As Begley lays out in her article, to compare the effectiveness of two or more treatments involves running expensive, multi-year, double-blind trials with patients randomly assigned to one treatment or the other. The cost to perform these controlled trials runs into the millions, often costing even a hundred million dollars or more. Given the costs of comparing treatments and the number of treatments needed to compare, the reality is that most decisions about which treatment to use in a given situation are left to the best judgment of the provider involved. Referring to the guidelines provided by the Infectious Disease Society, Begley notes that more than half of recommendations are based on expert opinion alone.
Well, so what, you might say. If it really costs so much to compare the treatments, in most cases, expert judgment is probably good enough, right? I mean, sure, if you're having heart surgery, you might want to know for sure, but what about treating a cold or high blood pressure? Isn't the doctor's judgment good enough?
So, here's where your pocketbook gets involved.
One expert quoted in the article (Elizabeth A. McGlynn from Kaiser Permanente's Center for Effectiveness & Safety Research) estimates that we're spending as much as a third of our health care dollars for treatments that are unnecessary or ineffective. This isn't small change we're talking about. A third of our health care spending amounts to close to $900 billion dollars a year. As Begley highlights in her article, with health care costs in the trillions and growing, one way to bring spending under control would be to pay only for the most effective treatments... If only the cost of finding out which treatments are the most effective weren't so high.
Here's where the good news begins. In a bright idea that began with David J. Magid, director of research for Kaiser Permanente's Colorado Permanente Medical Group, researchers are beginning to turn to the data locked in electronic health records to answer the same questions that controlled trials have answered--at a fraction of the cost. The practice is known as comparative effectiveness research, and it's already yielded impressive results. In the case of Magid, with only $200,000 he was able to determine in only a year and a half which drugs patients should use to supplement their blood pressure treatments if a diuretic alone wasn't sufficient. Still not chump change, but certainly a fraction of the $120 million spent on an earlier controlled study about the effectiveness of hypertension treatments, and a minute fraction of the estimated $3.1 billion dollars that were being spent on unnecessary medications as determined by the earlier controlled study.
The thing that stands out to me about the researchers described in Begley's article is that they are looking at their challenges through a different lens and finding new ways to make use of the resources they have available to them to answer questions that matter. Reading about them excites my imagination. What they are doing makes people's lives better. I wonder if there isn't some way to extend their ideas. What if the data in electronic health records were enriched with data from publicly available research databases? Would new insights about treatment emerge? What about opening up the data locked in institutional databases to hobbyists and outside researchers? Would collaboration and crowd-sourcing lead to more rapid research? I'm certain any of these ideas would entail technical, legal, and political challenges. But what would they enable? The impressive performance of comparative effectiveness research hints that the gains might be significant. It really feels like we may be on the edge of something big.