Comparative effectiveness research

Comparative effectiveness research (CER) is the direct comparison of existing health care interventions to determine which work best for which patients and which pose the greatest benefits and harms. The core question of comparative effectiveness research is which treatment works best, for whom, and under what circumstances.

The Institute of Medicine committee has defined CER as "the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care. The purpose of CER is to assist consumers, clinicians, purchasers, and policy makers to make informed decisions that will improve health care at both the individual and population levels." ^[1]

An important component of CER is the concept of Pragmatic Trials^[2]. These clinical research trials measure effectiveness—the benefit the treatment produces in routine clinical practice. This is different than many regularly clinical trials, which measure efficacy, whether the treatment works or not.

Dr.John Wennberg and his colleagues at The Dartmouth Institute for Health Policy and Clinical Practice have spent over 40 years documenting geographic variation in health care that patients in the U.S. receive - a phenomenon called practice pattern variation. The Dartmouth researchers concluded that if unwarranted variation were eliminated, the quality of care would increase and health care savings up to 30% would be possible ^[3] - a statistic that has been often repeated in the case for CER.

Several groups have emerged to provide leadership in the area of Comparative Effectiveness Research. The Agency for Healthcare Research and Quality (AHRQ) is a federal agency focused on health care quality, while the Center for Medical Technology Policy is a non-profit organization that brings disparate health care stake holders together to build consensus on practical models for comparative effectiveness research. ECRI Institute has undertaken systematic reviews of clinical procedures using metaanalysis for the Medicare program, other federal and state agencies and clinical specialty organizations.

In the 2010 U.S. health care reform

The rising cost of medical care in the U.S. has triggered an immediate need for better value in our health system. Researchers at the Dartmouth Institute for Health Policy, in addition to the Congressional Budget Office, have documented a large gap in the quality and outcomes and health services being delivered. Unwarranted variation in medical treatment, cost, and outcomes suggests a substantial area for improve and savings in our health care system. Statistical findings show that "patients in the highest-spending regions of the country receive 60 percent more health services than those in the lowest-spending regions, yet this additional care is not associated with improved outcomes." ^[4] New models of shared decision making promise to bring greater emphasis to informed patient choice for "preference-sensitive" care, improving quality, safety, and effectiveness of health care by providing both patients and their health care providers with the evidence to assist in informed decision making.^[5]

In 2009, $1.1 Billion of President Obama's stimulus package was earmarked for CER.^[6]. There was initial disagreement regarding whether CER will be used to limit patient health care options^[7], or help lower health care costs.^[8] Ultimately the bill approved by Senate contains measures to utilize CER as a means for increasing quality while reducing rising costs.^[9][10][11]

References

1. ^ Initial National Priorities for Comparative Effectiveness Research
2. ^ http://www.bmj.com/cgi/content/extract/316/7127/285
3. ^ http://www.healthdialog.com/Main/Research/TheDartmouthAtlas
4. ^ [Fisher et al., 2003 http://www.nap.edu/openbook.php?record_id=12648&page=30]
5. ^ [Wennberg et al., 2007 http://www.nap.edu/openbook.php?record_id=12648&page=31]
6. ^ http://www.nytimes.com/2009/02/16/health/policy/16health.html
7. ^ http://online.wsj.com/article/SB123423024203966081.html
8. ^ http://content.nejm.org/cgi/content/short/360/19/1925?rss=1&query=current
9. ^ [Science Magazine | Comparative Effectiveness Research Boosted in Health Care Bill http://blogs.sciencemag.org/sciencecareers/2010/03/comparative-eff.html]
10. ^ http://www.cq.com/display.do?docid=3098444&productId=5&binderName=healthbeat-20090417
11. ^ http://www.nap.edu/catalog.php?record_id=12648

Further Information

• Carroll, John (6/2011). "Payers Step in With ‘Real-World’ Comparative Effectiveness Research" Managed Care Magazine.

• Thill, Mark (2010). "CER and Personalized Medicine Face Hurdles" Journal of Healthcare Contracting.

• Alexander GC, Stafford RS. Does comparative effectiveness have a comparative edge? JAMA. 2009;301:2488-2490.

• In 2009, The Institute of Medicine released Initial National Priorities for Comparative Effectiveness Research(CER). This report is designed to assist patients and healthcare providers across diverse settings in making more informed decisions. In this report, the Institute of Medicine's Committee on Comparative Effectiveness Research Prioritization establishes a working definition of CER, develops a priority list of research topics, and identifies the necessary requirements to support a robust and sustainable CER enterprise.

• In April 2009, the New England Healthcare Institute released a white paper identifying ways to design and implement the new federal comparative effectiveness research program without stifling valuable innovation in health care.

• Comparative effectiveness research is conducted by AHRQ through its Effective Health Care Program http://effectivehealthcare.ahrq.gov/.

• Weinstein MC, O'Brien B, Hornberger J, et al. Principles of good practice for decision analytic modeling in health-care evaluation: report of the ISPOR Task Force on Good Research Practices—Modeling Studies. Value Health 2003; 6:9-17.

• Hornberger J, Wrone E. When to base clinical policies on observational versus randomized trial data. Ann Intern Med 1997; 127(Part 2):697-703.

• Weinstein MC, O'Brien B, Hornberger J, et al. Principles of good practice for decision analytic modeling in health-care evaluation: report of the ISPOR Task Force on Good Research Practices—Modeling Studies. Value Health 2003; 6:9-17.
• Hornberger J, Robertus K. Comprehensive evaluations of healthcare interventions: The realism – transparency tradeoff. Med Decis Making 2005; 25:490-2.

External links

• Doing Their Homework: Times Reporters Respond in Dartmouth Atlas Spat. Goozner, Merrill.
• "Comparative effectiveness research" and Kindred Delusions. Hadler, Nortin.
• A Tale of Two Diseases: Repairing Comparative Effectiveness Research. Williams, David.
• Cedar Associates LLC - Clinical Effectiveness Decision Analytical Research
• http://www.economist.com/debate/overview/155 Economist Magazine debate on the motion "This house believes that the widespread use of comparative effectiveness reviews and cost/benefit analyses will stifle medical innovation and lead to an unacceptable rationing of health care. (Supporting the motion: Newt Gingrich Former Speaker of the U.S. House of Representatives and Founder, Center for Health Transformation. Against the motion: Sir Michael Rawlins Chairman, National Institute for Health and Clinical Excellence (NICE)).
• http://www.value-strategies.info/comparative-effectiveness offers explanations of clinical and economic comparative effectiveness