Retired Doc is a wonderful blogger. He thinks clearly and writes well. I personally believe that both he and Jerome Groopman (whom he cites) still do not understand comparative effectiveness research. Enactment of Comparative Effectiveness Research -Libertarian Parternalism or Orszag type coercion
As I read his rant, he worries about misinterpretation of CER and therefore misuse of the information. Groopman also writes eloquently. Health Care: Who Knows 'Best'? He focuses on the misuse of performance measures due to incomplete information. I agree with much of what he writes, but I disagree with his conclusions. I actually believe that he makes a great case for the need for comparative effectiveness research. If we had had good CER, then we likely would not have had the performance measurement snafus that he describes.
As I read the criticism of CER, I read paranoia. The critics imagine the government funding and using CER to worsen health care. I really do not follow the argument.
We need good data to make medical decisions. CER can provide new data that physicians need to address our patients' complexity.
I do not understand how more clinical research information can make things worse.
{ 4 comments… read them below or add one }
I am afraid I do not write as clearly as you suggest.I never intended to argue against doing comparative effectiveness research.Of course it should be done and has been done for years.We certainly need good data.I do see problems with overzealous and premature conclusions regarding results that translate into guidelines that are perceived as mandates and morph into economically enforced rules.
I’m afraid you’re mischaracterizing Dr. Grooman’s arguments. It seems very clear that the politicians, who are driving CER, are intending to use CER as a tool to “standardize” medical care and create “performance measures.” The politicians are confusing “best practices” with CER. While these are technically different (the former being many times opinions about disease management, screening, etc, and the latter such another word for clinically meaningful research), the current arguments from Obama and Orzsag are clearly melding the two. Obama calls for a “commission of doctors” to define best practices—don’t those already exist?—and combine those with financial incentives. CER, as envisioned by the politicians, will not be simply be improved clinical trials “that provide new data that physicians need to address our patients' complexity” but rather a set of guidelines to determine “quality” and therefore payment. CER is a buzzword. I haven’t actually heard any argument from Obama about how research in this country will be done differently, only about how “knowledge” will reduce cost. I see no paranoia, and the argument is simple to follow. CER=best clinical practices=reduced costs + better care is simply not true. And “If we had had good CER, then we likely would not have had the performance measurement snafus that he describes” is simply not true. Each generation likes to think it understands things better than the previous one. As medicine is not an exact science, there will always be failure to capture the entire picture at any one time. Except this time, the politicians want to legislate that picture, and force physicians and patients to keep staring at that picture. Groopman has been around long enough to recognize that folly.
The issue is how CER will be implemented. There are three treatment outcomes: effectiveness, side effects, and cost. The priority is different for different parties. CER often solely means a randomized clinical trial (RCT). Consider the major prostate cancer treatments: surgery (open and laparoscopic) radiation (brachytherapy, IMRT, proton beam), cryotherapy, active surveillance. An unbiased RCT for the above treatments is not practical. However, since these are all existing treatments, with around 200,000 annually diagnosed prostate cancer patients, if there were a standardized form for reporting treatment effectiveness, side effects, and cost, one could answer in a relatively short time which treatment is “best.” The question is will retrospective data be accepted.
DB, I have a post in preparation which agrees with Retired Doc and Groopman, but first I would like to know why you think they are critical of CER. I do not see Retired Doc or Groopman or anyone else, for that matter, arguing against CER.
When I enter my post I will express concern about the government’s agenda behind CER, not about the research itself. I hope in advance you won’t think I am against CER. If anyone in our profession really was against clinical research it would be an easy target for ridicule but, as one who has followed this issue from the beginning I have yet to see opposition to the pure notion of comparative effectiveness research.