Thursday, December 13, 2018

Treating the Individual, Not the 'Average' Patient

Treating the Individual, Not the 'Average' Patient

The new trend is to strictly embrace evidence-based medicine (EBM) with the perception that the patients will do better and one can avoid legal consequences. In chart reviews, EBM looks easy: diagnosis A means use drug B and C.

Late David Sackett, MD, a pioneer in EBM, reveals the challenge: Evidence-based medicine is the conscientious explicit and judicious use of current best evidence in making decisions about the care of individual patients.

But in practice we do not treat patients but an individual patient.

Anyone with internet access can look up the guidelines or the results of a randomized controlled trial, but the challenge comes when deciding whether or not the patient in front of you is similar to those enrolled in the clinical trials underpinning the evidence.

Let’s take the example of the best blood pressure goal for a patient with multiple risk factors, hypertension and diabetes: Strict application of the evidence will be in ACCORD-BP trial, which showed that a systolic blood pressure target of 120 mm Hg, compared with a target below 140 mm Hg, did not reduce the rate of the composite outcome of fatal and nonfatal major cardiovascular events. And patients who received intensive treatment had more adverse effects. Evidence, therefore, points to the higher target.

But there is also the SPRINT trial, which showed that treatment to a lower BP goal resulted in serious reductions in cardiac events. But SPRINT excluded patients with diabetes

Is my patient closer to SPRINT or ACCORD? A trial's inclusion/exclusion criteria and the actual characteristics of enrolled patients may often differ greatly. The patient in the clinic might technically meet a trial's inclusion criteria but be poorly represented by the actual baseline characteristics of the patients enrolled in the study. Or, the patient might have a single exclusion criterion (e.g., diabetes) but resemble the trial population in many other ways.

My answer to this would be to treat the individual patient based on my experience of clinical practice.

When deciding on the line of management, I would take into consideration the social determinants of health, my past experience and not treat my patient as per the findings of any trial.

WHO has defined health has as “not just the absence of disease, but a state of complete physical, mental and social well-being”. This clearly indicates that the conditions we live in and work also affect our health.

So, it is not enough to address just the immediate presenting complaint, it is also important to treat the person as a whole in context of his/her social circumstances. Treatment has to be tailored to each individual patient taking into consideration their individual characteristics, culture, personal preferences, expectations etc.

Also many times I will use the harm reduction approach and keep the BP control on the higher side just to reduce the harm.

Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Immediate Past National President IMA

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