Testimony on Comparative Effectiveness Research

James H. Bray, American Psychological Association

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).

Statement of James H. Bray, Ph.D.
President of the American Psychological Association
Submitted to the National Advisory Council for Healthcare Research and Quality
Priorities for Comparative Effectiveness Research
April 2, 2009

Thank you for this opportunity to provide comments on behalf of the American Psychological Association (APA) regarding national priorities for comparative effectiveness research. I am Dr. James Bray, APA President and Associate Professor of Family and Community Medicine and Psychiatry at the Baylor College of Medicine.

APA is the largest scientific and professional organization representing psychology with 150,000 members and affiliates. APA is also the largest publisher of behavioral science research, with 52 premier scholarly journals.

Comparative effectiveness research is a critically important tool for advancing an evidence-based approach to health care decision-making. However, the full public health benefits of such research will only be realized if behavioral, psychosocial, and medical interventions for the prevention and treatment of mental and physical health conditions are evaluated individually and in combination. Even when strictly medical treatments are compared, it is important to expand the range of outcome measures to include behavioral and psychological outcomes, such as quality of life and adherence to treatment protocols. It is also essential to evaluate promising new models of care, such as the use of integrated, interdisciplinary behavioral and medical teams in primary care settings. And finally, the effectiveness of health interventions across the lifespan and for different minority and gender groups must be considered.

Therefore, APA is recommending that comparative effectiveness research focus on these five areas:

We encourage research that compares different behavioral and psychosocial interventions for the prevention and treatment of specific health conditions. This research is crucial given that the leading causes of chronic health problems and mortality in the United States—such as heart disease, diabetes, and many forms of cancer—are due to modifiable behavioral factors, such as smoking, improper diet, lack of physical activity, and excessive alcohol consumption, among others. In addition, mental disorders, such as depression, represent a significant disease burden in the U.S. and worldwide. Fortunately, effective behavioral and psychosocial interventions exist to reduce life-threatening behaviors and treat health conditions, such as depression, heart disease, chronic pain, and diabetes. Now is the time to test the comparative effectiveness of these interventions to improve the health of the public.

Next, we strongly encourage research that compares behavioral and psychosocial interventions with medical interventions, and combinations thereof. This type of research allows for an examination of the relative and combined effectiveness of behavioral and medical interventions for specific health conditions.

A classic example of the value of this form of comparative research comes from the randomized controlled trial of the Diabetes Prevention program, which found that intensive lifestyle intervention, as compared to placebo or medication, reduced the incidence of type 2 diabetes to half that of placebo, and was significantly more effective than medication alone. Enhanced outcomes have also been found for combined behavioral and pharmacological interventions for depression and smoking.

Next, we should pursue research that compares integrated systems of care comprised of interdisciplinary teams of medical and behavioral health providers versus routine medical care. There is some indication that co-locating medical and behavioral health providers improves patient access and health outcomes.

For example, the integrated care approach has shown the largest reduction in depression levels and highest patient satisfaction. Interestingly, mortality was reduced on one recent large trial of integrated, primary care-based treatment of depression.

We also believe that all health research studies should include measures of behavioral and psychosocial outcomes, such as life quality, adherence to treatment protocols, behavioral functioning, depression, and anxiety. Such attention to patient-centered care builds upon the IOM's own definition of evidence-based practice.

As new life-saving medical advances are developed, we must strive to maintain patient quality of life. For example, depression and anxiety have been shown to increase in heart disease patients using implantable cardioverter defibrillators. Both the positive and negative outcomes of medical procedures need to be considered and evaluated before they are adopted as standard practice.

And finally, research that examines health intervention outcomes across the lifespan and for different minority and gender groups is needed to understand the effectiveness of interventions within and between population groups. This type of comparative research is important given the well documented health disparities that exist between different racial/ethnic, age, socioeconomic status, gender, and sexual minority groups, and because it is not clear if specific behavioral and medical interventions are equally effective across groups. This type of comparative research is critical as the U.S. population becomes more diverse.

Thank you for the opportunity to provide this brief statement. The American Psychological Association looks forward to the outcome of your deliberations.

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Current as of April 2009
Internet Citation: Testimony on Comparative Effectiveness Research: James H. Bray, American Psychological Association. April 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/newsroom/speech/apa.html