CER: Friend or Foe?

The Hospitalist. 2012 May;2012(05):

May 25, 2012 | The Hospitalist

Physicians who in the past might have resisted traditional evidence-based guidelines as “cookie cutter” algorithms that “don’t apply to my particular patient” will find it harder to dismiss CER findings on that basis, Dr. Meltzer notes, because CER is designed at the outset to be relevant to specific subsets of patients in actual clinical settings.

Nevertheless, incentives will be required to drive rapid and widespread adoption of CER findings, Dr. Conway believes.

“Just creating evidence doesn’t create change,” he says. “Cycle time from research finding to implementation matters, and the typical 17 years [time lag from bench to bedside] is not going to cut it. We need to work with clinicians and patients to take new findings and implement them sooner.”

CMS already has selected some evidence-based process and outcome metrics for its value-based purchasing program. “As CER identifies new evidence-based process and outcome metrics, we could incorporate them,” Dr. Conway adds.

Private insurers could use CER findings when making coverage decisions for their health plans. By law, CMS is obligated to provide coverage to Medicare beneficiaries for healthcare services that are “reasonable and necessary,” and cannot exclude coverage based on the cost of services.

“CMS could use CER findings to make coverage determinations based on ineffectiveness, when there is compelling evidence that a service is ‘not reasonable and necessary,’” Dr. Conway states.

HM Opportunity

Dr. Conway says hospitalists are uniquely poised to seek funding for CER that builds upon several critically important topics, such as examining the best discharge planning processes and transition-of-care protocols for certain types of patients. Dr. Meltzer, who is chief of the section of hospital medicine at University of Chicago, says he is seeking funding for a study of alternative transfusion thresholds for older patients with anemia across different levels of patients’ functional status.

“That’s the type of patient-centered study that CER is especially equipped to handle,” Dr. Meltzer says.

CER promises to produce important evidence for clinical questions that hospitalists struggle with day to day, Dr. Conway says. “Hospitalists should take the lead in developing effective ways to disseminate those findings, to teach medical trainees about them, and to spearhead CER-based QI [quality improvement] implementation and tracking efforts at their institutions,” he adds.

Christopher Guadagnino is a freelance medical writer in Philadelphia.

PCORI: Built to Reject the Myth of Coercive Rationing

The Patient-Centered Outcome Research Institute, or PCORI, has been carefully designed as an independent body with its own board to allay concerns over it becoming a rationing board that dictates treatment options or denies care that is too costly.

Unlike in Great Britain, whose National Institute for Health and Clinical Excellence (NICE) factors cost-effectiveness into its recommendations whether the National Health Service should cover new therapies, PCORI is proscribed by law from developing or employing such a measure, or from permitting its funded research to mandate coverage or reimbursement policies for any public or private payor.

“One of the things that the PCORI has to do is simply promote the notion that comparative-effectiveness research is a good model for research,” PCORI executive director Joe V. Selby, MD, MPH, told Health Affairs.³ Even with overt cost-effectiveness analysis left out of the equation, he noted, “It’s much better for us to generate good comparative evidence on outcomes, and let others think about the findings.”

As further evidence of “CER, American-style,” PCORI’s agenda is set by private stakeholders with input from physicians and other clinicians, researchers, hospitals, consumers, industry, payors, and governmental agencies. It will focus on common and widespread conditions, particularly chronic disease, and will pay close attention to reducing disparities in health outcomes among patient subpopulations.

The agency deliberately was named and structured to reflect the importance of patient preferences—toward the nature of research that will be conducted, the outcomes that are most important to them, and in the manner in which they can discuss the best treatment decisions with their physicians.