Comparative effectiveness research: policy and politics
Neurosurg Focus 33 (1):E6, 2012 1 C omparative effectiveness research is defined by the Institute of Medicine as the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care. 8, 10, 11 Randomized controlled trials, which identify causal relationships between treatments and health outcomes, are not designed to answer more intricate questions about how a new
... about how a new therapy should be considered for use in the context of existing treatment options. Comparative effectiveness research, however, may have the potential to generate more and better evidence on what works best and therefore add to the evidence used in selecting treatments. 9 Widely used in other countries, and supported at one time by both Democrats and Republicans in the US, CER has at once been cited as a tool to improve health care quality, control health care costs, and, most controversially, to ration health care. 4,7 History Although a new concept to many in today's political arena, the roots of effectiveness research can be traced back to mid-18th century Scotland and the "arithmetical medicine" practiced by the graduates of Edinburgh Medical School, 5 where 6 treatments for scurvy were tested and compared in a controlled trial. In Paris in the 1830s, Pierre Louis developed a method demonstrating that phlebotomy did not improve survival rates of patients with pneumonia, 5 and at the beginning of the 20th century, an American physician, Ernest Codman, founded "outcomes management," in which he examined hospital efficiency by tracking patient care errors. American policymakers most often cite CER in England, where in the 1930s health services research gained popularity. Later, after decades of socialized medicine, researchers found evidence of geographic variations in the provision of care including operations such as appendectomy, caesarean section, cholecystectomy, hysterectomy, tonsillectomy, and prostatectomy. 5 In the US, geographic variations in prostate care were highlighted in a 1972 paper by Archie Cochrane, leading to concerns that care was delivered differently depending on the recipient's geographic location. In some areas, there was underprovision of care, whereas in other areas there was overprovision of care, and many of the treatments delivered were deemed ineffective. Since then, various agencies have evolved in the US to conduct and promote research on the evidence of technologies and treatments, as well as their cost effectiveness, and the results have differed. The agencies include the National Center for Healthcare Technology (1978Technology ( -1981 and the Office of Technology Assessment, which from 1972 to 1995 issued a series of reports on a variety of processand disease-oriented health care matters. 9 Evidence-based medicine, a similar strategy, emerged in the 1980s 6 as a formal approach to using scientific data to inform medical decisions and to assist in the devel-Comparative effectiveness research (CER) is the basis for some of the fiercest rhetoric of the current political era. While it is a relatively old and previously academic pursuit, CER may well become the foundation upon which the future of health care in the US is based. The actual impact of CER on-and uptake among-doctors, patients, hospitals, and health insurers, however, remains to be seen. Political considerations and compromises have led to the removal of key aspects of CER implementation from policy legislation to prevent alienating stakeholders critical to the success of health care reform. Health care providers, including specialists such as neurosurgeons, will need to understand both the policies and political implications of CER as its practices becomes an indelible part of the future health care landscape. KEy Words • comparative effectiveness research • socioeconomics • health policy • Affordable Care Act • health care reform 1 Abbreviations used in this paper: AHRQ = Agency for Healthcare Research and Quality; CER = comparative effectiveness research; EBM = evidence-based medicine; PCORI = Patient-Centered Outcomes Research Institute; QALY = quality-adjusted life year.