On 2015 Apr 21, David Keller commented:

Clinical recommendations should not be biased by economic considerations

These recommendations for treatment of pressure ulcers ("bed sores") ignore the evidence in favor of certain mattress types, simply because of cost considerations. For example, air-fluidized beds have moderate quality evidence of reducing pressure ulcer size, compared with other surfaces, leading to an improved overall treatment effect (see Table 3 of this paper). In trying to understand why air-fluidized beds were not included in the recommended treatments for pressure ulcers, I noted that the section on "High Value Care" states that "the use of advanced support surfaces adds unnecessary costs to the health care systems". However, the evidence demonstrating improvement due to electrical stimulation was of similar quality ("moderate") as air-fluidized beds. Electrical stimulation was included in the recommended treatments for pressure ulcers. Is electrical stimulation really less expensive than an air-fluidized bed, after accounting for the professional fees charged by the clinician providing that service? How many communities have such a clinician? The cost of air-fluidized beds, like any other commodity, is flexible and based on the volume of orders received. A recommendation by ACP for air-fluidized beds would increase the number of orders and decrease the cost of such beds, due to economies of scale. Economic considerations should not bias clinical recommendations. We are physicians, not economists. We should make recommendations purely on the basis of clinical benefits, and leave the economic analysis to experts in that field, who are more qualified to provide such analysis.

On 2015 Apr 21, David Keller commented:

Clinical recommendations should not be biased by economic considerations

These recommendations for treatment of pressure ulcers ("bed sores") ignore the evidence in favor of certain mattress types, simply because of cost considerations. For example, air-fluidized beds have moderate quality evidence of reducing pressure ulcer size, compared with other surfaces, leading to an improved overall treatment effect (see Table 3 of this paper). In trying to understand why air-fluidized beds were not included in the recommended treatments for pressure ulcers, I noted that the section on "High Value Care" states that "the use of advanced support surfaces adds unnecessary costs to the health care systems". However, the evidence demonstrating improvement due to electrical stimulation was of similar quality ("moderate") as air-fluidized beds. Electrical stimulation was included in the recommended treatments for pressure ulcers. Is electrical stimulation really less expensive than an air-fluidized bed, after accounting for the professional fees charged by the clinician providing that service? How many communities have such a clinician? The cost of air-fluidized beds, like any other commodity, is flexible and based on the volume of orders received. A recommendation by ACP for air-fluidized beds would increase the number of orders and decrease the cost of such beds, due to economies of scale. Economic considerations should not bias clinical recommendations. We are physicians, not economists. We should make recommendations purely on the basis of clinical benefits, and leave the economic analysis to experts in that field, who are more qualified to provide such analysis.