Friday, March 27, 2009

Kevin MD on comparative effectiveness research

I agree on most issues with my blogging colleague Kevin MD. Today, however, I must take issue with him concerning his recent USA Today op-ed on comparative effectiveness research (CER).

The title of the piece, Unbiased research for doctors is good medicine, implies that government funded CER is somehow inherently and uniquely unbiased. That premise, while it may appeal to popular belief, is false. The boosters of CER have revealed their biases. According to this New York Times article Representative Pete Stark, an enthusiastic supporter of CER and chairman of the Ways and Means Subcommittee on Health, seems to know what the research results will be before the research even starts: it’ll save money. Translate: it will favor cheaper drugs.

If you’ve any doubt about whether this program is biased just read the Congressional Budget Office paper which originally pitched the proposal, prefaced by the not-so-unbiased Peter Orzag, the new White House budget director. From the introduction to the paper (italics mine):

…because federal health insurance programs play such a large role in financing medical care and account for such a large share of the budget, the federal government itself has an interest in generating evaluations of the effectiveness of different approaches to health care.

The government has a financial interest in the outcome of the research. That’s a conflict. It’s a bias.

There’s more:

To affect medical treatment and reduce health care spending in a meaningful way, the results of comparative effectiveness analyses would not only have to be persuasive but also would have to be used in ways that changed the behavior of doctors, other health professionals, and patients.

That's telling. The government is already planning how to use the results. And this:

Generating additional information about comparative effectiveness and making corresponding changes in incentives would seem likely to reduce health care spending over time—potentially to a significant degree.

There’s more, but enough for now. Clearly this is agenda-driven, through and through. It’s politics informing science. It’s supposed to be the other way around! An unbiased, objective approach would seek to find out which treatments are best. The government’s plan is to design research to prove what they already think they know. That’s not objective science. Objective science is neutral and disinterested.

Much of the government’s enthusiasm is driven by interest in the Dartmouth Atlas Project. What’s the Dartmouth Atlas Project? It’s a large repository of data on health care expenditures and outcomes. In a collection of maps it demonstrates that there’s great variability in care by region and no correlation between expenditures and quality. That is, regions that spend more don’t necessarily get better care. The reasons for this are multiple and complex, often cultural and may involve systems of care as much as drugs and devices. It is a stretch to divine from such data that cheaper treatments are generally better. Yet, that’s the stretch the government sponsors seem to be making, and they are setting out to prove it with their CER agenda.

If all that’s not enough to convince you that government sponsored research can be very biased just look the track record of another $1 billion (and counting) government project, the National Center for Complementary and Alternative Medicine, a subsidiary of the NIH. Wasteful, conflicted and biased, and the sponsor of arguably one of the most disgraceful research boondoggles in all of medicine.

After pointing out the obvious, that doctors need research to help them make clinical decisions, Kevin goes on to say Currently, comparison research is largely conceptual… I disagree. As I pointed out in a recent post, comparative effectiveness research is a reality and has been with us for years.

Do we need more research? Sure. Always have, always will. Science is a work in progress. Is a politically driven agenda the best way to go about it? No.

On a final note, what about the wasteful variation in health care so vividly demonstrated by the Dartmouth Atlas Project? What’s the etiology of the problem? Is it a lack of research? No. It’s the abysmal penetration of evidence we already have into clinical practice. It’s less than 50%. It’s as low as 10% in some surveys. 10% uptake of $1.1 billion worth of research won’t fix the problem.

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