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Comparative effectiveness research is the rage.  $1.1 Billion in the economic stimulus bill (right after the provision giving Disney control) is enough to make anyone take notice.  But why the heck to we need it?  Isn’t medicine scientific?  Doesn’t medicine make decisions based on the scientific evidence?  Isn’t non-evidence care the job of alternative medicine providers?

It’s complicated.

First, let’s define what CER is.  Michael Cannon of the Cato Institute explains:

Evidence suggests Americans spend $700 billion annually on medical care that provides no value.

Yet patients, providers, and purchasers typically lack the necessary information to distinguish between high- and low-value services. Advocates of such an agency argue that comparative- effectiveness information has characteristics of a “public good,” therefore markets will not generate the efficiency-maximizing quantity. While that is correct, economic theory does not conclude that government should provide comparative- effectiveness research, nor that government provision would increase social welfare.

Wait a minute…no value?  Where did he get that?  You don’t have to look far to see obvious examples:

• Antibiotic use – The rise of antibiotic resistence is laid at the feet of antibiotic overuse.  The cost of the antibiotics themselves could be dwarfed by the cost of treating resistant infections (just ask the mother of the boy I care for who was admitted last week for MRSA – his second admission).  Patient demand is part of the problem, but unclear expectations are also to blame.  Here are some examples:
  • Sinusitis – There is no clear consensus as to whether acute sinusitis requires antibiotics.  One analysis showed that while antibiotic treatment resulted in moderate improvement over placebo, only 9% patients saw that improvement and that benefit was offset by an 8% adverse-effect rate from antibiotics.  (Young, et. al; Lancet. 2008 Mar 15;371(9616):908-14.)
  • Ear infections – From UpToDate.com: “Several meta-analyses suggest that most children with AOM do well, even without antibiotic therapy.  These meta-analyses concluded that the benefit of antibiotics was modest.  Symptoms improved in 61 percent of children within 24 hours and in 75 percent at one week, whether they received placebo or antibiotics. Few serious complications occurred in children who received placebo or antibiotics.”
• Prostate Specific Antigen (PSA) screening for prostate cancer – While it is accepted and reimbursed by all insurers, there is little to no evidence that routine PSA screening reduces deaths from prostate cancer or even improves quality of life.  Most preventive care task forces don’t recommend for routine PSA testing, and some actually recommend against it.
• Coronary artery disease – There is not clear evidence that interventions (bypass grafting, stenting) are actually beneficial over the long-term.  This is a huge cost to society (a local hospital just built a multi-million dollar cardiac wing in honor of this cost) and puts patients through a lot.  The evidence seems to show that aggressive risk-factor management (lowering cholesterol using a statin, aspirin therapy, blood pressure control, diabetes control, smoking cessation) is at least of equal efficacy.

So where is the confusion?  The confusion is in the fact that insurance companies (including Medicare and Medicaid) pay huge amounts for these treatments, yet the evidence doesn’t support this.  As a physician, I am hard-pressed to go against the “standard of care” due to legal risk.  If I don’t order a PSA in a 60 year-old man and he gets cancer, will I get a letter from a lawyer saying that I was being sued?  After all, most other doctors would do the test.

Obama rightly stated that the first priority in healthcare is to control cost – simply throwing more money at a failing system won’t fix things.  We need to know what works and what doesn’t, and we need to be backed up in our decisions to follow those rules.

Public education on this will be a big thing.  My hope is that CER will show the public what actually works.  What they get now from the press is at best confusing, at worst inaccurate.  Gary Schweitzer posted about the persistence of the media to portray PSA testing as a proven life-saver.  How can I then tell a patient that I don’t think they need it done?

Medicine is not science as much as it is applied science. Science looks at large groups of people and finds truths that apply to them.  We don’t see large groups, we see individuals that may or may not fit into these groups.  When faced with a decision, it is not acceptable to say “let’s wait until a study comes out on this.”  We have to decide based on the best-evidence.

Yes, there is much to fear in the goverment leading the charge in CER.  They may try to boil healthcare down to a recipe book or decision tree.  Too broad of generalizations can lead to patients being harmed due to care being inappropriately refused.  But doctors need to be behind anything that emphasizes evidence and gives clear guidelines.  We need to be involved enough that the decisions on care are made by us, not by politicians.