Comparative effectiveness symposium addresses research, cost concerns

Comparing the effectiveness of different orthopaedic treatments pre-sents several problems for researchers. How, for example, do you design a randomized controlled trial that is both ethical and effective in measuring outcomes among different treatment options?

At the Comparative Effectiveness Research (CER) Symposium, held earlier this year in Washington, D.C., and cosponsored by the AAOS and the Orthopaedic Research Society, participants focused on this and other questions.

Research synthesis
According to Charles Turkelson, PhD, director of the AAOS department of research and scientific affairs, a full understanding of CER requires research synthesis; no single trial is definitive or able to answer all relevant questions. Additionally, clinical trials funded by industry can present significant conflicts of interest.

Dr. Turkelson introduced an emerging CER model—network meta-analysis—that seeks to address the inherent limitations of clinical trials by making indirect treatment comparisons. Using network meta-analysis, researchers can construct models that can compare a variety of treatments while preserving the randomization in the original trials.

“Network meta-analysis enables us to make comparisons that answer the questions of decision-makers without depending on the results of industry-funded research,” said Dr. Turkelson. Although he acknowledged that meta-analysis models require more examination and fine-tuning to ensure their efficacy, he affirmed that they have significant potential.

Can’t ignore cost
Although cost should never be the sole factor in treatment decisions, the unstable U.S. economy and its unsustainable healthcare system are triggering consideration of whether the use of costly technology is actually better than older, less expensive treatments. Kevin Bozic, MD, MBA, vice chair of the University of California, San Francisco department of orthopaedic surgery, described the “technology creep” in orthopaedics (Fig .1).

Both patients and providers seek the newest, most up-to-date technology. As a result, manufacturers have an incentive to introduce high-priced devices into the marketplace without any real proof that the benefits of these new technologies outweigh those of older technologies. Without any incentives for providers or payers to lower costs and with no evidence on the most efficacious treatments, healthcare costs will continue to rise, particularly for spine and joint procedures.

Both public and private sectors see CER as a means to lower costs and improve quality. Government agencies that are particularly interested in the CER movement include the Agency for Healthcare Research and Quality (AHRQ) within the Department of Health and Human Services, the Department of Veterans Affairs, and the National Institutes of Health. In addition, the Patient Protection and Affordable Care Act established a public-private entity, the Patient-Centered Outcomes Research Institute (PCORI), to focus primarily on CER.

Mark Helfand, MD, MPH, MS, of the Oregon Evidence-Based Practice Center, provided symposium attendees with information about the Institute’s duties and objectives. According to Dr. Helfand, patients and other stakeholders will have multiple opportunities to provide meaningful input on the Institute’s work, including opportunities to submit ideas for the PCORI National Priorities and Research Agenda. Beginning this summer, PCORI will also be awarding Innovation Grants to enable researchers to define barriers to research and explore new research infrastructures and approaches to patient engagement.

Although current CER efforts do not explicitly incorporate cost, CER does provide information that can help distinguish which treatment options are effective, which are ineffective, and which are equally effective. This information, according to Dr. Bozic, could enable payers and policymakers to establish incentives to support the most effective options.

Involving the patient
Symposium presenters stressed that the knowledge gained from CER should be communicated to patients when treatments are being discussed, a process called shared decision making. Michael Barry, MD, president of the Foundation for Informed Medical Decision Making, promoted patient decision aids as beneficial tools for disseminating information. Informed patient decisions can lead to more accurate risk perceptions, greater comfort with decisions, fewer surgeries or tests, and a reduction in practice variation.

The symposium’s keynote speaker, John Wennberg, MD, MPH, founder and director emeritus of The Dartmouth Institute for Health Policy and Clinical Practice, echoed Dr. Barry’s message. Dr. Wennberg emphasized the importance of considering both patient preference and surgical indications in evaluating the need and appropriateness of surgery.

“The frequency of use is governed by the assumption that resources should be fully utilized,” said Dr. Wennberg. “In the absence of evidence, and under the assumption that more is better, available supply governs frequency of use and, as a consequence, the number of diagnoses per patient continues to rise.”

Dr. Wennberg believes that, appropriately used, CER is key to reducing overuse and unwanted variations in treatment. “We can constrain the undisciplined growth in capacity and spending if we replace disorganized, chaotic ‘systems’ with organized systems capable of following patients over time,” he said. “We can establish high quality shared decision making as an ethical standard of practice.”

Madeleine Lovette is the communications specialist in the American Association of Orthopaedic Surgeons office of government relations. She can be reached at lovette@aaos.org

Editor’s note: This is the second of two articles covering the Comparative Effectiveness Research Symposium cosponsored by the AAOS and the Orthopaedic Research Society and held May 19–21, 2011, in Washington, D.C.

CER Symposium available on DVD
The proceedings from the 2011 AAOS/ORS Comparative Effectiveness Research (CER) symposium are now available on DVD. The symposium was led by principal investigators Kristy L. Weber, MD, chair of the AAOS Council on Research and Quality; Mark Helfand, MD, MPH, MS, director of the Oregon Evidence-Based Practice Center; and James N. Weinstein, DO, MS, director of the Dartmouth Institute for Health Policy and Clinical Practice.

The symposium brought together a forum of experts from multiple disciplines to discuss various aspects of CER. The CER symposium had the following goals:

• to increase understanding of the broad definition of comparative effectiveness research
• to highlight available research design methods
• to identify strategies to maximize cost effectiveness
• to identify tools to measure effectiveness
• to identify markers of successful CER initiatives.

The DVD features audio and presentation slides, as well as abstracts and speaker bios. To request your complimentary copy of the CER DVD, e-mail your name, AAOS member number, and mailing address to ransford@aaos.org

A limited supply is available, so only one DVD per request received will be mailed.

Additional Links:
Making the case for orthopaedic procedures  (first article)
AAOS sponsors comparative effectiveness research symposium
2011 AAOS/ORS Comparative Effectiveness Research Symposium