Author + information
- Received October 31, 2008
- Accepted November 5, 2008
- Published online March 24, 2009.
- Michael S. Lauer, MD* ()
- ↵*Reprint requests and correspondence:
Dr. Michael S. Lauer, Director, Division of Prevention and Population Sciences, National Heart, Lung, and Blood Institute, 6701 Rockledge Drive, Room 10122, Bethesda, Maryland 20892
“Let me tell you how Ilike to ____________.”
Cardiovascular medicine trainees hear their faculty utter this phrase often. Let me tell you how Idecide when, how, or whether to prescribe statins, or to order some type of noninvasive test, or to send a patient to the catheterization laboratory, or to recommend medical or surgical revascularization. Trainees amuse themselves by noting the enormous variability in how their faculty fills in the blank; for some scenarios, there seem to be as many approaches as cardiologists!
What may be amusing, and confusing, for trainees is, in fact, the basis of serious health care and research policy debates. Enormous variations in practice have been well documented for many cardiovascular procedures (1). Patients in some parts of the U.S. are 10 times as likely as similar patients elsewhere to be referred for stress imaging or coronary revascularization (2,3). Furthermore, there seems to be little association between the patterns of cardiovascular practice and cardiovascular health: people who live in regions where more cardiovascular tests and procedures are performed do not live longer or have fewer cardiac events (4). Health policy experts cite practice variation as symptomatic of uncertainty, waste, inefficiency, and poor performance of the health care enterprise (5,6).
Why is there so much practice variation? While it may be easy to dismiss it as “the art of medicine,” the main causes are uncertainty and lost translation. Uncertainty, because for many common clinical scenarios, definitive evidence demonstrating that 1 approach is better than another does not exist. We do not know, for example, if a patient with new-onset chest pain will have a different outcome if referred for 1 type of noninvasive test as compared to another (7). Even when definitive guidelines are disseminated, evidence-based practices are often slow to be widely incorporated into routine practice.
A number of health policy experts and professional groups have identified comparative effectiveness research (CER) as a solution to the problem of unjustified practice variation (8,9). The Congressional Budget Office defines CER as “a rigorous evaluation of the impact of different options that are available for treating a given medicine condition for a particular set of patients” (10). CER may compare competing drugs (e.g., atorvastatin vs. simvastatin), competing modalities (e.g., antiarrhythmic drugs vs. defibrillators, or stents vs. coronary bypass grafting, medical therapy vs. revascularization), or may primarily focus on the costs and benefits of specific options. CER includes traditional randomized trials, pragmatic trials, cost-effectiveness analyses, and observational studies.
During the past few years, as health care costs seem to spiral out of control, CER has taken center stage on Capitol Hill. As of this writing, at least 10 bills have been introduced into the 100th U.S. Congress that directly address CER. Senator Max Baucus (D-MT) introduced the Comparative Effectiveness Research Act of 2008, which proposes to establish a private, nonprofit corporation called the Health Care Comparative Effectiveness Research Institute (11). The Institute would be governed by a Board with representatives from multiple sectors, would be charged with identifying national priorities for CER, and would be allowed to enter into contracts with different entities for conducting research.
While the phrase “comparative effectiveness research” is relatively new, CER has long been a high priority for the cardiovascular community and for the National Health, Lung, and Blood Institute (NHLBI). Over many decades, the NHLBI has funded or co-funded numerous landmark comparative trials that have had a major impact on practice. Just a few examples, nearly all well known to practicing cardiovascular specialists, include the CASS (Coronary Artery Surgery Study), the ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) (12), the WHI (Women's Health Initiative) (13), and the SCD-HeFT (Sudden Cardiac Death in Heart Failure Trial) (14) studies. More recent and ongoing major NHLBI-funded comparative trials include the OAT (Occluded Artery Trial) (15) and the ACCORD (Action to Control Cardiovascular Risk in Diabetes) (16) studies. A major trial now in planning is the SPRINT (Systolic Blood Pressure Intervention Trial) study, which will compare aggressive and conservative management strategies for prevention of complications of systolic hypertension.
The NHLBI's interest in CER is not limited to randomized trials. The Cardiovascular Research Network (CVRN) is taking advantage of a rich electronic data structure covering >10 million patients to analyze 3 important therapeutic questions: 1) How is hypertension recognized, treated, and controlled within community practices? 2) How is warfarin used to prevent adverse thrombotic events in atrial fibrillation and venous thromboembolism? 3) What are the clinical characteristics, outcomes, and costs for patients receiving implantable defibrillators for primary prevention of sudden cardiac death (17)? The CVRN represents a viable example of Paul Ellwood's call for “outcomes management” in his 1988 Shattuck Lecture (18).
The NHLBI's commitment to CER is longstanding and was recently explicitly recognized as a critical component of our Strategic Plan (19), which states that we hold it as a high priority “to generate an improved understanding of the processes involved in translating research into practice … [and to] evaluate the risks, benefits, and costs of diagnostic tests and treatments in representative populations and settings.” We are pleased that the health policy community and the public at large have a renewed interest in CER. We are eager to be active not only in initiating, catalyzing, and supporting CER but also in participating in the national policy debate about how CER is best prioritized and directed.
The national CER debate includes a number of critical questions, all of which are relevant for the cardiovascular community. What should be the relative roles of randomized controlled trials versus observational studies? Given some of the well-known observational failures, such as the impact of hormone replacement therapy on outcomes, can observational studies ever be trusted for developing guidelines or public health policies? How should CER priorities be established, even within a field like cardiovascular medicine? Should diagnostic tests, like computed tomography angiography, also be considered a target for CER just like more conventional therapeutic strategies? Should government-sponsored CER primarily be directed by existing federal agencies (like the National Institutes of Health, the Agency for Healthcare Research and Quality, and the Veterans Administration), or should a separate entity be established? How can optimal coordination be achieved among existing federal agencies as well as between federal agencies and private sector research sponsors? Can research methodologies be improved, making it possible to perform large scale trials at substantially lower costs or to generate more trustworthy outcomes from observational studies? Should cost effectiveness be part of CER, or should it be explicitly divorced from it, given political sensitivities (8,20)?
The NHLBI is, and plans to be, an active player in addressing all of these questions. We are funding work that attempts to reconcile differences between randomized trials and observational studies; as an example, parallel analyses are being performed of the WHI trials, observational studies, and Nurses Health Study (21). Nonetheless, because of multiple “bad experiences” with ultimately debunked observational findings, we recognize that controlled trials must remain the gold standard for evidence, with observational studies primarily functioning for hypothesis generation and extension of trial findings to routine care. Using our Strategic Plan (19) as a guide, we are actively engaged in ongoing dialogues with investigators, clinicians, professional societies, community groups, and other government agencies to define those areas of uncertainty where high-quality CER is most likely to have a major impact on public health and clinical practice. We are particularly excited about expanding CER beyond traditional therapeutics; this past summer, we held a workshop on CER opportunities in diagnostic imaging, which is now 1 of the most rapidly growing technologies within the Medicare program. We have explicitly recognized the importance of cost, as our Strategic Plan recognizes as a critical challenge the need “to identify cost-effective approaches to prevention, diagnosis, and treatment” (19).
The NHLBI also recognizes that high-quality CER is only of value if it is incorporated into routine practice. We have a longstanding history of synthesizing the literature and generating practice guidelines for primary prevention of vascular disease, including management of hypertension, obesity, and hypercholesterolemia. We are now preparing updated guidelines in these specific areas, as well as engaging in an ambitious effort to write integrated guidelines that will provide coherent, cohesive recommendations for all life-style and medical approaches to primary prevention. We look forward to working with clinicians, academic leaders, and professional societies to assure rapid and widespread implementation of these guidelines.
Cardiovascular medicine is at a crossroads. On the one hand, the NHLBI and the cardiovascular community have a long, proud tradition of initiating and performing outstanding CER that has led to strong evidence-based guidelines and dramatic improvements in clinical outcomes. On the other hand, cardiovascular medicine is in the crosshairs of critics who decry widespread variations in practice, failure of physicians to adhere to guidelines, and promotion of expensive diagnostic technologies in the absence of any evidence of better patient or public health.
As we work closely with our cardiovascular colleagues and with the public, the NHLBI sees CER as a critically important tool to render obsolete the phrase “Let me tell you how Ilike to ______.”
- Abbreviations and Acronyms
- comparative effectiveness research
- Cardiovascular Research Network
- National Heart, Lung, and Blood Institute
- Received October 31, 2008.
- Accepted November 5, 2008.
- American College of Cardiology Foundation
- Gibbons R.J.,
- Smith S.,
- Antman E.
- Wennberg J.E.,
- Birkmeyer J.D.,
- Birkmeyer N.J.O.
- Skinner J.S.,
- Staiger D.O.,
- Fisher E.S.
- ↵(2003) Reducing the Costs of Poor-Quality Health Care Through Responsible Purchasing Leadership (Midwest Business Group on Health, Chicago, IL).
- Kirschner N.
- Orszag P.R.
- Baucus M.S.
- The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group
- National Heart, Lung, and Blood Institute