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The Latest on Comparative Effectiveness Research and Care Guidelines

By May 28, 2010Commentary

Our understanding of human physiology and biochemistry, diseases and treating diseases is an evolving body of knowledge.  Therefore, the medical professional training process imparts what is known at the time and hopefully physicians and others keep up with the state of the art.  There are many influences at work besides training, however, to affect how they practice, including peer and community practice patterns, marketing by drug and device companies and patient requests.  For some time there has been a movement to counter many of these influences by developing practice guidelines based on solid evidence for effective treatment, often comparing one possible treatment with another.  More money has been dedicated to this movement by recent federal legislation.   Several recent articles discuss aspects of  comparative effectiveness.

The Commonwealth Fund report is a Blueprint for the Dissemination of Evidence-based Practices.  (Commonwealth Fund Report) As the title suggests, the focus is on how to shorten the gap between development of a guideline and its widespread use in the medical community.  This process of diffusion has been widely studied, with results suggesting it takes several years for an innovation to be fully implemented.   The report examined some national quality improvement campaigns and found eight key factors to creating a successful dissemination strategy.

Mathematica put out a short brief called Basing health Care on Empirical Evidence.  (Mathematica Report) This report just gives a quick review of the status of various comparative effectiveness and evidence-based medicine efforts.  It repeats the claim that massive amounts of spending could be saved by following conservative, evidence-based treatment protocols.  That is really an unsubstantiated assertion at this point.

The Rand website has an analysis of comparative effectiveness research along several dimensions.  (Rand Analysis) The authors looked at the potential effects on spending, waste, patient experience, coverage, consumer financial risk, reliability of care, health outcomes and at the operational feasibility of conducting and spreading the results of the research.  In general, they found that to-date there is little empirical support for the purported benefits of comparative effectiveness research, although the potential is there.

Finally, a publication of the Massachusetts General Hospital contains an article on evidence-based medicine.  (MGH Article) This article is an excellent summary of the dilemmas and pitfalls of creating and implementing care guidelines.  The authors describe the difficulty and cost of creating evidence-based guidelines, the uncertainty attached to even the most rigorous studies, and the difficulty in helping physicians understand when and how to apply a general guideline to a specific patient, particularly a patient with multiple diseases.  The article also discusses the debate over whether to include relative or absolute in the analysis leading up to creation of a guideline.

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