Testimony on Comparative Effectiveness Research

On April 3, 2009, public testimony on comparative effectiveness research was given at a meeting of the National Advisory Council for Healthcare Research and Quality. The testimony represents the views of the presenter and not necessarily those of the Agency for Healthcare Research and Quality (AHRQ) or the Department of Health and Human Services (HHS).

Strong Medicine for America

Statement of the American Academy of Family Physicians

To The

Agency for Healthcare Research and Quality

on

Comparative Effectiveness Research Priorities

April 3, 2009

The American Academy of Family Physicians submits this statement for the record to the Agency for Healthcare Research Quality (AHRQ) on the importance of comparative effectiveness research (CER) and our priorities in this area.

The AAFP was founded in 1947 and represents more than 94,600 physicians and medical students nationwide. It is the only medical society devoted solely to primary care.

Nearly one in four of all office visits are made to family physicians. That is 208 million office visits each year—nearly 83 million more than the next largest medical specialty. Today, family physicians provide more care for America's underserved and rural populations than any other medical specialty.

In our increasingly fragmented world of health care, family physicians are dedicated to treating the whole person, across the full spectrum of ages. The cornerstone of family medicine is an ongoing, personal patient-physician relationship focused on integrated care.

As a result of the number of patients we see each day, and our "first breath to the last breath" relationship with them, the AAFP is committed to research that allows us to provide high quality, cost-effective care.

Comparative Effectiveness Research Is Key to Quality and Cost in Health Care
The AAFP strongly supports high quality comparativeness effectiveness research. If we wish to improve patient care and control costs in this country, this type of research is crucial. It is only with it that we can provide evidence-based information to patients and physicians for use in making health care decisions. Our policy on this issue is guided by the following principles:

  • Comparative effectiveness research is critically important to our members—family physicians see patients with common problems every day for which there is no solid clinical evidence.
  • As CER develops, some therapies will be proven to work better than others and the deliverers of those therapies will challenge the results. Nevertheless, the health of the public should trump individual business concerns.
  • We are pleased that the National Institutes of Health (NIH), like AHRQ, will be receiving funding to perform CER. We hope that NIH recognizes a core value of CER: consideration of different patient populations, comorbidities, cultural differences and values, which will be challenging but important.

The AAFP applauds the provisions in the American Recovery and Reinvestment Act that support aggressive comparative effectiveness studies through AHRQ and NIH. We believe these additional dollars likely will lead to important advances in our knowledge, and in a relatively short time. However, we also realize that CER must be ongoing and that we will not answer all questions in the next few years. We recommend continued funding of and emphasis on CER as a means to improved health care in this country.

Importance of Comparative Effectiveness Research
Despite the numerous randomized clinical trials that are conducted each year, around the world, there still is a surprisingly large gap between what we know and what we need to know to provide optimal care. This is true even in highly-prevalent illnesses such as diabetes and depression. The recent AHRQ Comparative Effectiveness Reviews in these two areas highlight the current gaps in our knowledge.

Family physicians provide care to individuals throughout their lives, including patients with numerous chronic illnesses. As a result of this broad scope of practice, it is not surprising that our members deal constantly with gaps in medical knowledge. As practicing family physicians, our members may feel as though they spend more time "practicing in the gaps," than practicing medicine that is supported by randomized clinical trials.

Given the complexities of clinical care and the multitude of treatment options available for many conditions, as a nation, we cannot expect, afford or in many cases ethically conduct, all the randomized clinical trials that would be needed to fill in the existing gaps in knowledge. As a result of this practical consideration, the AAFP is a strong supporter of ongoing development and support of comparative effectiveness research.

CER Must Be Guided By The Health of the Public
Comparative effectiveness research can improve our understanding of different treatment options across a broad spectrum of patients, as well as provide an analysis of the treatments' cost effectiveness. While there has been criticism of comparative effectiveness research recently, we believe these concerns are unfounded for several reasons.

First of all, the AAFP believes that comparative effectiveness research means careful analysis of the relative benefits and costs of various treatments across different populations of people and illnesses. In a nation that spends the largest amount, per capita, on health care with mediocre to poor health outcomes, and has more than 46 million uninsured individuals, we believe research that will improve quality, lower costs, improve access and increase efficiency is imperative.

The AAFP does not subscribe to the belief that comparative effectiveness research necessarily will lead to arbitrary regulation or limits. Certainly, if a treatment is shown to be routinely inferior and more costly, we believe it is reasonable to ask why this treatment should continue to be used. However, the more important question is how to respond when a more effective treatment for a patient is more expensive. In our view, we have long opposed any action that would limit our patients' access to physician-prescribed interventions if we believe it is the most appropriate therapy.

The Strength of CER Results from its Inclusion of Different Populations
Comparative effectiveness research must take into consideration different populations, comorbidities, cultural differences and values. While this type of research will be more difficult, it is vital to providing health information that is relevant to different individuals. In particular, family physicians support this type of research not only because we practice in rural, urban and suburban areas that have different levels of resources, but because our wide variety of patients makes appropriate CER essential.

AAFP Involvement with AHRQ and Research Priorities
The AAFP has worked closely with AHRQ to help shape the priorities included in the agency's Comparative Effectiveness Reviews. Given the broad scope of care encompassed by family medicine, it is impossible to select one or two clinical topics as the highest research priority.

Nevertheless, unsurprisingly, the recent topics that the AAFP has forwarded to AHRQ for consideration relate to the common conditions seen every day by our members. Suggested topics have included:

  • Best options for treatment-resistant depression.
  • Best options for treating hyperglycemia across various ages and co-morbid conditions.
  • When is neuroimaging indicated for headache, and,
  • Optimal treatment for dyslipidemia when a statin either is not tolerated or is insufficient.

Needless to say, there are numerous other research topics we could suggest. Among the many clinical questions that could be asked, we favor prioritizing those that affect the most people and that have the largest impact on quality and length of life.

DARTNet: An Example of EHR-Based CER
While the AAFP believes it is important to conduct studies, we must develop further the science of comparative effectiveness research, as well as the technologies to support the collection of more robust data sets.

As a result, the AAFP has played a leading role in a public/private consortium of institutions, which is developing new approaches to comparative effectiveness research. This research is being performed through collaboration with hundreds of family physicians and other primary care physicians. The goal of the project is to show that practice-based network research must be used in tandem with traditional clinical trials. Through the Distributed Ambulatory Research in Therapeutics Network (DARTNet), the AAFP is seeking to improve the quality and safety of medical care by collecting and sharing clinical data and best practices. This program uses electronic health records, practice-based research networks and practical clinical trials to advance comparative effectiveness research.

Through DARTNet, the AAFP is examining how using the electronic data from a patient's medical home can inform and expand our knowledge of effective and safe medical care. In addition, DARTNet physicians are studying the care they provide and learning from the best practices that are discovered. Further, DARTNet physicians have agreed to seek out top performers within the network and have pledged to share with others their methods.

The AAFP is working actively with DARTNet to build relationships with what we hope eventually will be thousands of primary care physicians. The DARTNet system is providing participating physicians with the technology to learn from the care they have provided, and to track their efforts to make improvements. The use of these data clearly can improve care at the practice level—and enhance our understanding of therapies that are the most clinically and economically effective.

Conclusion
In conclusion, the AAFP believes that rather than focus on a small set of priority areas, it is critical for comparative effectiveness research to study the conditions that affect the most Americans. In addition, the broader research community must recognize the value of practice-based research networks, along with traditional clinical trials, as a means to include diverse populations. Finally, while CER will produce results that may be controversial, or questioned, we believe its guiding principle should be on producing information on what is most effective to improve the overall health of the public. It is only with these principles that we can answer the pressing questions our members face each day as they strive to provide the best care to their patients.

Thank you for allowing us to express our views on this critically important issue.

AAFP Headquaters
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AAFP Washington Office
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Current as of April 2009
Internet Citation: Testimony on Comparative Effectiveness Research. April 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/newsroom/speech/aafp.html