Thursday, June 11, 2009

Problems with the Definition of Comparative Effectiveness

The quote below is from a news posting on February 27. I received it in an email to AcademyHealth members ( This is a professional organization of people interested in jhealth policy and health services research.

The quote I put below is from the summary of the budget and part of a document titled “A New Era in Responsibility”. It has been sitting and waiting for me to think about ever since then. Back on March 12, I offered a comment on the definition of comparative effectiveness. I am returning to this, as it is even more difficult to believe what was printed in light of our nation’s continued discussions of which of the several options we have for health care reform will be of greatest benefit to society and control costs best. Here is what was printed nearly four months ago:

"Building on the unprecedented $1.1billion included in the recovery Act for comparative effectiveness research, the Administration will continue efforts to produce state-of-the-science information on what medical treatments work best for a given condition. When coupled with electronic health records, these findings can form the basis for clinical decision support tools-distilling all available evidence on the outcomes of different treatment options into user-friendly pop-up alerts for physicians at the point of care. These findings can thereby enhance medical decision-making by patients and their physicians."

Note what this says. We are going to spend $1 billion of taxpayer money to further study which treatment works best. We really do still have some questions about what works best for some conditions, but we also know a lot about what works best for some things already. Do we need to spend $1.1 billion on this? Maybe.

In theory, we are going to combine this with electronic health records to make better decisions. Well, we still don’t have an electronic health records system. So far, what has developed has not been coordinated. I know that a lot of people are concerned about centralized decision making, but if we have multiple electronic health records systems that have to talk to each other we may find that we are little better off than we are now. So, spending $1.1 billion to gain information to combine with an as yet non-existent system seems problematic.

Finally, the last sentence talks only about enhancing patients’ and physicians’ decision making. It doesn’t say anything about the constraints that both will face. Supposedly “better” medical decisions that ignore constraints may lead to higher costs.

One might be left with the impression that a lot of what we are doing is for show and not actually going to save us money and not going to make a big difference in our ability to make the best decisions with constraints. To be “kind” to the statement from the budget we could say, “It is just politics to leave cost out for now.” However, this is not a time for subtlety. The best way to allow fellow politicians, bureaucrats and citizens to properly evaluate policy recommendations is to clearly state exactly what is meant.

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