On writing a talk about CER and PCMH


Category : Medical Rants

I will be giving a talk on CER and PCMH in September – The National Comparative Effectiveness Summit.  I did not choose the title, and now I must decide how to frame my remarks.

So I am interested in your suggestions.  I will now share my initial thoughts:

The PCMH concept is an important way to organize outpatient practice.  However, the medicine practiced in the PCMH should not differ greatly from any generalist outpatient practice. 

What do generalist physicians need from CER?  As I took care of outpatients for 20 years and as I take care of hospitalized patients (now for over 30 years), for many patients physicians must make many decisions:

  1. Which medication should I use next?
  2. What test should I order?
  3. Should I add another medication for hypertension, hypercholesterolemia, diabetes control, etc?

And every one of these decisions has both cost and effectiveness as considerations.  Patients often raise money as an issue in their care.  I offer these examples from recent patient care decisions:

  1. Are the benefits of generic statins as great as atorvastatin?  How much difference is their – does the difference justify the cost?
  2. The patient has muscle pain from his statin, will a lower dose help him?  Should I try every other day statin?
  3. The patient has a HgbA1c of 7.5 – should we be satisfied?

So I am asking you, the readers of db's Medical Rants, to provide me with more real life examples.  I will acknowledge your contributions in my remarks.  What questions would you like comparative effectiveness research to answer?

Comments (3)

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The real purpose of the PCMH is to make a large practice look, feel, and function like a solo doctor to the patient. That's why much of it is so irrelevant to my practice and other small offices.
As to what I'd like to see CER on:
Roles of SSRIs +/- long acting benzos (clonazepam), with or without psychotherapy (and what kinds) in chronic anxiety. (There's a slightly better handle on treatment of depression; anxiety can be tougher, especially since a lot of these people resolutely deny depression symptoms.)

Outcomes of expensive extended-release formulations, vs. immediate-release generics.
 Does the presumed increase in compliance with once-daily-dosing lead to better outcomes?
I would be especially interested with the various forms of extended-release methylphenidate.

Also, it would be nice to know the comparative effectiveness of newer antidepressants approved for fibromyalgia. Are Cymbalta and Savella really more effective than venlafaxine? Are any of them more effective than amitriptyline? If amitriptyline is $4 a month, and Cymbalta is $150, is it really 37 times as good?

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