Comparative effectiveness

In the current New Yorker, an excellent piece reflects on the Avandia controversy – A Drug on the Market. The author speaks of the specific issue of Avandia, but then goes on to lament our lack of high quality information on treatments.

This kind of brouhaha, with volleys of personal attacks and fights for the biggest headline, doesn’t look much like science. But it’s all too typical of the way we measure the safety and efficacy of drugs. The U.S. has no rational system for “post-market surveillance”—the evaluation of drugs after they’ve been approved. Instead, oversight is left to a motley collection of altruists, academics, lawyers, self-publicists, and drug companies, who make their own arbitrary decisions about which drugs to study, how to evaluate them, and what risks to look for. Somehow, the truth is expected to rise to the surface from among all these competing interests and random decisions.

There is currently a proposal in Congress which would take some positive steps to address these issues. Here is the CBO testimony on comparative effectiveness – Research on the Comparative Effectiveness of Medical Treatments: Options for an Expanded Federal Role

Furthermore, hard evidence is often unavailable about which treatments work best for which patients or whether the added benefits of more-effective but more-expensive services are sufficient to warrant their added costs. In many cases, the extent of the variation in treatments is greatest for those types of care for which evidence about relative effectiveness is lacking. Together, those findings suggest that better information about the costs and benefits of different treatment options, combined with new incentive structures reflecting the information, could eventually yield lower health care spending without having adverse effects on health—and that the potential reduction in spending below projected levels could be substantial. Moving the nation toward that possibility—which will inevitably be an iterative process in which policy steps are tried, evaluated, and reconsidered—is essential to putting the country on a sounder long-term fiscal path. But even if it did not bring about significant reductions in spending, more information about comparative effectiveness could yield better health outcomes from the resources devoted to health care.

Our organization – SGIM – provided testimony on this proposal. Our organization supports this concept strongly.

I hope that we see positive action from Congress on the proposal to fund comparative effectiveness research. Other countries support such studies.

Other developed countries also face challenges financing health care costs and have taken various steps to assess the comparative effectiveness of treatments. Many of those countries establish overall budgets for their national health systems and use comparative effectiveness analysis to help determine which treatments and procedures will be covered or how they will be reimbursed. Perhaps the best known example is the National Institute for Health and Clinical Excellence (NICE), which was established in 1999 as part of the United Kingdom’s national health service. It provides guidance on the use of new and existing medicines, procedures, and treatments and on appropriate treatments for specific diseases. With a staff of about 200 and an annual budget of about 30 million pounds (roughly $60 million), NICE does not fund new clinical trials or other forms of primary data collection but, rather, bases its determinations on systematic reviews of existing research.

Other countries such as Australia, Canada, France, and Germany have similar review processes. Discussions have sometimes focused on those countries’ procedures for reviewing prescription drugs, but all of them have systems in place to evaluate medical and surgical treatments and technologies as well. It is therefore worth noting that, for all the attention that prescription drugs receive, they currently account for less than 15 percent of total U.S. health spending. Therefore, if additional research in the United States on comparative effectiveness focused only on medications, the impact would probably be much smaller than if that research encompassed the whole spectrum of medical care.

I believe that we will see funding for this proposal. As I understand, both conservatives and liberals are supporting this concept. This is a much better strategy for understanding and perhaps decreasing health care costs than any other proposal of which I am aware.