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Effectiveness Research Won't Help Much in Current System

Physicians should encourage comparative effectiveness research (CER), rather than fear it as a strategy that could potentially infringe on their professional autonomy, argue a pair of professors at New York's Weill Cornell Medical College in a recent article. I agree, and I also concur with the assertion of Alvin Mushlin and Hassan Ghomrawi that CER will be necessary to counter increasingly strident demands to cut healthcare costs across the board, which could harm patients. They rightly point out that CER could just as easily uphold the effectiveness of expensive technologies like implantable defibrillators for certain kinds of patients as show that other costly drugs and devices were less or no more effective than cheaper interventions.

However, I dispute their contention that "CER can inform and promote changes in careand outcomes that would never have been envisioned, much lessachieved, through shifts in the financing, organization, ordelivery of care." In fact, it's clear that CER must accompany and support these changes in healthcare financing and delivery if we are to make progress in controlling costs and improving quality.

One of Mushlin and Ghomrawi's examples proves my point: They note that a large, government-supported study known as the ALLHAT trial demonstrated that inexpensive diuretic medications (aka "water pills") are more effective than more expensive treatments such asangiotensin-converting-enzyme inhibitors, calcium-channelblockers, and alpha-blockers. A national group of hypertension experts validated these findings with a recommendation that physicians use diuretics as first-line therapy for high blood pressure. But several years later, the majority of doctors are still using the costlier drugs, which have been extensively promoted by pharmaceutical companies. Some patients do benefit from these medications, but the ALLHAT study has not changed the treatment of hypertension. Only if medicine were reorganized so that physicians practiced in larger groups and were incentivized to follow evidence-based guidelines would we would see a different result.

Similarly, only a restructuring of the healthcare system will change how physicians treat depression. A recent study showed that the antidepressants Paxil and imipramine work no better than placebos for people with mild to moderate depression. They do, however, help people who are severely depressed. A New York Times Op-Ed points out that these findings ignore the larger picture, which is that too many depressed people are not receiving any help. Those who do are likely to be treated by primary-care physicians, who often prescribe anti-depressants without adequate screening or follow-up, instead of referring these patients to behavioral specialists. We can't blame the doctors, because they must see so many patients that it's easier to prescribe a pill than undertake the lengthy referral arrangements involved in mental health. But again, if the physicians practiced in larger groups that included psychologists or psychiatrists, and mental-health services were usually covered by insurance, patients would be better served and a lot of money for useless medications would be saved.

Comparative effectiveness research is indispensable to a high-performing healthcare system, but it won't be of much use unless we rebuild the system.