Tyrannized by Evidence? Making 'Outcomes' Work for Our Patients
Stanley A. Herring, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 10 - OCTOBER 2021
The high cost of modern medicine has helped shape our social, political, and practice agendas for years, and we now have a managed care system strongly focused on cost containment. Thirty percent of people over age 16 report morbidity or use of the healthcare system for musculoskeletal conditions, 20% of which are chronic (1). And they are expensive, costing about $126 billion annually (2). Consequently, musculoskeletal-related costs are a prime target for containment, and—since primary care and sports medicine physicians treat many patients who have these problems—so is our practice.
The challenge we face is to channel the current emphasis on cost-saving guidelines toward developing evidence-based outcomes that help us care more effectively for individual patients. This effort will require a new model for the investigation, diagnosis, and treatment of musculoskeletal injuries.
The Guideline Quandary
Access to musculoskeletal care appears to depend more and more on guidelines, supported by population-based evidence, that can be used to contain costs. On the one hand, we are aware that these guidelines are not standards of care, overall effectiveness does not equal efficacy for the individual patient, cost effectiveness is often confused with lowest-cost care, and data are incomplete at best for many musculoskeletal conditions. The increasingly frequent result is that deserving patients may be denied diagnostic and treatment options.
On the other hand, we know that the best individualized care depends on establishing clear outcomes to guide and justify treatment that effectively rehabilitates our patients in a cost-effective manner. Such outcomes should provide measures of decreased pain and increased function in our patients. Without these outcomes, medical practice runs the risk of being criticized as subjective and fashionable, which can also hurt patients.
Steps to Meet the Challenge
Our task, then, is to carry out the research necessary to develop evidence-based outcomes that will help us determine—on an individualized basis—which patients should be treated and the efficacy of their treatment. To accomplish this task, however, we must change the way we view musculoskeletal problems.
Research. Reducing the variability of healthcare for a particular disorder requires quantifiable outcomes. Expanding our research and knowledge regarding the pathophysiology, epidemiology, and natural history of these disorders will help to establish these outcomes. Also, skeletal muscle and connective tissue inflexibilities, strength losses, muscle imbalances, proprioceptive changes, other (mal)adaptations, and patient-based measures can often be quantified.
Carrying out such research can be challenging for a number of reasons. Musculoskeletal disorders are often difficult to classify, and the lack of clear classification makes the measurement of treatment efficacy problematic. In addition, Manniche (3) notes two further challenges in musculoskeletal research: (1) Significant ethical and practical factors may make the use of control groups nearly impossible, and (2) current methods of measuring outcomes may not be adequate to distinguish small but clinically relevant differences between treatment groups.
A new view. Equally critical is changing the way we view musculoskeletal conditions, because our vision helps create a model of medical care that determines healthcare delivery, clinical research, and the selection of outcome measures that have financial implications, including implications for physician reimbursement.
Traditionally, we have seen a musculoskeletal injury or disease as an event that requires a cure rather than as a process that needs management. The latter view can generate a more comprehensive approach to these disorders that will yield better patient care based on restoration of function and will define objective measures of treatment that can be used to develop outcomes.
A Comprehensive Approach
A useful model. A model for this kind of comprehensive approach is Kibler's vicious overload cycle (4) (figure 1: not shown), which provides a framework for the thorough evaluation of a broad range of overuse (overload) injuries.
For example, take a patient who has a relatively uncomplicated condition such as plantar fasciitis. The patient may have clinical symptoms of tenderness at the base of the calcaneous and morning stiffness. Using Kibler's model, we see how these symptoms are related to all components of the cycle. The symptoms are the result of overloading a variety of structures, which injures the plantar fascial attachment and leads to inflexibility and weakness and alteration of gait.
Traditional treatment of this patient would often be limited to resolving the clinical symptoms through prescribing heel cups and anti-inflammatories. This would seem to be cost effective but in reality makes the patient vulnerable to reinjury—and further cost—because it does not address all components of the cycle (figure 2).
The goal of a comprehensive model is not just the control of clinical symptoms, but rather the management of a complex of interrelated problems that must be addressed fully if function is to be restored. Thus, this patient would benefit from more comprehensive therapy to address inflexibilities, weakness, gait alterations, and other deficits that contribute to the condition. In fact, quantifiable findings of inflexibilities and strength imbalances have been demonstrated in patients who have plantar fasciitis (4).
Without such research-based data, it would be difficult to justify the expense of this treatment. With such data and the understanding of the vicious cycle of injury, we hope to show that addressing these issues will not only restore the patient's function but limit frequently reported reinjury (5-7) and further treatment and expense.
Such an approach ensures the best care of the individual patient and allows us to track parameters of progress in strength, strength balance, flexibility, proprioception, and other quantifiable components of the injury cycle. (It will also likely lead to sustained function by proper training and conditioning to maintain these gains long after symptoms have resolved.)
Tracking these parameters is reasonable and important, particularly if the results demonstrate that correcting and maintaining the components lead to meaningful and appropriate outcomes—limiting recurrent injury and pain, maximizing function and performance, and reducing costs. But tracking them means first defining them through innovative research guided by an innovative paradigm for musculoskeletal problems. Given the previously mentioned challenges of conducting this research, investigators will have to be patient and persistent in developing these outcomes that enhance care.
A balanced practice. Clinical experience can be tyrannized by evidence, especially when it is population-based, because even excellent data may not apply or be appropriate for an individual patient. However, without the best, most current data, the practice of medicine risks becoming rapidly out of date (8). Physicians who balance their own clinical expertise with the best external evidence can continue to improve their management of common disorders that prevent many patients from participating in activities essential to their well-being.
Dr Herring practices at Puget Sound Sports and Spine Physicians in Seattle. He is a clinical professor in the departments of rehabilitation medicine and orthopaedics at the University of Washington, Seattle; a team physician for the Seattle Seahawks; a fellow of the American College of Sports Medicine; and an editorial board member of The Physician and Sportsmedicine. Address correspondence to Stanley A. Herring, MD, Puget Sound Sports and Spine Physicians, 1600 E Jefferson, Suite 401, Seattle, WA 2021122-5647.
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