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Brown MM, Brown GC, Sharma S. Evidence-based to value-based medicine. Chicago: American Medical Association, 2005. ISBN 1-57947-625-2
  1. Michael Parker
  1. University of Oxford, Oxford, UK

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    Aims: Evidence-based medicine (EBM) is an approach to clinical care based on the claim that the appropriateness of clinical interventions should be justified by the existence of high quality evidence for the effectiveness of the intervention rather than on other grounds, such as the authority of the clinician, tradition, or politically motivated policy. EBM continues to have a significant impact on the development of medicine and more widely on healthcare practice; for example, it is a key motivating factor in the creation of the UK’s National Institute for Clinical Excellence (NICE). In Evidence-based to value-based medicine, Melissa Brown, Gary Brown, and Sanjay Sharma argue that the evidence base of EBM should be broadened to take into account the patient perceivedvalue of interventions. The authors argue that this will lead to a more sophisticated and accurate measure of the comparative worth of interventions to patients and to other stakeholders and thereby both improve the quality of health care and lead to significant savings through a more appropriate use of limited healthcare resources.

    In this book, the authors set out the values-based medicine agenda and explain how this approach might be introduced into day to day medical practice. Through case studies and explanation, the authors introduce ways in which healthcare workers can develop values-based clinical care and give advice about how best to communicate the rationale for interventions to patients and policy makers.

    Contents: The values-based medicine approach is introduced as a 3-layered pyramid. At the base of the pyramid, the foundation of values-based medicine is provided by EBM as traditionally conceived. The middle layer of the pyramid is evidence about the patient perceived value of the intervention. The final layer, the apex of the pyramid, is the integration of values and costs, using cost utility analysis, to arrive at value-based medicine itself. Through this model, and a related structuring of chapters, the authors introduce the concept of values-based medicine in a clearly written and accessible way. The book begins with an introductory overview of the concept of values-based medicine, followed by sections introducing the 3 levels of the pyramid. The first introduces the concept and techniques of EBM (the foundation of the pyramid). The second introduces mechanisms for assessing the values component of values-based medicine using the twin concepts of “quality of life” and “length of life.” The final section shows health professionals and policy makers how to bring together EBM and information about quality in values-based medicine (the top level of the pyramid).

    Clinical usefulness: This book is well structured and presented in a way that most health professionals will find accessible. Each chapter is interspersed with important points to consider and concludes with a summary of core concepts. The authors are evangelists for the values-based medicine approach and do a good job of showing readers its attractions and practical utility. Like any approach to healthcare policy, it raises as many questions as it answers. Firstly, the idea that values-based medicine introduces value into EBM suggests, implicitly, that EBM is relatively value free. Values-based medicine does introduce value considerations that were not explicit in EBM by importing previously excluded data about the extent to which patients place value on interventions. But this is not strictly speaking to introduce value into EBM, which is, like any other scientific approach, already an expression of value. Perhaps it is more accurate to argue that an EBM approach that does not take into account evidence about patient value is not in fact evidence-based.

    The second set of important questions raised by the values-based medicine approach is the role of patient choice. The book concludes by listing the key groups who stand to benefit from the values-based medicine approach and suggests that one of these is patients themselves. The claim is that being values-based will provide patients with standardised information that enables them to make better decisions about their healthcare management. This raises important policy and ethical issues. For example, is it ever acceptable for patients to choose treatments other than those most highly rated by the values-based medicine approach? If so, this implies that to be truly values-based, medicine needs, in addition to good evidence about effectiveness and information about the ways in which patients in general have valued such interventions, to be a genuinely patient centred approach. For the values of individual patients may on occasion include considerations other than those of quality or length of life.

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