Published 13 August 2009
Reform Will Refocus a Long-standing Problem
It's almost impossible to write an opinion about a health-care topic today without referencing the health-care reform frenzy in Washington. I won't even try. Since the Senate has decided that it's summertime and the living is easy and this can all wait until their well-earned vacation is over, I'll follow their lead.
One of the longer-term but essential components of making health-care reform work, regardless of how the current legislative process plays out, is establishing evidence-based guidelines that allow, or more accurately, encourage clinicians to choose the course of treatment most likely to produce a favorable outcome, and discourage practices that are less promising. The Institute of Medicine this month released its initial list of priorities for so-called comparative effectiveness research. Of the current approach to clinical decision-making, the IOM report says, "All too often, the information necessary to inform these medical decisions is incomplete or unavailable, resulting in more than half of the treatments delivered today without clear evidence of effectiveness."
The flaws in the current system of reaching consensus on treatments are well-documented; the artificiality of clinical trials versus real-world practice, the under-representation of key populations, and the influence of marketing are just a few. Of the latter, you need only look to the Arkansas trial where a federal judge this month ordered the release of thousands of pages of "ghostwritten" articles published in peer-reviewed journals, allegedly ordered by Wyeth marketers who were able to entice physicians to lend their byline to an article they did not author. Even ignoring that possibility, the time lag in peer-review publishing obviously works against rapid dissemination. The flip side of that is on display in our cover story this month detailing the current state of combination therapies. We're able to go right to clinicians and investigators in the field and quickly report their results. We're not peer-reviewed; we're fast. Are those results reliable? Are we free of commercial influence? You can take my word for it. (No, I wouldn't either.)
What comparative effectiveness research and the resulting practice guidelines need to succeed is: transparency; freedom from commercial influence; much faster turnaround than the current peer-review system; and real incentives for clinicians to implement proven strategies (the idea of physicians policing their ranks has never worked and never will).