Of Policies and Uncertainties
We love Russian literature because of its philosophy.
Words arranged into sentences that narrate and teach wisdom of the ages with deft precision. But the words themselves carry no philosophy. Rather, it is the arrangement of words when read that creates the philosophy.
Similarly, when analyzing healthcare decision-making, and the impact on it from policy changes, we must focus on the sequence of decisions made based on the policy change itself.
In a way, a policy change is just one change of a decision in a sequence of decisions, that may or may not be impactful – it is less about the one policy change and more about the sequence of decisions.
Recently, the US Preventive Services Task Force (USPSTF) indicated that aspirin may be appropriate for cardiovascular prevention in high-risk adults ages 40-59, but not for those ages 60 and older. This comes as a change from 2016 guidelines that recommended aspirin for people ages 50-59 that have a 10% or greater 10-year atherosclerotic cardiovascular disease risk – as calculated by the American College of Cardiology – and recommended individualized decisions for those ages 60-69 with similar risk, to be decided by the provider caring for the patient.
Drs. Prasad and Cifu wrote about this recent policy change, contextualizing it as a form of medical progress. At a broad level the description is accurate, medical progress is a complex field moving in unpredictable, nonlinear ways. Decades old data highlighting the value of aspirin as a preventative measure may no longer remain valid in today’s world of technology-driven healthcare. This is the nature of change in healthcare policy.
But when we examine the impact of this policy change at a more granular level, at the level of individual provider decision-making, it appears differently. It appears as one in a series of decisions that may not have much of an impact in patient care.
The reason being – the policy change affects preventative care, an aspect of medicine lacking the familiar objectivity of data analysis that has consumed healthcare. We cannot put a data point around prevention, because prevention is inherently uncertain.
And within the uncertainty lies different ways of responding, leading to different decisions regarding patient care.
Some providers may continue to prescribe aspirin as a preventative measure because their response to uncertainty is to default to additional preventative medications – better safe than sorry. And some may continue to prescribe aspirin because they have instinctively associated aspirin as a preventative medication against cardiovascular disease.
For individual providers, the policy change is a shift in preventative care management. A field of medicine in which data is harder to understand and the studies take place over years. Healthcare has been notoriously inconsistent in applying short term changes in decision-making based on broad, long term data.
Providers do not make decisions through an in depth analysis of all available data, symptoms, and signs. They make it through thought patterns. When a patient presents with a host of symptoms, the provider diagnoses the patient through pattern recognition of the symptoms.
The decision to prescribe aspirin for preventative care has been ingrained to the point that it has become an instinctive thought pattern, which has been reinforced through years of patient care emphasizing risk-adverse healthcare. Needless to say, providers will struggle to adjust.
Not because providers are unable to adjust to changes in policy, but because there is little incentive to change. Providers will only make changes in decision-making when they are certain the change will be definitively better. This is not the case with the aspirin policy change – because it fails to address individual patient uncertainty.
Providers instinctively respond to uncertainties in patient care. This instinct derives out of established thought patterns reinforced over years of repetition. Most policy changes do little to address these uncertainties, and are therefore largely ignored.
This is what most policy makers fail to understand. We often see policy changes met with little to no implementation, and communication efforts highlighting the policy fail to move the implementation needle.
Status quo in healthcare is powerful because there is a lot of uncertainty in healthcare. The uncertainty is a powerful driver of individual decision-making, more powerful than most policy changes. If policy makers wish to make meaningful change, or to advance the progress of healthcare, then they should focus on the uncertainty underlying the decisions relative to a given policy.
Policy changes should address changes in uncertainty, correlating how decisions are currently made with how they are intended to be made. This requires a philosophical shift in how policy makers think, and how individual providers respond to policy changes.
A shift from enacting policy to understanding uncertainty – that is really the philosophy of medical decision-making.
Antibiotic Prescriptions Associated With COVID-19 Outpatient Visits Among Medicare Beneficiaries, April 2020 to April 2021
Outpatient Visits for COVID-19 and Associated Antibiotic Prescriptions Among Medicare Beneficiaries Aged 65 Years or Older, by Setting, US, April 2020 to April 2021. The volume of COVID-19 visits differed by setting: emergency department, 525 608 (45.8% of all visits); office, 295 983 (25.3%); telehealth, 260 261 (22.3%); and urgent care, 77 268 (6.6%).
Source: Journal of American Medical Association Network