Wednesday, February 25, 2009

Who says we don’t have comparative effectiveness research?

A lot of folks, apparently. I can think of few issues in medicine about which there’s been more public confusion. This is the first opportunity I’ve had to weigh in in any detail, and it may be the first of several posts from here on the topic.

Several of my respected blogging colleagues have already written posts. DB said (my emphasis):

I strongly believe that CER will help physicians practice better, more cost-effective medicine. ….

When I can spend less money for equal benefits, then both the patient and I are happy. CER will provide the data to help us make such decisions.

And, in another post:

We cannot get such data unless we have a centralized process. Industry will never do such studies. No foundations have supported such expensive research.

Kevin M.D. weighed in here, saying we need CER.

Bob Wachter wrote:

Since nothing can happen without the research, the new funding for comparative effectiveness is welcome and helpful.

The faulty premise implied in each of those statements is that we don’t already have CER. Here are a few---just a few, mind you---examples to challenge that premise. This is just a drop in the bucket of CER we already have:

Which pressor is better in septic shock (multiple comparative studies)?

Discharge planning using a multidisciplinary intervention group is better than usual care.

CT is no better than V/Q for diagnosis of PE.

In sepsis, an early quantitative resuscitation strategy is better than a late quantitative resuscitation strategy or a qualitative resuscitation strategy (meta-analysis of multiple comparative studies).

In the early post operative period after cardiac surgery tighter glycemic control is better than less tight glycemic control.

Multiple studies comparing glycemic targets in medical patients with critical illness have failed to establish the best target.

In mechanically ventilated patients, integrating sedation interruption and spontaneous breathing as a single protocol works better than when these protocols are separate.

In patients with type 2 diabetes, intensive glycemic control is no better for macrovascular disease than less aggressive control over 5 years.

Intensive glycemic control is better for macrovascular outcomes when measured at 10 years.

Amiodarone is more effective than sotalol or propafenone for the prevention of recurrences of atrial fibrillation.

Rate control is as good as rhythm control for patients with atrial fibrillation (two comparative studies).

Devices are better than drugs post MI for prevention of sudden cardiac death in patients with reduced ejection fraction (two comparative studies).

Amiodarone is better than lidocaine for shock resistant VF.

Device therapy is better than amiodarone for ischemic and non-ischemic dilated cardiomyopathy.

Aspirin plus a PPI was a better strategy for prevention of GI bleeding than substitution of clopidogrel in patients with a history of aspirin induced GI bleeding.

Benazepril–amlodipine is better than benazepril–hydrochlorothiazide in hypertension treatment.

Four antihypertensive agents were compared head to head.

Streptokinase compared head-to-head with aspirin in patients with myocardial infarction.

Three thrombolytic drugs compared head-to-head in patients with MI (ISIS 3).

Two thrombolytic agents compared head-to-head in patients with MI (GISSI 2).

Rifaximin compared with lactulose in hepatic encephalopathy.

Magnesium compared to antiarrhythmic drugs in the acute management of atrial fibrillation.

Multiple studies have compared the hospitalist model of care with the traditional model, with mixed results.

Rivaroxaban compared with enoxaparin for DVT prophylaxis.

Fixed dose unfractionated heparin compared with low molecular weight heparin for VTE.

For ARDS and ALE, at least three studies have compared recruitment PEEP with conventional PEEP.

Crystaloid compared colloid for volume resuscitation.

Unfractionated heparin compared with low molecular weight heparin for VTE prophylaxis (many studies).

Tygecycline compared with levofloxacin for community acquired pneumonia.

PA catheter compared with CVP guided treatment of ALI and ARDS.

Two fluid management strategies compared in ALI and ARDS.

Enoxaparin compared with fondaparinux in patients with NSEMI.

Nesiritide compared with nitroglycerine in acute decompensated heart failure.

Not convinced yet? OK, then check out the Cochrane Collaboration where countless other comparative effectiveness studies are reviewed.

Yes, we have comparative effective research to guide us. Lots of it. The notion that doctors don’t have data with which to compare treatments is just plain wrong. Do we need more? Sure. Is another $1.1 billion or our tax dollars earmarked for CER going to bring uniform adherence to best practice? No, not when we can’t even adhere to the evidence we already have. Will there be unintended consequences? You bet. More soon.

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