Sunday, August 16, 2009

Comparative Effectiveness and Health Reform

The house health reform bill makes interesting reading once one gets past the arguments and into the details. One interesting section is Title IV - Quality, Subtitle A - Comparative Effectiveness Research, Section 1401, Part D. This section takes a mere 1 billion dollars (a very small part of the 1 trillion dollar total) to set up an infrastructure to fund and develop comparative effectiveness research. In the words of the bill, "a Center for Comparative Effectiveness Research to conduct, support, and synthesize research with respect to the outcomes, effectiveness and appropriateness of health care services and procedures in order to identify the manner in which diseases, disorders, and other health conditions can most effectively and appropriately be prevented, diagnosed, treated, and managed clinically" will be established. It goes on to form a "Comparative Effectiveness Research Commission to oversee and evaluate the activities carried out by the Center to ensure such activities result in highly credible research and information resulting from such research". In other words, it sets up an oversight Board and a bureaucracy to develop, monitor and prioritize this type of research.

Comparative Effectiveness Research Today

One of the pioneers of effectiveness research for the past twenty plus years has been Dr. Robert Brook who has done his work at the Rand Corporation. In an article in July in the Journal of the American Medical Association, Dr. Brook clearly and concisely described what comparative effectiveness research really is. He gives a simple example to illustrate the research. "Consider, for instance, a company manufactures an improved surgical needle. Comparing that needle to the needle currently used could be included in comparative effectiveness research. A nearly infinite number of studies could be conducted to determine how often a person with back pain should receive chiropractic treatment, how often a person with hypertension should receive follow-up care, how often a patient should obtain a dental checkup, or what form of radiation and chemotherapy will achieve the best outcome for a patient with cancer."

In the article he goes on to describe guiding principles that should be used to ensure that the government funded comparative research does not turn into a "free-for-all or a full employment program for health services researchers and epidemiologists".

The Real Need for Comparative Effectiveness Research

I agree completely with Dr. Brook's approach and I encourage all to read it. I do, however have a different thought. How about comparative effectiveness research for legislation. Rather than just pass a health care bill, let's spend 1 billion dollars setting up a Comparative Effectiveness Research Center and Commission to fund studies on the comparative effectiveness of different bills and different government programs. I for one would love to know if paying for end of life counseling, as called for in HR 3200 actually results in people dying with more dignity and with more support from family. How about expanding it and assessing the comparative effectiveness of specific congressmen and senators? I really think we may be on to something with a bill like that.

Comparative effectiveness is a concept whose time has come. Let's just not limit it to medicine. I believe it is in assessing the outcomes of the work of our governing bodies where it is most sorely needed.