Do doctors already have a source of comparative effectiveness research?

Comparative effectiveness research is the current, trendy buzzword in the health care debate.

And certainly, doctors need an authoritative, unbiased, source in which to base their decisions on.

But, do we already have that kind of information? Why, yes, we do. It’s called UptoDate.

For those who don’t know, UptoDate is a peer-reviewed, evidence-based, medical encyclopedia available via DVD or online that’s revised every 3 months. It does not carry advertisements, and is funded entirely via paid subscriptions. I am a big proponent, and like many other doctors, could not practice medicine effectively without it by my side.

In fact, a recent study showed that hospitals who used UptoDate scored better on patient safety and complication measures, as well as length of stay, when compared to institutions who did not use the resource.

Val Jones wonders, what if we incentivized doctors to use UptoDate? It can range from pay for performance bonuses to malpractice immunity for physicians who adhere to UptoDate’s, evidence-based, unbiased, clinical recommendations.

It will never happen, of course. But it sure beats spending $700+ billion to fund comparative effectiveness research that will only serve to re-invent the wheel.

Comments

joshuamarr
Isn’t the issue that the research that needs to inform a source like UptoDate (which I agree, is impressive) isn’t being funded? Comparing new treatments head to head is dicey, while comparing them to a placebo/no treatment and being able to publish a narrowly significant result in a while/middle-class/middle-age group of men is not difficult–and it is also not very useful.
I understand the two to be distinct parts with the same goal, UptoDate could not exist without good evidence-based research.
Dr. Matthew Mintz
I use Up to Date, regularly and think it is an extremely valuable tool. However, it don’t think it is a replacement for comparative effectiveness research.
First, UptoDate is not completely unbiased. Some of their authors are top notch, and in general the product is quite good. However, many of the authors have substantial ties to the pharmaceutical industry. I am not saying that this makes UptoDate worthless or that these financial ties are even necessarily bad, but rather UptoDate is not a true unbiased source just because it isn’t sponsored by pharma.
More importantly, the authors of UptoDate are providing their own summary of already published data, which most is funded by industry. This is similarly true of other so-called unbiased sources. The Medical Letter, which is like the Consumer Reports for medications, is likely “purer” than UptoDate, but it too reviews studies that are mostly industry funded. Consumer Reports actually does their own testing. They drive the cars, use the computers, run the batteries, etc. That’s comparative effective research! Also, a note to pharma, despite having consumer cost-effective research for common products, most industries generally seem to do fine. Though a favorable report for Toyota over Honda may benefit the former car company, it’s not like the later is going out of business any time soon.
The problem goes even deeper than the potential bias of industry funded research, which has been consistently shown to be favorable to the sponsor. The fact that most research, and virtually all therapeutic research is funded by the industry allows the industry to dictate what scientific knowledge is available, and by default clinical practice. Many studies that would be valuable to patients and physicians are simply not done because 1) the requirements to make an FDA claim (which allows drug companies to market a drug) are so rigorous and expensive, it is usually not a good business decision to do the study, especially when doctors will likely use the product off-label and 2) the industry will often not fund a study that could potentially be negative. The ENHANCE study made front page headlines when Vytorin failed to show a difference in atherosclerosis progression. Merk was so convinced that Vytorin was going to work, that it thought the results would be a “sure thing.” However, there are hundreds of important studies that are never done because the industry only takes a “safe” bet.
We need comparative effectiveness not just to see whether the more expensive treatment is worth the cost, but we also need it to answer scientifically important questions that the industry will unlikely fund. Cardiovascular disease is the leading cause of death in the US. I would love to see study comparing simvistatin 80mg vs Crestor 20mg in patients with moderate risk for heart attack and stroke. Current data suggest that there might be fewer heart attacks and fewer side effects with Crestor which might justify using the more expensive drug. However, we will never know because it would be a ridiculous business decision for Astra Zeneca to fund such an expensive study that might just blow up in their face.
By the way, doctors do already have a source of comparative effective research. It’s across the pond in the good old UK. Though NICE does not do original research, it actually works with multipe stakeholders to guide research and objectively evaluates data to come up with guidelines. This actually a more realistic, and more affordable model that health care policy folks should take a close look at. I find myself using this source clinically more and more. There recommendations are often quite different the the those in the USA (check out hypertension and diabetes). Web site is http://www.nice.org.uk
Clinical Cases and Images – Blog
Some thoughts on the topics here:
Are You Dependent on UpToDate for Your Clinical Practice?
http://casesblog.blogspot.com/2007/07/are-you-uptodate-dependent-for-your.html
and
Study: UpToDate More Likely than PubMed to Answer Patient Care Questions
http://casesblog.blogspot.com/2008/10/study-uptodate-more-likely-than-pubmed.html
SarahW
” malpractice immunity for physicians who adhere to UptoDate’s, evidence-based, unbiased, clinical recommendations.”
Dream on. You don’t even see the thinking error here, and that’s very troubling.
Physicians will still have to do what’s right for the individual patient, and the relative skill of the physician will always be judged in hindsight – it will be possible to say “this physician was on automatice pilot – he refused to listen – he ignored xyz – he treated a mythical herd, not this patient”
Best practices is not what works best for most patients most of the time, and this emphasis on treatment of a herd is pehaps useful for rationing or cost cutting, but is incredibly dismissive of the art of medicine and the individual.
Plus, please comprehend, it will not be much protection when serious errors are made in faithfulness to a scripted treatment for other persons.
There is too much variability among individuals – genetics, life situation, constellation of issues…and no expert system can replace real judgement or excuse a by-the-book practice.
carl
Looks promising, but I notice it’s cheaper for doctors than for the public. Without harshing on this particular company, the fact that there isn’t a massive, free CER database on the web tells volumes about our approach to “healthcare” as a society.
Anonymous
Thank you Dr. Mintz! UpToDate is great for what it is, but it doesn’t have much comparative effectiveness info because the research simply isn’t out there. I’m constantly frustrated by the lack of sound comparative evidence both in UpToDate and elsewhere. (Read some of the AHRQ’s Research Reviews to get an idea of just how much evidence we’re lacking.)
Anonymous
Don’t overlook the fact that there is a lot of good research outside of UpToDate. This is a great source, but if it’s your only source you’re closing off a tremendous amount of the literature. The articles are also written by people, and are subject to the biases of individuals.

Do doctors already have a source of comparative effectiveness research?

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