Health Affairs: Barriers to comparative effectiveness hinder patient care
Jerry Avorn, MD, and Michael Fischer, MD, from Brigham and Women’s Hospital in Boston, sought to investigate and highlight the obstacles that physicians face in implementing the most effective, evidence-based clinical decisions and practices. In the midst of changing laws and the establishment of the Patient Centered Outcomes Research Institute, the authors noted that “with the expected avalanche of new comparative-effectiveness research, we need to overcome these longstanding barriers to translating results into practice, to make sure that these new insights are applied appropriately.”
While applauding the boom of medical research and innovation, Avorn and Fischer emphasized several obstacles to implementing these practices. The first was the “if you discover it, they will come” philosophy of many biomedical researchers: “Although enormous effort and expense are devoted to conceiving and implementing a carefully wrought clinical trial, there is often no plan for putting its results into practice once it is finished,” the authors expressed.
The study acknowledged that a handful of efforts, such as reviews of research, do exist to disseminate new medical findings, but the authors found such efforts for the most part ineffective. “The reviews are typically extremely thorough, but the resulting documents are so long and detailed that they often fail to influence—or even get read by—most practitioners.”
Avorn and Fischer emphasized the potential role that continuing medical education could play in bridging the dissemination gap, while protesting education’s misuse. The authors pointed out that drug and medical device manufacturers spend more than $1 billion each year to educate physicians about new drugs and procedures as part of marketing campaigns. “Many doctors meet with several such representatives each week. Beyond the sometimes skewed nature of the comparative data presented, these encounters in the past have created an opportunity for the representatives to promote off-label prescribing, even in the absence of evidence supporting it.”
The study found that poor dissemination plans by researchers and effective counter-marketing by drug companies has kept many more expensive, patented drugs, such as various hypertension medications, the anti-depressant Lexipro (escitablopram oxalate, Forest Laboratories) and the antiplatelet Plavix (clopidogrel, Bristol-Myers Squibb/Sanofi-Aventis), over-prescribed when those drugs have demonstrated little or no benefit to alternatives and generics. The study also blamed the FDA’s failure to require more “unbiased, evidence-based findings” as further enabling physicians’ failure to implement comparative-effectiveness practices.
Another source of concern for the authors was distortion of physician incentives. The study offered examples of CT and coronary angioplasty as at times more risky procedures without demonstrated advantages over safer alternative therapies. These findings, the authors argued, are often “ignored by the clinicians who depend on such procedures for their livelihood.”
The study offered several solutions to facilitate the implementation of more effective treatments. Medical detailing, which the authors likened in effectiveness to informal meetings with drug companies but with “neutral,” evidence-based education, have demonstrated strong results in informing doctors of new research.
The article also emphasized the role that medical technologies such as informatics and electronic order entry systems can play in guiding doctors to make the most comparatively effective medical decisions. Such systems, though still imperfect, can guide clinicians to determine the most proven effective medications and treatments given a variety of patient conditions and characteristics.
The study sought to defend to the importance of new findings while pointing to particular areas where improved dissemination of medical findings are critical to patient care. “The unattractive alternative,” the authors concluded, “is that the nation’s ambitious research agenda will simply add to the long list of medical discoveries that are valid, relevant, and largely ignored or misapplied in practice.”