The Stimulus Package’s Gift to Comparative Effectiveness

The $1.1 billion earmarked for comparative effectiveness research in the economic stimulus bill passed on February 13 could be a sound investment in improving health care’s efficiency, cutting costs, and improving patient outcomes. Or it could be more roadkill on the much-traveled highway to a cheaper and better health care system.

Comparative effectiveness research (CER) is the rigorous evaluation of the impact of different options available for treating a given medical condition for a particular set of patients. The Congressional Budget Office (CBO) posits that there are a variety of opportunities to constrain health care costs, in both public programs and the rest of the health system, without adverse health consequences. It cites factors such as substantial geographical differences in spending without corresponding improvement in outcomes, lack of evidence about which treatments work best for which patients, the private sector’s lack of incentives to do CER, patient disincentives because of limited cost sharing, and the dearth of electronic health records to facilitate data exchange as impediments to CER. That may change if the $1.1 billion allocated to compare drugs, medical devices, and common medical procedures’ effectiveness succeeds. Ronni Sandroff, Director/ Editor of Health and Family at Consumer Reports, explained, As we learn which treatments really work best for which types of patients, the knowledge can be used to set up unbiased treatment guidelines to help prevent mistreatment, overtreatment, and undertreatment.

The recent CER initiative is off to a good start with the selection of its two lead agencies: the Agency for Healthcare Research and Quality (AHRQ) and the National Institutes of Health (NIH). AHRQ’s mandate is to synthesize scientific evidence to improve quality and effectiveness in health care and to disseminate information via summary guides for consumers, clinicians and policymakers (visit www.ahrq.gov to view, for example, guidelines on allergic rhinitis and acute bacterial sinusitis). In 2005 it added the Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) Network to conduct accelerated practical studies about the outcomes, comparative clinical effectiveness, safety, and appropriateness of health care items and services. The network consists of research-based health organizations using electronic health information databases, with the capacity to conduct and turn around research. Although NIH wasn’t built for CER, it has the clinical firepower to produce it.

The $300 million allocated to AHRQ and $400 million to NIH will fund a host of important activities, including synthesizing findings from existing studies, analyzing available medical claims data, conducting new head-to-head clinical trials, comparing treatment options (surgery vs drug therapy), and analyzing different approaches to the same basic treatment (different levels of follow-up after surgery). How the information comparing high value and low value drugs, medical devices, and treatments from CER will be handled by stakeholders in the United Stats’ $2 trillion health care system remains unclear. Its back-door rationing will put economic losers on the defensive. For example, National Pharmaceutical Council president Dan Leonard endorses CER, with the caveat that CER examines all aspects of health care, including drugs, devices, and other medical treatments. When CER researchers start issuing guidelines based on comparing drugs head-to-head on efficacy and cost, look out!