Q: What main point should hospitalists take away from this report?
A: This research will address primary questions about which medicine is best for which patient but also address larger issues, such as care coordination and how care is organized within the hospital and outside the hospital, so that we focus on the gamut of questions that have the potential to improve patient outcomes.
Q: What were some common themes you heard in the public listening sessions and online comments you solicited during the report’s preparation?
A: One of them was the importance of engaging stakeholders throughout the process, getting input from patients, physicians, policymakers. … We also heard themes about the need for infrastructure development, also the need for data infrastructure. We also heard a theme about the need for more work on research methodology and training of researchers. And then we heard a strong theme around “This needs to actually be disseminated and translated into care delivery.” So producing knowledge is helpful, but translating that knowledge into better outcomes is the ultimate goal.
Q: The report repeatedly mentions “real world” healthcare settings. Is this meant as a criticism of the idealized outcomes of efficacy research as it is typically conducted?
A: I don’t know that I would frame it as a criticism. I will say that as hospitalists, we are faced with patients every day where there’s unclear evidence about how best to manage that patient. And therefore, we need more evidence on the real questions that patients and physicians encounter in practice. I think we’ve had a long history of strong, well-funded randomized trials in this country, and I think we need to complement that with other methods of research as well, including databases, quality improvement, and measuring interventions.
Q: What are the limitations in translating all of this knowledge to interventions for the patients who need it?
A: I think the research paradigm traditionally has been: We fund an investigator. They go off for years and do their research. And then they publish it in the New England Journal [of Medicine] or JAMA, and we call that a success.
I would argue that we’re at a time where we need to think about a new paradigm, where just publishing it is some middle step. And we need to think about how you actually link the research enterprise to the care delivery enterprise, so research is rapidly implemented and you’re measuring outcomes and ensuring that research actually reaches the patients and clinicians.
Q: Are there any real-world examples of how to do this?
A: Say we had a national patient library and we thought about things that we have not traditionally thought about in healthcare—social networking, Twitter, Facebook, media channels that reach people now. How do you insert health content into those channels to actually change people’s behavior, or at least inform them? The medical establishment thinks we publish it in the New England Journal [of Medicine] and the world changes. That’s just fundamentally not true.
On the provider side, how do we think about the lay media? How do we think about channels that providers use, like UpToDate and Medscape? How do we get comparative effectiveness content into those channels that are used by providers and physicians?
Q: How should CER address the needs of patient groups that are under-represented in traditional medical studies?
A: I think that’s a huge area. Efficacy trials generally will show something works for the average patient. But the issue is, and I’ll give you a concrete example, if you are an elderly, African-American female with a couple of conditions (diabetes and heart disease), how will that treatment work for you? So I think the power of comparative effectiveness is that we, especially with the data sources we just talked about, can look at patient subgroups and get as close as possible to the individual level to really present information. Instead of [saying], this works on average patients, which includes lots of patients that don’t look at all like you, [we can] say we’ve looked and it actually works well for racial and ethnic minorities, or persons with disabilities, or the very elderly.