Challenges with CER Uptake in Clinical Practice
The goal of comparative effectiveness research (CER) is to improve health care decision making by patients and providers. Given the expected influx of CER in coming years via public and private funding, stakeholders are beginning to closely examine how that research will be translated and disseminated among end-users, as well as some of the challenges in seeing that evidence adopted into clinical practice.
The goal of comparative effectiveness research (CER) is to improve health care decision making by patients and providers. Given the expected influx of CER in coming years via public and private funding, stakeholders are beginning to closely examine how that research will be translated and disseminated among end-users, as well as some of the challenges in seeing that evidence adopted into clinical practice.
Understanding the reasons behind the adoption of evidence, such as what are the elements driving change, whether the science is at issue, or if there is a “wow factor” to the findings, can improve the development of future CER, explained National Pharmaceutical Council Chief Science Officer Dr. Robert Dubois, speaking during a panel discussion at the ISPOR 17th Annual International Meeting in Washington, DC.
“The ROI of CER will depend on how quickly it is adopted into practice,” said Dr. Teresa Gibson, director of health outcomes at ThomsonReuters. She noted that change in clinical practices tends to be slow, and that multiple studies might be needed to inform change; sometimes change occurred prior to the publication of study results, and sometimes it lagged significantly, according to Gibson’s analysis of the issue. Clarity and the strength of the findings also play a key role in their adoption into clinical practice, she said.
There are barriers to that adoption of evidence, however, according to a study conducted and presented by RAND Associate Policy Researcher Dr. Justin Timbie. Based on a literature review and interviews with key stakeholders, Timbie discovered five main challenges: misalignment of financial incentives, ambiguity of CER results, cognitive biases, failure of CER design to address the needs of end-users, and limited use of decision support by patients and clinicians.
By far, financial incentives had the most impact on uptake. “Financial incentives are important along all parts of the implementation pathway,” said Timbie. For example, “Fee-for-service reimbursement favors intervention,” he added.
Too often, CER does not produce a clear “winner” among treatment options, and there is difficulty in interpreting flawed randomized controlled trial or observational study data, said Timbie. Similarly, as the panelists discussed, “There are bad studies published, and how many times does the same patient cohort study get published in different journals? It is problematic, there is no doubt about it."
One organization with a lot of experience in translating and disseminating research is the Agency for Healthcare Research and Quality (AHRQ). AHRQ Center for Outcomes and Evidence Director Jean Slutsky shared her insights about what her organization has learned through its efforts in working with patients and other stakeholders.
“Patients need to be at the table from the very beginning to the end,” said Slutsky. “Patients as participants are far more effective than patients as ‘recipients’ [of research].” By involving stakeholders earlier in the process, the research is more likely to address relevant questions and concerns.
AHRQ carefully considers “what actions should be translated and to whom. We don’t need to reach out on every study, unless there is a catastrophic impact,” Slutsky said. It tends to be more of “a body of information over time” that is conveyed to specific end-users via a variety of communications vehicles.
Still, the “potential for CER results to influence practice is not fully realized,” said Timbie, but “prospective studies of the CER translation process could guide future improvements.”