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Academia and the Profession |

Why Some Health Policies Don't Make Sense at the Bedside

David A. Asch, MD, MBA; and John C. Hershey, PhD
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From the Veterans Affairs Medical Center and the University of Pennsylvania, Philadelphia, Pennsylvania. Requests for Reprints: David A. Asch, MD, Division of General Internal Medicine, 317 Ralston-Penn Center, 3615 Chestnut Street, Philadelphia, PA 19104-2676. Acknowledgments: The authors thank Robert A. Aronowitz, MD; Michael L. DeKay, PhD; Arthur Elstein, PhD; Jose J. Escarce, MD; Jeffrey H. Silber, MD, PhD; Gail Slap, MD; Peter Ubel, MD; and Sankey V. Williams, MD, for critical reviews of earlier drafts of the manuscript. Grant Support: In part by grants R011HG00616 and R011HG00621 from the National Center for Human Genome Research. Dr. Asch is the recipient of a Department of Veterans Affairs Health Services Research and Development Service Career Development Award.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1995;122(11):846-850. doi:10.7326/0003-4819-122-11-199506010-00007
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Cost-effectiveness analysis and other forms of decision analysis are becoming more common in the medical literature and are increasingly influential in the development of health policy. Nevertheless, many clinicians find it difficult to apply policies developed from these analyses to individual encounters with patients. We examine the assumptions behind these analyses and argue that the perspective they embody can make clinical strategies appear to be less risky in theory than they are at the bedside. We believe that this problem underlies the intuitive concern many physicians have about policy analyses and calls into question the value of these analyses in shaping clinical practice. These analyses aggregate the benefits and burdens of alternative interventions across different individual persons. Thus, overall population risk appears blunted, as it would in a diversified portfolio of stocks that react differently to financial forces or in a herd of cattle that react differently to veterinary interventions. The assumptions behind these analyses make sense if aggregate outcome is what matters, but not if one cares about each individual investment or animal. Because such aggregation tends to understate individual risk, when applied to human health policy, it may misrepresent the interests of patients and cannot be assumed to provide useful guidelines for decision making at the bedside.

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Grahic Jump Location
Figure 1.
Distribution of potential dollar returns for investments in stocks or bonds assumed to be normally distributed. Top.Middle.Bottom.

Individual return anticipated after investment in a single stock with an expected return of $700 ±$600 or in a single bond with an expected return of $600 ±$100. Aggregate return anticipated for 100 individuals investing in 100 similar stocks or 100 similar bonds when the return of each individual stock or bond is assumed to be independent of that of the others. Individual returns anticipated for each investor in the pool or fund represented in the middle panel. The distributions, narrower compared with those in the top panel, reflect the risk reduction provided by diversification. An investment in stocks rather than bonds is relatively more attractive in the bottom panel than in the top panel.

Grahic Jump Location

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Why some health policies don't make sense at the bedside. Ann Intern Med 1995;122(11):846-50.

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