Using Comparative Effectiveness Research to Examine and Improve Health Care Reform

Our understanding of the effectiveness of healthcare interventions continues to grow – in particular, our understanding of the impact of such interventions on individuals with mental illness and substance use disorders is becoming more robust. And yet, research evidence indicates that the realities of care delivery don’t always parallel established clinical guidelines. In the light of state budget cuts and other financial considerations, efforts are underway to realign direct care practices and clinical guidelines as one of several means to control healthcare costs and improve overall quality of care.

For the first time, significant amounts of money are being allocated to the federal government to evaluate the effectiveness of our nation’s healthcare. The economic stimulus bill approved by the U.S. Congress in February, 2009 provides $700 million to federal agencies to conduct or support Comparative Effectiveness Research. Congress characterizes CER as research that compares the clinical outcomes, effectiveness, and appropriateness of items, services, and procedures that are used to prevent, diagnose, or treat diseases, disorders and other health conditions.

The Patient Protection and Affordable Care Act establishes an independent CER entity, the Patient Centered Outcomes Research Institute. CER is being embraced by public and private healthcare stakeholders as a leading solution to rising healthcare costs, poor quality, and safety concerns.

Despite this recognition, many healthcare stakeholders remain apprehensive about the impact of CER. In fact, while the national healthcare reform bill creates a new federal CER entity, it does not authorize its findings to be used to make decisions about the coverage or reimbursement of services. Clinical guidelines reinforced by financial incentives might become coercive tools, curtail treatment choice, and undermine recovery for a group of clients with very complex, co-morbid mental and physical health conditions.

A recent study in a major health publication reveals that the general public may value other considerations – for example, recommendations from family and friends – more highly than findings from CER. Such subjective value judgments are at odds with the underpinnings of CER; clearly, additional efforts must be undertaken to achieve consumer buy-in of the value of CER in their decision-making process.

Healthcare advocates are calling for clear language that would prevent the use of CER to deny healthcare recipients needed treatments and therapies. Evidence should drive quality decision-making by the provider and the client. Cost is a factor after determining options most appropriate to the individual. CER should support individualized care and not dictate “one-size fits-all” treatment.

As bipartisan congressional action continues to shape how value and quality are defined in healthcare, there are clear action steps that researchers and providers need to take:

  • Encourage Congress and the federal government to further examine important issues, such as population versus individual applications of evidence-based medicine, accountability in generating evidence used by policymakers, and accurate communication of evidence gaps and uncertainties. CER must consider a wide array of evidence that includes observational studies, disease registry data, and expert opinions drawn from clinical guidelines.
  • As federal agencies develop their research agenda, it’s imperative that providers engage in the development, translation, and dissemination of research findings into policy and practice. The application of research findings within complex healthcare systems requires increased interaction between researchers and users to show a way for adaption and implementation of research results.
  • Examine how we effectively translate research into everyday public health policies and programs. Previous efforts to accelerate the translation of research into practice often fail to characterize the knowledge gap between evidence-based interventions and effective delivery and adoption by diverse healthcare delivery systems. We must be diligent in articulating the need to support practice- based research in conjunction with dissemination of comparative research.

Any CER efforts must be publicly accountable. All stakeholders, including clients and providers, can play an active role in the entire research process from setting research priorities to disseminating research results. Greater focus is needed for identifying the best methods to include clients in translating, disseminating, and implementing evidence to ensure that research is useful for policymaking.

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