This 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
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
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.