What is the Fuss about Comparative Effectiveness Research?

By Rachel Walden

Of all the bizarre arguments that have come out of the health care reform debate, perhaps the most unexpected has come from opponents of comparative effectiveness research (CER). CER is research that takes different health care procedures used to prevent, diagnose, or treat the same condition and compares them head-to-head to figure out which is most effective — which can help health care providers and patients make better decisions when they have to choose between different options.  CER can improve the quality of the health care we get, and can also help improve the health system as a whole, because it can help us stop wasting money on options that don't work as well (which is why it arose in the health reform debate to begin with). CER is also valuable because, as respected medical blogger Kevin Pho expains, physicians "need an authoritative source of unbiased data, untainted by the influence of drug companies and device manufacturers. With treatments and medications announced daily, having an entity definitively compare these newer, and often more expensive, options with established treatment regimens will be particularly useful in everyday practice."(1)

Better quality care and less health care waste…who could object? Well, it turns out that not everybody appreciates the idea that people might make health care decisions based on good comparative data. A PhRMA-funded lobbying group called the Partnership to Improve Patient Care was created to attempt to influence the debate and – while ostensibly supporting CER – wants to insure that CER treatment comparisons don’t consider cost factors. Pho puts these objections in context, explaining: “The pharmaceutical and device industry would like both the public and physicians to continue to assume that ‘newer means better.’ Not asking these questions allows them to continue promoting profit-making brand-name treatments.”(1)

Although the issue may still arise in the continuing health care reform efforts, expanded CER efforts are definitely coming to town, because last year’s stimulus bill (The American Recovery and Reinvestment Act of 2009) included $1.1 billion for it.(2) Supporters of the legislative language included “Consumer groups, labor unions, large employers and pharmacy benefit managers."(3)

Yet, in the stimulus bill debate, CER's critics suggested that the funds would result in the government mandating or withholding medical treatments (although the conference report specifically prohibited this).(4) Republican National Committee (RNC) co-chair Jan Larimer suggested that "women should be afraid" of CER, and threatened that CER could remove screening decisions from doctors and patients.(5) RNC Chair Michael Steele intimated that CER endangered older people, and insisted that it "could actually lead to government boards rationing treatments based on age."(6) In fact, noted experts have rejected concerns that CER might lead to health care rationing, “one size fits all” medicine, exclusions of special or minority populations, and the loss of drug and device makers' incentives for creating new treatments.(7)

With expanded CER funding ensured by stimulus funding, we are getting a better idea of what form federally funded CER efforts may take. The Institute of Medicine (IOM) has made specific recommendations to Congress for how these funds should be prioritized.(8)  The IOM's report, Initial National Priorities for Comparative Effectiveness Research, includes the 100 top topics (out of 1,268 unique suggestions) the authoring committee believed should be prioritized for funding.(9) The priority list includes several topics CER could explore that are of specific interest to women, incuding:
• The use of genetic and biomarkers to prevent, screen for, and treat cancers (breast, colorectal, prostate, lung, and ovarian) and other clinical conditions;
• The effectiveness of various interventions to reduce health disparities in cardiovascular disease, diabetes, cancer, musculoskeletal diseases, and birth outcomes;
• The benefits of film vs. digital mammography breast cancer screening, and of mammography-plus-MRI for women at high risk for breast cancer.
• Clinical interventions to reduce infant mortality, pre-term births, and low birth weights (especially among Black women), including prenatal care, nutritional counseling, smoking cessation, and substance abuse treatment;
• Pregnancy prevention strategies like over-the-counter access to oral contraceptives; expanding young women's access to long-acting contraceptive methods; and providing contraceptive methods at public clinics and other locations.
• Comparison of weight-bearing exercises vs. bisphosophonates for preventing fractures in older women with osteoporosis.
• Pregnancy outcomes with versus without the use of obstetric ultrasound in normal pregnancies.
 
Although it's not yet clear when research will be completed on any of these specific topics, we look forward to reviewing the findings. Although CER was a focal point for partisan and industry opposition, we hope that, now it's passed as part of the stimulus package, CER will provide needed information about which medical interventions work best to promote and protect women's health. And that is something we should all get behind.
 

Rachel R. Walden, MLIS is a medical librarian and blogger for Women's Health News and Our Bodies Our Blog.

Full disclosure: One project I contribute to in my daily work is funded through the AHRQ, an agency which receives some of the comparative effectiveness dollars included in the stimulus package.

References
1. Pho K, “We need comparative effectiveness research, or, I agree with Paul Krugman for the first time ever, ” KevinMD.com: medical weblog. Available at: http://www.kevinmd.com/blog/2009/02/we-need-comparative-effectiveness.html Accessed: March 7, 2010.

2. American Recovery and Reinvestment Act of 2009. HR 1, 111th Congress. Became Public Law No: 111-5. Available at: http://hdl.loc.gov/loc.uscongress/legislation.111hr1 Accessed: March 7, 2010
 

3. Pear R, “U.S. to Compare Medical Treatments. New York Times, February 15, 2009, ” Available at: http://www.nytimes.com/2009/02/16/health/policy/ 16health.html Accessed March 7, 2010.

4. U.S. House of Representatives, House Report 111-016: Making Supplemental Appropriations for Job Preservation and Creation, Infrastructure Investment, Energy
Efficiency and Science, Assistance to the Unemployed, and State and Local Fiscal Stabilization, for the Fiscal Year Ending September 30, 2009, and for other Purposes, Washington, DC: US Congress. Available at: http://thomas.loc.gov/cgi-bin/cpquery/ &dbname=cp111&sid=cp111knHMy&refer=&r_n=hr016.111&item=&sel=TOC_1478545&. Accessed March 7, 2010

5. Larimer J, “Women Should Be Afraid Of Democrats’ Comparative Effectiveness Research,” Republican National Committee: RNC Women. November 18, 2009. Available at: http://www.gop.com/index.php/rnc_women/comments/women_
should_be_afraid. Accessed March 7, 2010

6. Steele, MS, “Protecting Our Seniors: GOP Principles for Health Care,”
Washington Post, August 24, 2009. Available at: http://www.washingtonpost.com/wp-dyn/content/article/2009/08/23/AR2009082302036.html. Accessed March 7, 2010

7. National Partnership for Women and Families, Myths and Facts: Comparative Effectiveness Research, Washington, DC: National Partnership, no date. Available at
http://www.nationalpartnership.org/site/DocServer/CER_Myths___Facts_FINAL.pdf?docID=5421. Accessed March 7, 2010

8. Walden R, “Public Input Sought on Priorities for Comparative Effectiveness Research”, Our Bodies Our Blog, March 23, 2009. Available at: http://www.ourbodiesourblog. org/ blog/2009/03/public-input-sought-on-priorities-for-comparative-effectiveness-research. Accessed March 7, 2010

9. Institute of Medicine. Initial National Priorities for Comparative Effectiveness Research. National Academies Press. Washington DC. 2009. Available at: http://www.nap.edu/catalog.php?record_id=12648 Accessed March 7, 2010