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Cochrane lecture from 1997. Basically prescient given the current discussions about NHS reform and market forces. Although I'm not sure I buy the assertion that Archie Cochrane was a free-marketeer in the mould of Freidman and Hayek, Worth reading if only for the magnificent Florence Nightingale quote at the end.

via +Anne Marie Cunningham
Copyright notice. Cochrane Lecture 1997. What evidence do we need for evidence based medicine? JT Hart. Department of Primary Health Care, Royal Free Hospital Medical School, London. Abstract. As pres...
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Yes, Florence Nightingale's quote is wonderful. Hart is quite critical of Cochrane, isn't he? Harrison here makes him seem more of a political pawn rather than an instigator. Is that worse?
Mixed feelings about the Harrison paper:
First the bad stuff: He wilfully misappropriates the term "Moral Hazard" which has a specific meaning in economics. The issues of supply/demand, agency problems and information asymmetry are real, but they don't fall under the subject of Moral Hazard. It's really about the inducement of bad behaviour in an industry by an implicit or explicit government guarantee. The obvious example being banks engaging in riskier investments if they believe the government will bail them out.

Harrison also describes laboratory medical science and RCTs as though they were in opposition to one another. Plenty of drugs look great in the lab but fail utterly in RCT. I don't think I've ever met a biomedical scientist who at that point would still claim that their drug worked.

The real meat of the argument (and I think this also applies to Hart) is that this isn't really about science. RCTs work and produce useful evidence which should inform medical practice. But what you do with that evidence is going to depend on what value system you use to decide what a good outcome is.

I thought the discussion of QUALY versus effectiveness was interesting. I'd thought that NICE already took QUALY into account for some things?

I feel like the bottom line is that EBM, cost-benefit etc are all just tools that provide different metrics to work with. The interesting discussion is going to be what value system should be used to make decisions based on those different metrics.

As to Cochrane being a pawn. I really don't know the history well enough. It just seems extremely unlikely that someone who worked in socialised medicine his entire life could be a devotee of either the Austrian or Chicago school of economics.

Usual disclaimer: I am neither an Economist nor a Clinician so the above is potentially entirely wrong.
Remember this was written in 1998- NICE only came in to existence in 1999. I have read other bits of Harrison's more recent work and was actually looking for a different paper when I came across this one, but I thought I'd share it since it specifically mentioned Cochrane too. It was actually this reference that I was looking for : but unfortunately it is not open-access.

I have no reason to disbelieve your assertions about biomedical scientists. But many RCTs now are not of interventions which have been developed in labs. And many of these 'complex' interventions are found by RCT not to work. And if they do work in one situation/place/country they don't necessarily work in another. But that's another very interesting aside!

I think you are saying that metrics such as RCTs or cost-benefit analysis are value-less and I would disagree with that. We need to realise that before we can make decisions about how to utilise the evidence that they give us.
Sorry, I meant the NICE comment to be a question. Have things changed since 1997? Is QUALY something that gets used now? I'm sure I read somewhere that it was.

I think I've oversimplified due to it being Sunday afternoon. The methodology of the RCT is value-free in and of itself (assuming we can agree on methodological naturalism being a sufficiently basic assumption). However any particular RCT does contain some value judgements. We have to decide what criteria we are going to use to measure the outcome of the RCT. That right there is a value judgement. This is even more true of cost-benefit analysis.

If we measured outcomes based on how happy the patient is with the treatment then spending money on Homeopathy and Accupuncture would come out very well in a cost-benefit analysis. Despite both treatments having no medical benefit whatsoever.

So I think I'm basically agreeing with you. We can't decide how to measure healthcare outcomes until we've decided what outcomes we want to measure, and that is really a discussion about what values we want the NHS to embody.
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