Testimony on Comparative Effectiveness Research
Lawrence P. Casalino, Department of Public Health, Weill Cornell Medical College
Delivered Via Electronic Mail
I realize that this is/sounds self-serving, but I believe it will be very unfortunate if CER is taken to mean solely comparing treatments (in the narrow sense, drugs, and devices). It's necessary to learn whether treatment A is better than treatment B, but it's not sufficient: learning this doesn't do much good if treatment A isn't delivered to the patients who should have it. So I believe there would be an enormously beneficial impact on patients' health (and on health care costs) if research were funded to learn more about what types of organizational structures in the delivery system, using what types of processes, are best able to actually provide indicated care. At present, we know almost nothing about this.
I'm concerned that an analogous thing will happen with comparative effectiveness research to what has happened with translational research. Funding for translational research has overwhelmingly been for work to translate basic biological work into something a bit more applied. Very little funding has been available for learning how to translate knowledge of what treatment should be used into ways to improve the chances that it actually will be used (you're probably familiar with the attached article, which makes this point.).
I was delighted to see that the IOM committee's working definition for CER includes "improve delivery of care," and that your Web questionnaire includes "systems of care" as a possible object of study. You have an enormous opportunity - one that may not come again - to help Congress, and others, understand that comparative effectiveness is not just about surgery, drugs, and devices. Congress clearly does not understand this, as the language re CER in the stimulus bill shows. But without "reform" of the delivery system, putting more money into the financing side of medical care (covering more people), while obviously a worthy goal, will be like pouring water into a sieve (I'm not suggesting that we wait to cover more people until the delivery system changes - that could be a long wait! But it's important to begin). CER could help provide information to guide this reform - at present we know almost nothing about the structures and processes that are best able to deliver high quality, efficient care.
PLEASE NOTE: CONTACT INFORMATION BELOW IS NEW AS OF MARCH 13, 2009
Lawrence P. Casalino MD, Ph.D.
Chief, Division of Outcomes and Effectiveness Research Department of Public Health Weill Cornell Medical College
402 E. 67th St.
New York, NY 10065-6304