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Preparing for Comparative Effectiveness Research

Philip Betbeze, for HealthLeaders Magazine, October 8, 2009
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To get ready, start with evidence-based medicine.

If your hospital is implementing evidence-based medicine protocols, you may be well on your way to being prepared for comparative effectiveness research. Many countries with a single-payer health system have for years been using CER, generally regarded as an offshoot of the evidence-based medicine initiative, to try to combine clinical best practices with financial ones. CER is slowly making its way into the mainstream in this country, principally in the form of a $1.1 billion allocation for CER in the $787 billion stimulus package passed by Congress earlier this year. That money will be used to fund side-by-side studies to determine which medical treatments work best for the majority of patients with a certain malady. But at this point, the funding amount is minuscule compared to what it would take to implement CER.

Melody Craff, MD, PhD, MBA, is utilization director for VHA Inc. and clinical liaison to Providence Health & Services, a not-for-profit health system headquartered in Renton, WA, that includes 26 hospitals and 45,000 employees in five states. She is hopeful that CER will bring independence into a research field that's populated liberally with vendor-funded research, which is subject to conflict-of-interest challenges.

"This is essentially clinical science, but the novelty in the approach that is appealing is that it's independently funded," she says.

CER has been called a tool to ration care, but the political divide obscures the important work being done right now in hospitals across the country on evidence-based medicine as a way not only to improve patient care, but to eliminate waste, improve standardization of medical supplies and devices, and reduce duplication of services.

EBM: Physicians decide
Smart hospital leaders aren't waiting for comparative effectiveness research to decimate their bottom lines. They're doing something about it now by creating physician-led committees who agree to treat patients with a common malady in a way that medical evidence suggests will derive the best outcomes and the most value for the majority of patients. For practical purposes, EBM differs from CER in that conclusions are generally reached not through strict scientific research, but by what works best in the field.

"The basic underlying premise is that you compare one treatment option to others," says Timothy D. Ranney, MD, MBA, vice president of medical affairs at 267-licensed bed Good Samaritan Hospital, a Catholic Health Initiatives institution in Kearney, NE.

Ranney, who also serves as executive lead for quality at CHI Nebraska, a four-hospital division of CHI, says there are some serious shortcomings with CER, including that it doesn't allow for the changing of practice patterns.

"Just because a treatment is effective in one environment doesn't mean it will be in another," he says. "When you have CER, you have to take the practice situation in account."

At CHI, Ranney is part of an executive team that is rolling out an evidence-based medicine initiative. The group is focusing on practice areas that make the most impact on value and, where evidence is the strongest, creating standard modes of care and standardized elements to drive local hospitals' order sets and processes.

"Physicians are still going to make the decisions, but we need to have them sit together and find out what that standard should be," he says. "That's not 'cookbook medicine'; it's taking evidence that is increasing and applying today what you could not apply yesterday."

CER: EBM with teeth?
The bill that funded the $1.1 billion comparative effectiveness initiative is interesting not only because it's independently funded, but also because it states the results cannot be used to deny coverage under Medicare.

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