A good summary of the objections of this was posted by Hilzoy at Political Animal. I'll deal with the objections simply by posting the link, as refuting them is not the point of this post. Let it suffice to say that there is no substance there.
The background of the push toward CER is provided by the Institute of Medicine's publication, Initial National Priorities for Comparative Effectiveness Research. You can read it online using the link above, or download the (uncorrected proof) PDF version using the link. (The book is 1.9MB, 207 pages, and it does not download directly from the link; you have to go to the page, fill out a form, then download it)
The U.S. Congress mandated this study in the American Recovery and Reinvestment Act of 2009, which the President signed into law 19 weeks ago. The legislation required the Institute of Medicine (IOM) to convene a committee to establish a list of research questions that would have the highest priority for study with comparative effectiveness research (CER) funds that the law placed at the discretion of the Secretary of Health and Human Services. Moreover, the law required the committee to seek advice from stakeholders who might benefit from the research: researchers, physicians, professional organizations, and the general public. Basing its approach on methods developed by the Agency for Healthcare Research and Quality, the committee held a public meeting to get advice from professional and consumer groups and from the general public and solicited nominations for research questions through a web-based questionnaire. The committee developed a process for deciding which conditions to place on its list of the highest priority research questions, and, over a 10-day period, winnowed several thousand nominations to a list of 100 high priority topics.
Pretty impressive: 19 weeks to design the study, collect the data, and write a coherent book about it. Congress should just go home and let these people take over.
The overall priorities are reviewed in a free-access article at NEJM: Prioritizing Comparative-Effectiveness Research -- IOM Recommendations, by John K. Iglehart. The priorities are summarized in a chart (click to make big) :
Psychiatric Disorders are fifth from the left, a reasonably high position. Add the substance-abuse topics, and the total would be the third in terms of the number of high-priority topics. I was curious to see what priorities they established for mental health. It turns out that their system of ranking priorities is complex. I won't go into it here, other than to say it is confusing at first.
There are four top priorities noted in mental health:
- Compare the effectiveness and costs of alternative detection and management strategies (e.g., pharmacologic treatment, social/family support, combined pharmacologic and social/family support) for dementia in community-dwelling individuals and their caregivers.
- Compare the effectiveness of pharmacologic and non-pharmacologic treatments in managing behavioral disorders in people with Alzheimer's disease and other dementias in home and institutional settings.
- Compare the effectiveness of various primary care treatment strategies (e.g., symptom management, cognitive behavior therapy, biofeedback, social skills, educator/teacher training, parent training, pharmacologic treatment) for attention deficit hyperactivity disorder (ADHD) in children.
- Compare the effectiveness of wraparound home and community-based services and residential treatment in managing serious emotional disorders in children and adults.
These are the items that are in the top quartile of priority, that include psychiatric disorders as part of their classification.
Additional items, that are not in the top quartile, but which are designated as pertaining primarily to psychiatric disorders, are as follows:
- Compare the effectiveness of pharmacologic treatment and behavioral interventions in managing major depressive disorders in adolescents and adults in diverse treatment settings.
- Compare the effectiveness of atypical antipsychotic drug therapy and conventional pharmacologic treatment for Food and Drug Administration-approved indications and compendia-referenced off-label indications using large datasets.
- Compare the effectiveness of management strategies (e.g., inpatient psychiatric hospitalization, extended observation, partial hospitalization, intensive outpatient care) for adolescents and adults following a suicide attempt.
- Compare the effectiveness of different treatment approaches (e.g., integrating mental health care and primary care, improving consumer self-care, a combination of integration and self-care) in avoiding early mortality and comorbidity among people with serious and persistent mental illness.
- Compare the effectiveness of different treatment strategies (e.g., psychotherapy, antidepressants, combination treatment with case management) for depression after myocardial infarction on medication adherence, cardiovascular events, hospitalization, and death.
- Compare the effectiveness of traditional training of primary care physicians in primary care mental health and co-location systems of primary care and mental health care on outcomes including depression, anxiety, physical symptoms, physical disability, prescription substance use, mental and physical function, satisfaction with the provider, and cost.
There are three things that stand out. One is that most of the priorities are rather broad. Indeed, some are too broad to be meaningful. Another thing that I notice is that they include treatment modalities spanning the biopsychosocial spectrum. The third thing I notice is the relative lack of attention to psychosis in general, and to schizophrenia in particular. There is no mention of bipolar disorder.
It is very strange that treatment of depression after myocardial infarction would make the list, but earlier diagnosis of bipolar disorder would not, or early interventions for persons at risk for schizophrenia.
There are some priorities that make sense. Integration of mental health care with primary care, and improvements in community-based care are two things that have been lagging for decades, and seem likely to be highly cost-effective. The problem up until now has been that reimbursement is based upon procedures and patient volumes. Time spent in the community, or coordinating with other providers, is either not reimbursed, or is reimbursed poorly.
Perhaps additional research in these areas would help change the reimbursement scheme to something that provides the incentives that would lead to more cost-effective treatment. But anytime you tamper with the reimbursement scheme, you run into two problems. For one, there is a lot of resistance. Two, people immediately try to figure out how to exploit the change.
I don't mean to be highly critical of the IOM report. It actually is an impressive document, especially given the short time frame. Unfortunately, it simply wasn't possible to do a properly thorough job. Perhaps the significance of their accomplishment is not so much the list of priorities, but the methodology in collecting and collating suggestions. It probably would take several iterations of a similar process, in order to refine the list to something that is more realistic and more practical.
Medicine & Health
