Creative thinking about the CER agenda

Picture 13This week the Institute of Medicine (IOM) released its list of the top 100 topics that should be addressed in  comparative effectiveness research (CER) now — thanks to $1.1 billion in the American Recovery & Reinvestment Act
— that the federal government actually has the resources to do
substantial CER. IOM has prioritized the list by creating four
quartiles, noting that the first quartile is the highest priority
group, etc.

In order for the federal government to make good use of the huge pot of CER money, there are at least five things that they need to do to ensure its value and actually change care delivery.
I’m all for trying to find out whether me-too drugs add any significant
value. However, the greatest opportunities for implementing delivery
system change that improves care effectiveness and efficiency relate to
innovations in how care is organized and delivered, and how insights
are communicated to the broad range of health care actors — most
notably consumers.

That’s why I was heartened by the IOM’s top 100 list — though
certainly I’d move a few up a quartile or two. The list has many
projects that fit my priorities, including a strong emphasis on CER to
reduce health disparities.

Here are some examples of potentially valuable CER projects in the first quartile:

  • Compare the effectiveness of dissemination and translation
    techniques to facilitate the use of CER by patients, clinicians,
    payers, and others.
  • Compare the effectiveness of comprehensive care coordination
    programs, such as the medical home, and usual care in managing children
    and adults with severe chronic disease, especially in populations with
    known health disparities.
  • Compare the effectiveness of interventions (e.g., community-based
    multi-level interventions, simple health education, usual care) to
    reduce health disparities in cardiovascular disease, diabetes, cancer,
    musculoskeletal diseases, and birth outcomes.
  • Compare the effectiveness of literacy-sensitive disease management
    programs and usual care in reducing disparities in children and adults
    with low literacy and chronic disease (e.g., heart disease).

And those in the second quartile that really should be moved up:

  • Compare the effectiveness of shared decision making and usual care
    on decision outcomes (treatment choice, knowledge, treatment-preference
    concordance, and decisional conflict) in children and adults with
    chronic disease such as stable angina and asthma.
  • Compare the effectiveness of strategies for enhancing patients’ adherence to medication regimens.
  • Compare the effectiveness of patient decision support tools on
    informing diagnostic and treatment decisions (e.g., treatment choice,
    knowledge acquisition, treatment-preference concordance, decisional
    conflict) for elective surgical and nonsurgical procedures—especially
    in patients with limited English-language proficiency, limited
    education, hearing or visual impairments, or mental health problems.
  • Compare the effectiveness (including resource utilization,
    workforce needs, net health care expenditures, and requirements for
    large-scale deployment) of new remote patient monitoring and management
    technologies (e.g., telemedicine, Internet, remote sensing) and usual
    care in managing chronic disease, especially in rural settings.

Some from the third quartile that definitely could be prioritized higher:

  • Compare the effectiveness and cost-effectiveness of conventional
    medical management of type 2 diabetes in adolescents and adults, versus
    conventional therapy plus intensive educational programs or programs
    incorporating support groups and educational resources.
  • Compare the effectiveness of alternative redesign strategies—using
    decision support capabilities, electronic health records, and personal
    health records—for increasing health professionals’ compliance with
    evidence-based guidelines and patients’ adherence to guideline-based
    regimens for chronic disease care.
  • Compare the effectiveness of different quality improvement
    strategies in disease prevention, acute care, chronic disease care, and
    rehabilitation services for diverse populations of children and adults.
  • Compare the effectiveness of different strategies to engage and
    retain patients in care and to delineate barriers to care, especially
    for members of populations that experience health disparities.

And finally some from the fourth quartile that I also think deserve higher ranking:

  • Compare the effectiveness of different techniques (e.g., audio,
    visual, written) for informing patients about proposed treatments
    during the process of informed consent.
  • Compare the effectiveness of different disease management strategies for activating patients with chronic disease.
  • Compare the effectiveness of different delivery models (e.g., home
    blood pressure monitors, utilization of pharmacists or other allied
    health providers) for controlling hypertension, especially in racial

These examples are not meant to be an exhaustive accounting of all
the worthy projects proposed by the IOM. There was considerable
attention to re-thinking the locus of care delivery — that is,
evaluating the comparative effectiveness of emphasizing care that
transpires outside traditional health care delivery settings. It’s also
important to note that there are also a number of projects on the list
that specify the need to assess CER using patient-reported outcomes.

I’m looking forward to the evolution of the CER agenda.

6 replies »

  1. Interesting stuff, much to be said for CER certainly – so I’m glad to see this emphasized. But you have to wonder how long it’ll be before this list gets wider play on the talk shows and in the blogosphere. That said, I’d imagine some of the inclusions will be politically difficult to sustain. The quartiles are also potentially seriously hot potatoes.

  2. I fully concur with Joshua’s observations that by and large, the Institute of Medicine did a fine job of prioritizing the areas to be examined under the federal government’s newly funded comparative effectiveness research function. Let’s hope that the actual work is carried out with equally high academic rigor and political savvy.

  3. All of this CER stuff presupposes that the HIT devices being utilized to administer the care and record the results are safe and efficacious, let alone cost effective. Why is it that the measuring devices have not undergone the scientific rigors applied to other medical devices and all pharmaceuticals? C’mon Man