Costs, Risks and Benefits of Surgery: a milestone in the development of health services research.

Abstract

In 2006, the Journal of Health Services Research and Policy included Costs, Risks and Benefits of Surgery1 in a list of 26 books considered to have been most influential in changing health services and health care policy over the previous century and a half.2 How did Costs, Risks and Benefits of Surgery come to be written? The early 1970s was characterized by a growing acknowledgement in medicine, public health and the social sciences that contemporary health provision was neither evidence-based nor necessarily what people would prefer, given true choices. The great variation in health care utilization rates observed across countries and communities gave rise to legitimate questions about macro-economic effectiveness and efficiency. Archie Cochrane’s book Effectiveness and Efficiency: Random Reflections on Health Services3 asserted and justified the view that much of modern health care was not based on reasonable evidence about efficacy or safety. This came as a shock to many. Cochrane’s book was especially popular in the USA, exemplified by Cochrane’s recollection of meeting an American who said ‘So you are Archie Cochrane. I bought fifty copies of your book as Christmas cards this year.’ Fifty years previously, Codman had proposed and implemented systematic assessment of the end results of surgery at his hospital in Boston.4 Although questions about the use of discretionary surgery had been raised in the 1930s by Glover’s demonstration of widely varying rates of tonsillectomy,5 the late 1960s and early 1970s witnessed an explosion of studies documenting unexplained interand intra-national variations in surgical rates.6–11 Each of these studies raised fundamental questions about what health care was for, and ultimately for whose benefit. When such different amounts of it were being delivered to apparently similar patient populations with similar outcomes, it was not possible any longer to entertain the notion that all of it was unambiguously beneficial and appropriate. The variations in cost were also fairly clear (surgery is expensive), but the benefits and the consequent risks of these variations were much less obvious. It seemed irrational to remain so ignorant when it was so unclear that greater expenditure resulted in greater aggregate benefit. Given the general level of uncertainty evident throughout health provision, both about morbidity levels and the effects of most treatments, questions about how much health care is best for communities cannot generally be resolved by knowing whether treatment A is better (or not) than treatment B, among a specific group of patients. The justification offered for high rates of surgery was often that prophylactic procedures (cholecystectomy and hysterectomy, for example) prevented problems in the longer term. However, although prophylactic surgery with modern infection control and anaesthesia might well fulfil the needs of individuals, what were the costs for communities? Moreover, did the community want to use its resources in this way, given other options? Why was there no strong evidence that, within developed countries at least, more health care resulted in measurably better health? Was health care running away with itself in places, on essentially spurious implied clinical benefit grounds? The move to Harvard University of two of the researchers who had contributed to the surgical variations evidence—John Bunker and Jack Wennberg—provided a stimulus to address some of these quandaries. Fred Mosteller, Professor of Statistics at Harvard, and Howard Hyatt, Dean of the Harvard School of Public Health, had already planned to have multidisciplinary seminars, accompanied by a meal at the Faculty Club, and Bunker persuaded them that the questions raised by the surgical variations data should be addressed in these. The basis for this kind of question and indeed many of the methodologies to address them had already received impetus from the creation, in the School of Public Health, of the Centre for the Analysis of Health Practices (CAHP) in the early 1970s. People like Milt Weinstein and Don Shephard, under the direction of Hyatt, had progressed with the hard-nosed assessment of comparing treatments for chronic disease using models and other methods—clearly the nature of the question already had a resonance. Fortnightly seminars were held between 1973 and 1976, and, in all, about fifty people FR O M T H E JA M E S L IN D L IB R A R Y