Recently, researchers at Duke published a study looking at implantable cardiac defibrillators in patients and determined that one fourth of patients receiving them didn’t need them. For the past few years, researchers at UNC have been doing head to head analyses of older versus newer psychiatric medications, and they’re finding many patients have more success with older, cheaper drugs.
Both of these studies are examples of “comparative effectiveness research,” an area of research that’s booming in the Triangle. And the results of comparative effectiveness studies are already changing the way doctors practice medicine.
Shamartha Paisant has a slew of health problems… diabetes, some dental problems, she’s overweight, and has high blood pressure. On a recent morning, she was at Piedmont Health Services in Carrboro because, on top of all that, she had a nasty cold. Doctor Carol Klein listened to all of her complaints as she checked her out.
Dr Carol Klein: OK and then the other concern is your blood pressure it’s a whole lot better…
Shamartha Paisant: Yes, a whole lot better.
Dr Klein: So that’s good.
Paisant: So the medicine is working.
Dr Klein: Yes,
Paisant: Yesterday I went to Rite Aid and I just put it into the pressure cuff and it was 84 over 124
Dr Klein: 124 over 84
Dr Klein: Um hm. OK. So let me recheck your blood pressure.
Paisant: Do I need a sleeve up???
Once again, Paisant’s pressure is a little high. But she says it’s improved since she started coming to Piedmont regularly to get it, and her diabetes under control. One thing she says she likes about coming to the clinic is that Doctor Klein talks to her about her options:
"She makes sure she’s cautious when she prescribes something. She’ll tell me the price of the high end, and then she’ll find me something else that we can go with if I can’t afford it, that should do the job."
It turns out Paisant’s doctor isn’t just saving her money, she’s also providing higher quality care… for less. That’s done throughout Piedmont Health clinics, says medical director Tom Wroth:
"We have about 50 percent uninsured, self pay and about 30 percent Medicaid and 10 percent Medicare and the rest private insurance, so the vast majority of our patients have limited resources and they really look to us a lot of times to help them make decisions about how to use their limited resources."
Health economists would say these patients have ‘skin in the game’ – that they’re motivated to get only the care they need because they’re bearing a lot of the cost. Wroth says he and his doctors vigorously examine the evidence on what works best, not just what’s new:
"We try to review the most recent trials on different medications and there’s this whole area of comparative effectiveness research that’s been talked about, a lot now, in health policy circles, but it’s something we’ve looked at in primary care for a long time now."
Comparative effectiveness research is the hot topic in health policy circles now. There was some talk of comparative effectiveness during last year’s health care debate. Some conservative groups warn the practice could lead to rationing of care. But researchers like Til Stürmer who actually do the comparisons say it has the potential to improve health care:
"That’s the beauty of comparative effectiveness – because it immediately addresses a clinically relevant question… what should I do if I have a choice? It’s not about treating or non-treating – it’s very often about treating with what."
Stürmer is a practicing doctor, and a pharmaco-epidemiologist. He creates studies to compare drugs to one another. He explains that usually, to test a new drug, researchers give some patients the drug and some patients a placebo. That’s called a randomized controlled trial. But there’s a flaw in that strategy.
"Well, it’s obviously way easier to show that a drug works against placebo than something else that’s out there in the market."
For a long time, pharmaceutical companies resisted doing comparative effectiveness studies. But in recent years more drug companies and more researchers are comparing newer drugs, against other, older drugs to see not just what works, but what works better.
Tim Carey: "Not everything that works is new, and not everything that is new works."
Professor Tim Carey from UNC Medicine says the Triangle’s become a center for comparative effectiveness research. And it’s not just about comparing one drug to another. Carey’s research focuses on comparing which medical and surgical procedures work best:
"Many conditions, just as an example acute back pain, tend to get better no matter what we do. So if I try any given treatment for acute back pain the vast majority of patients are going to get better because they're going to get better no matter what I advise."
Carey says one treatment, injecting a surgical glue into compression fractures in the spine, used to be very common.
"And we found that through studies that came out just a year or two ago, that actually it may not work very well, and it may not be appropriate for many patients. And that's really a shame that we went for almost a decade subjecting patients to a treatment that may not have helped them… over a thousand of those procedures have been done per year over the past 10 years in North Carolina alone. So it’s been tens of thousands over the country."
Carey says those kinds of systemic mistakes end up costing patients, hospitals and the health care system too much money.
"It's a hard to ignore environmental issue that health care is very costly in the United States. But in our analyses, we actually do not take costs into account. Our work is looking at what works in whom, and in what circumstances."
And Carey believes comparative effectiveness research results in better discussions about treatment between doctors and patients. And in the end, those better conversations mean better care and less cost for patients and for the health care system as a whole.