Thursday, February 08, 2007

The Importance of the "Big Picture" Perspective

There is a very good article on the importance of the "big picture" perspective in healthcare in the latest issue of JAMA. It's a Commentary piece by Steven Woolf entitled "Potential Health and Economic Consequences of Misplaced Priorities". You can download it here (subscription needed). Here is a sample:

To maximize the health of its citizens, society should pursue interventions in proportion to the ability of those interventions to improve outcomes. All else being equal, a strategy that is more effective than its alternative should receive more, not less, attention. Doing otherwise can compromise the health of patients. For example, if intervention A is 10 times more effective than intervention B in reducing mortality, performing more of B than A will allow more deaths to occur. Just as errors of omission cause harm, inattention to how priorities are balanced can indirectly claim lives, contribute to disease, and generate costs that would not occur if priorities were in greater harmony with potential gains.

The "silo" mentality that pervades so much of clinical practice and policy in the United States often finds decision makers focusing their attention and resources on a specific patient or disease—any one is a worthy cause—without stepping back to examine the balance of their efforts. Most practitioners and policy makers rarely pause to consider whether more rational priorities would offer better outcomes for their patients.

Lacking this "big-picture" perspective, many choices in clinical practice, policy, and research end up concentrating resources on interventions that do less for health while shortchanging alternatives that would save more lives. Reordering priorities to maximize health benefits is essential not only on moral grounds—to lessen disease burden on the public—but also as a necessary countermeasure to increasing health care costs. To illustrate the importance of reordering priorities, this Commentary presents examples from 4 areas of practice and policy: choosing effective services, delivering care, preventing disease, and fostering social change.