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Increasingly, the cost of care is unnecessarily dear, rising exponentially while the return on investment is falling precipitously. What can be done about improving the value of health care?
Even as we "embrace advances in health care, we must remember that a number of what were thought to be advances turned out to not be beneficial, or even to be harmful." Nevertheless, a recent Institute of Medicine report gives reform its legs by auguring for "a culture that uses rigorous evidence-based standards to help patients feel better and live longer. To that end, the report describes the following areas of research and development: increasing the usefulness of information technology (i.e., computational power and connectivity), improving organizational capabilities and management science, and increasing focus on enabling patient-centered care."
Smith M, Cassell G, Ferguson B, Jones C, Redberg R.Institute of Medicine of the National Academies. "Best care at lower cost: the path to continuously learning health care in America" Last accessed September 9, 2012 [Therein, the "Components of a Learning Health Care System" are listed under three broad categories: Foundational Elements--The digital infrastructure and The data utility; Care Improvement Targets--Clinical decision support, Patient-centered care, Community links, Care continuity and Optomized operations; and Supportive Policy Environment--Financial incentives, Performance transparency and Broad leadership.]
Comparative-Effectiveness Research (CER) is that evidence--it is basis by which health care can be not only cost-effective, but also efficacious as applied. In brief, CER helps us determine what should and what should not be made available, accessible and covered.
Also referred to as "Patient-Centered Outcomes Research Act of 2009," CER makes information available to help "clinicians and patients choose the options that best fit the individual patient's needs and preferences." The "conduct and synthesis of research comparing the benefits and harms of various interventions and strategies for preventing, diagnosing, treating, and monitoring health conditions in real-world settings. The purpose of this research is to improve health outcomes by developing and disseminating evidence-based information to patients, clinicians, and other decision makers about which interventions are most effective for which patients under specific circumstances."
Per the Federal Coordinating Council for Comparative Effectiveness Research, which is established by the Office ofthe Secretary in the Department of Health and Human Services (DHHS)
CER, broadly, is concerned with the methodology of information technology (I.T.), data infrastructure, the translation of data into information and its promulgation (although they would undoubtedly prefer the word, "dissemination," it being less aggressive).
Conway PH, Clancy C. "Comparative-Effectiveness Research — Implications of the Federal Coordinating Council's Report" Published at www.nejm.org June 30, 2009 (10.1056/NEJMp0905631)
The IOM committee also recommended "supporting CER related to patients' decision making, unhealthy behaviors such as smoking, and determining the most effective dissemination methods to ensure translation of CER results into best practices."
Key Priority Areas of Interest
The graph shows 100 primary and 193 secondary research topics by topic with "Health Care Delivery System" being the most prevalent. After that, nearly 1/3 was racial and ethnic disparities, 1/5 was patients' functional limitations and disabilities. Thereafter, in terms of prevalence, were: cardiovascular disease that ranked second as a primary research area [1], geriatrics, psychiatric disorders that ranked third as an area for primary research [2], neurologic disorders [3], pediatrics and cancer [4].
[1] Cardiovascular and peripheral vascular (CV-PVD) diseases were the leading causes of death in the U.S. in 2006. Note: one might consider in this context that heart disease is a co-morbidity where the primary disease or condition is diabetes or obesity, respectively; and both of these are, unfortunately, increasingly more prevalent.
[2] Includes mental health care—venues and locations, provider training, pharmacologic treatments of or for depression and/or suicide consequent to mental disorders.
[3] Incorporates diagnostic imaging and interventions for headaches, multiple sclerosis, epilepsy and dementias including Alzheimer's disease.
[4] Cancer is second to CV-PVD in U.S. deaths and "one of the most costly diseases to treat. [It] is the focus of six recommended primary CER topics, including screening technologies for colorectal and breast cancers and the [appropriate] use of imaging technologies for diagnosing, staging, and monitoring all cancers.
Iglehart, John K. "Prioritizing Comparative-Effectiveness Research -- IOM Recommendations." N Engl J Med .June 30, 2009; pub. Online: 0: NEJMp0904133
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