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Evidence-based medicine promotes a scientific basis for medical decisions. It often goes beyond the argument that diagnosis and treatment is always valuable. In addition to finding (diagnosing) and fixing (treating) a disease, evidence must show that a patient can benefit from diagnosis and treatment. Our CLINECS model (see Chapter 1) distinguishes outputs from outcomes. Services received do not necessarily translate into value for patients. There are occasions when diagnosis and treatment offers no benefit or when they may even produce harm. In this chapter we consider circumstances in which accurate diagnosis may not necessarily lead to better patient outcomes.

Most people receiving chemotherapy and radiotherapy for cancer are not cured. One-third to one-half of radiation treatments delivered in Europe and North America are given with palliative, not curative, intent, with an even lower percentage for chemotherapy treatments (Coia et al., 1988; Maher et al., 1990; Lawton & Maher, 1991; Maher, 1991; Coia, 1992). Across Europe, the “cancer population” is becoming increasingly older with more co-morbidities and with changing attitudes toward cancer and its treatments.

Geography can contribute to the understanding of medicine and health care. Medical geography is a research tool used to map the incidence and prevalence of diseases. It has been used by epidemiologists to identify areas where certain problems are common and other areas where these problems are absent. Although medical geography has never become a major field of study, local variations in illness rates were recognized during the fourth century BC. Hippocrates1 stressed that the healer must understand the environment in which patients live to be effective. Between 1835 and 1855, maps were used to identify where people were at risk of contracting cholera. It was recognized that tables of numbers were ineffective in communicating important information and that visual maps more clearly identified regions where attention was necessary. During the 1970s, McGlashan and Armstrong (1972) published an entire book on techniques on medical geography.

For most major cancers, there is evidence that patients from affluent neighborhoods have better survival than patients from deprived neighborhoods, and that this is not simply due to chance (Kogevinas, 1990; Kogevinas et al., 1991; Carnon et al., 1994; Sharp et al., 1995; Pollock & Vickers, 1997; Coleman et al., 1999) or extent of disease at the time of diagnosis (Schrijvers et al., 1995a,b). The underlying mechanisms are complex and difficult to address (Tomatis, 1995).

Mistakes are at the very base of human thoughts, embedded there, feeding the structure like root nodules. If we were not provided with the knack of being wrong, we could never get anything useful done. We think our way along by choosing between right and wrong alternatives, and the wrong choices are made as frequently as the right ones. We get along in life this way. We are built to make mistakes, coded for error. The capacity to leap across mountains of information and land lightly on the wrong side represents the highest of human endowments (Thomas, 1974).

In times of increasing cost constraints, there is increasing tension between economic efficiency and safety. In numerous economic sectors, product quality is deliberately reduced to save costs. The expenses resulting from complaints are set off against the saving potential offered by cheaper production methods. This approach can be optimized by defining specific error or rejection rates (for example, production of cheap textiles). So long as this approach is used for products with no or few safety requirements, there is no reason to object to the concept, as customers themselves define the desired quality level by purchasing. In some areas, however, this type of cost optimization cannot be accepted. When human lives and health are at stake, management following cost-cutting principles can— as soon as the public takes notice—trigger the ruin of the respective company.

The application of information technology (IT) in all health care organizations has become a complex process. For a long time, IT was only used in administration, but hospitals with modern management recognized the potential of the optimal use of IT in all forms of service provision and established hospital information systems early.

Linking inputs, outputs, and outcomes requires systematic analysis. In previous chapters we have discussed the measurement of all three of these components. In this chapter, we consider linkages between the inputs and costs to patient outcomes. The goal is to show that systematic analysis can lead to efficiency in health care.

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death and a major cause of disability in the United States (National Vital Statistics Report, 2004). It is caused by a loss of elastic recoil related to parenchymal destruction due to emphysema in addition to chronic airway inflammation. Lungs often become hyperinflated, and there is an increase in the functional residual capacity. Hyperinflation may place greater strain on the muscles of respiration, increasing the effort required to breathe and reducing exercise capacity. The physiologic abnormalities include a reduction in diffusing capacity of carbon monoxide, hypoventilation, and hypoxemia (Sutherland & Cherniack, 2004).

Breast cancer is the most common type of cancer affecting women. Currently, the worldwide annual incidence of neoplasm of the breast is more than 1 million cases, with an increasing tendency, particularly in developing countries (Love et al., 2004). Initial local treatment of breast cancer includes breast surgery and postoperative radiotherapy. However, in about 50% of the women with a confirmed diagnosis of breast cancer the disease recurs within 5 years after initial therapy. Therefore, systemic adjuvant treatment with chemotherapy or hormonal manipulation is commonly provided to reduce the likelihood of relapse and prolong disease-free survival (Gelber et al., 1996; Emens & Davidson, 2003; Love et al., 2004).