Creative thinking about the CER agenda

By JOSHUA SEIDMAN

This week the Institute of Medicine (IOM) released its list of the top 100 topics that should be addressed in  comparative effectiveness research (CER) now — thanks to $1.1 billion in the American Recovery & Reinvestment Act — that the federal government actually has the resources to do substantial CER. IOM has prioritized the list by creating four quartiles, noting that the first quartile is the highest priority group, etc.

In order for the federal government to make good use of the huge pot of CER money, there are at least five things that they need to do to ensure its value and actually change care delivery. I’m all for trying to find out whether me-too drugs add any significant value. However, the greatest opportunities for implementing delivery system change that improves care effectiveness and efficiency relate to innovations in how care is organized and delivered, and how insights are communicated to the broad range of health care actors — most notably consumers.

That’s why I was heartened by the IOM’s top 100 list — though certainly I’d move a few up a quartile or two. The list has many projects that fit my priorities, including a strong emphasis on CER to reduce health disparities.

Here are some examples of potentially valuable CER projects in the first quartile:

• Compare the effectiveness of dissemination and translation techniques to facilitate the use of CER by patients, clinicians, payers, and others.
• Compare the effectiveness of comprehensive care coordination programs, such as the medical home, and usual care in managing children and adults with severe chronic disease, especially in populations with known health disparities.
• Compare the effectiveness of interventions (e.g., community-based multi-level interventions, simple health education, usual care) to reduce health disparities in cardiovascular disease, diabetes, cancer, musculoskeletal diseases, and birth outcomes.
• Compare the effectiveness of literacy-sensitive disease management programs and usual care in reducing disparities in children and adults with low literacy and chronic disease (e.g., heart disease).

And those in the second quartile that really should be moved up:

• Compare the effectiveness of shared decision making and usual care on decision outcomes (treatment choice, knowledge, treatment-preference concordance, and decisional conflict) in children and adults with chronic disease such as stable angina and asthma.
• Compare the effectiveness of strategies for enhancing patients’ adherence to medication regimens.
• Compare the effectiveness of patient decision support tools on informing diagnostic and treatment decisions (e.g., treatment choice, knowledge acquisition, treatment-preference concordance, decisional conflict) for elective surgical and nonsurgical procedures—especially in patients with limited English-language proficiency, limited education, hearing or visual impairments, or mental health problems.
• Compare the effectiveness (including resource utilization, workforce needs, net health care expenditures, and requirements for large-scale deployment) of new remote patient monitoring and management technologies (e.g., telemedicine, Internet, remote sensing) and usual care in managing chronic disease, especially in rural settings.

Some from the third quartile that definitely could be prioritized higher:

• Compare the effectiveness and cost-effectiveness of conventional medical management of type 2 diabetes in adolescents and adults, versus conventional therapy plus intensive educational programs or programs incorporating support groups and educational resources.
• Compare the effectiveness of alternative redesign strategies—using decision support capabilities, electronic health records, and personal health records—for increasing health professionals’ compliance with evidence-based guidelines and patients’ adherence to guideline-based regimens for chronic disease care.
• Compare the effectiveness of different quality improvement strategies in disease prevention, acute care, chronic disease care, and rehabilitation services for diverse populations of children and adults.
• Compare the effectiveness of different strategies to engage and retain patients in care and to delineate barriers to care, especially for members of populations that experience health disparities.

And finally some from the fourth quartile that I also think deserve higher ranking:

• Compare the effectiveness of different techniques (e.g., audio, visual, written) for informing patients about proposed treatments during the process of informed consent.
• Compare the effectiveness of different disease management strategies for activating patients with chronic disease.
• Compare the effectiveness of different delivery models (e.g., home blood pressure monitors, utilization of pharmacists or other allied health providers) for controlling hypertension, especially in racial minorities.

These examples are not meant to be an exhaustive accounting of all the worthy projects proposed by the IOM. There was considerable attention to re-thinking the locus of care delivery — that is, evaluating the comparative effectiveness of emphasizing care that transpires outside traditional health care delivery settings. It’s also important to note that there are also a number of projects on the list that specify the need to assess CER using patient-reported outcomes.

I’m looking forward to the evolution of the CER agenda.