Thursday, May 07, 2009

Three NEJM Perspective pieces on CER

The first piece, by Alan M. Garber, M.D., Ph.D., and Sean R. Tunis, M.D., addresses concerns by some groups that CER could impede the progress of individualized medicine if it drives a one size fits all approach. I view genomic medicine the way I view the electronic medical record. I believe it is the wave of the future but it may be decades before the science matures enough for it to be clinically useful on a broad scale. I agree with the authors that it’s difficult to know the impact of genomic medicine in any given time frame and even more difficult to know the impact of CER on genomic medicine. The Partnership to Improve Patient Care (PIPC), cited by the authors, expresses concern and skepticism but is not opposed to CER. Their web site says:

Used appropriately, comparative effectiveness research can play a valuable role in supporting good decision-making in health care. Moreover, improved quality is the best path to greater health care affordability….

While CER can play a positive role in improving patient care and health care delivery, it also can be misapplied in ways that unintentionally undermine patient access to care and physician-patient decision-making.

That's because comparative effectiveness research results typically are based on broad population averages that don't reflect the differences in needs of individual patients. Any research results need to be considered along with the broader body of evidence, the patient's individual needs and preferences, and the physician's clinical

That last statement (italics mine) merely urges the application of one of the fundamental principles of EBM (it’s straight out of David Sackett’s definition) to the findings of CER. The drug and device companies, who have been accused of opposing CER, are key players in PIPC. Clearly there’s no opposition to CER there.

The next piece, by Jerry Avorn, M.D., accuses skeptics of mounting a “vigorous and well-coordinated backlash” against CER. The problem is that the skeptics he cites, including Betsy McCaughey and Rush Limbaugh, were objecting to a hidden agenda in the stimulus package to increase government control over health care. That debate had nothing to do with CER. The whole piece was a straw man attack against legitimate skepticism towards the government’s plan for health care.

Aanand D. Naik, M.D., and Laura A. Petersen, M.D., M.P.H. discuss the problem of poor translation of evidence into practice and cite tools developed by the VA and AHRQ.

Finally, Daniel Carlat weighs in on the NEJM pieces and adds to the confusion in a post here by, again, suggesting there’s opposition to CER when in fact no such opposition exists. I have tried to read extensively about CER. In my reading, while I’ve encountered lively debate and opposition to Obama’s political agenda for health care I’ve yet to read any opposition to the pure notion of comparative effectiveness research. We all seem to agree it’s worthwhile.

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