyes of patients and doctors alike are frequently on the future rather than the present. 72 percent of Americans believe that new scientific and medical breakthroughs are essential for staying healthy.2 Yet the Institute of Medicine report in 2003 pulls us back to the present with this comment: "The stark reality is that we spend billions in research to find appropriate treatments… but we repeatedly fail to translate that knowledge and capacity into clinical practice."3
The truth is, we have trouble moving knowledge off the shelf and down the "translational highway."4 This is not surprising when you look at the major stops along the way. Basic science must give way to clinical research studies. The studies must weave through the regulatory process to become approved therapies. The therapies must challenge the status quo to become the new standard of medical practice. And even if clinicians broadly adopt a new approach, patients must comply to yield positive outcomes.
There is no better example of the chasm between knowledge and practice than cardiovascular disease. "What we know" is frequently not "what we do." We know that beta-blockers used post-myocardial infarction save lives. But a study in 1996 - 15 years after this discovery - showed only 62.5 percent of post-MI patients used this medication.5 We know that all patients post-MI should be screened for cholesterol, but in reality only one-half to three-quarters of them are.6 We know that aspirin is lifesaving for patients with coronary artery disease and MI, and yet only one-third of them use aspirin.7 And we know that patients with acute MI should receive clot-dissolving therapy or acute angioplasty, but only one-third of them do.8
Establishing and promoting professional standards of care can move the dial. The National Committee for Quality Assurance (NCQA), with its Health Plan Employer Data and Information Set (HEDIS), measures and informs practice in the majority of U.S. health plans. Significant improvement has occurred in NCQA members. For example, beta-blocker use post-MI has risen from 62.5 percent in 1996 to 92.5 percent in 2001. And appropriate use of blood pressure control medication has risen from 39 percent in 1999 to 55.4 percent in 2001. 9
Patients seem poised to assure greater responsibility as well. A study in 2001 revealed that 94 percent of U.S. patients were more involved in health decisions, 92 percent took more control of their own health and 82 percent had more discussions with physicians compared to ten years ago. That said, patients remain more focused on short-term than long-term benefits, with 93 percent willing to accept the risk of a prescription medicine if it will cure a disease, but only 49 percent willing to comply if it prevents a disease. 10
Building a successful "translational highway" requires speaking to clinicians and patients simultaneously. Publications are an important first step, and fundamental to scientific exchange of ideas. 11 However, there are some 400,000 medical scientific articles per year, many more than even the most highly motivated clinician can absorb.12 One strategy to manage this volume and complexity is the consensus conference; one or two days of highly focused discussion yielding consensus on a standard of care. Public education has also proven to be useful. For example, the "Back to Sleep" campaign, encouraging parents to place infants to sleep on their backs to prevent Sudden Infant Death Syndrome (SIDS), resulted in a 43 percent decline in deaths from 1992 to 1997.13 Consumer word of mouth, activated by voluntary health organizations, combines education and motivation. Advertising can help provide accurate information, consumer dialogue, and engagement between patients and physicians as we see in many "ask your doctor" campaigns. And finally, leveraging the patient-physician relationship to provide not only clinical support, but also educational support through coordinated teams - especially in the management of chronic disease - can be highly effective.
We're slowly learning how to translate discovery into practice. But with an explosion of discoveries on the horizon and boomer aging just around the corner we need to repave the "translational highway" and add a few lanes as well.
Until next week, for Health Politics, I'm Mike Magee.
References
7.Awtry, E.H., Loscalzo, J. 2000. Aspirin. Circulation.101:1206-18.
February 4, 2004
