The New Health Dialogue

What is comparative effectiveness research? If you need a reminder: comparative effectiveness means comparing two or more treatments for the same health problem to see which one works best for patients. The question has popped up quite a bit since comparative effectiveness research showed up in the economic stimulus package alongside other common sense health reforms, such as health IT adoption. Comparative effectiveness is about giving doctors and patients more information and facts for decision-making, not about taking away their autonomy.

Here's a real world example that's worth noting. The Institute for Clinical Systems Improvement (ICSI) in Minnesota is an example of an independent (private), non-profit organization that works to assemble and disseminate comparative effectiveness research. Clinicians in ICSI review medical literature and make recommendations about the most cost effective treatments based on the best available evidence. HealthPartners Medical Group, the Mayo Clinic, and Park Nicollet Health Services jointly founded ICSI in 1993. ICSI is made up of 57 member organizations and is funded by seven Minnesota and Wisconsin health plans. (The research funded by the federal stimulus bill looks at effectiveness, and doesn't make recommendations based on cost.)

ICSI maintains a list of evidence-based health care guidelines to encourage member organization to adhere to the best clinical practices. When better evidence comes along, previous guidelines get retired to make way for higher standards of care. For example, the most recent ICSI report updated care guidelines in several categories:

Obesity Guidelines. Because obesity presents such significant health concerns for the U.S., the Prevention and Management of Obesity in Mature Adolescents and Adults Guideline workgroup revised this document in 2008 to provide a more multi-faceted approach. It updated information on body mass index (BMI) and co-morbid conditions to include approaches to weight loss for each BMI category. Content and clarifying language were added to the waist circumference annotation. Conclusion grading worksheets on physical activity and low carbohydrate diet were incorporated into the related annotations, and one on surgical approaches to weight loss was added to the guideline.

Preventing Chronic Disease Through Primary Care. The guideline defines strategies and programs providers, communities, payers and employers can offer to support patients to make essential changes in four behaviors that contribute to roughly 40 percent of all deaths in the U.S. -- poor nutrition, physical inactivity, smoking and hazardous alcohol consumption. As a result, its recommendations are being used to address conditions like prediabetes, and are seen as a preventive component of care in health care homes.

Surgical Protocol: Before, During, and After an Operation. ICSI significantly revamped this protocol to describe all the steps performed throughout the pre-, intra- and post-operative periods of surgery. The protocol outlines the processes involved in obtaining patient consent, and verifying and marking the surgical site. It addresses the prevention of site infection for numerous surgical procedures, starting with the preoperative evaluation and surgical planning and proceeding through the perioperative period.

Guidelines and protocols describing the best standards of care are the primary goal of ICSI, though they also provide support for member institutions through strategic initiatives such as DIAMOND (Depression Improvement Across Minnesota, Offering a New Direction). DIAMOND is a collaborative care model that emphasizes depression detection and treatment. The program has six components:

• A checklist that helps the care team detect and monitor symptoms of depression (ICSI discovered that most primary care physicians only pick up about half the cases of major depression in their patients)
• A way for the care team to monitor the depressed patient
• A proven medical guide to know how best to change or intensify treatment
• Tools to keep a patient who is getting better from falling back into major depression
• A care manager to educate and help the patient reduce depression symptoms and improve functioning
• A psychiatrist to review patient cases with the care manager and consult with the primary care physician on any recommended changes in treatment

ICSI member organizations Community-University Health Care Center, Family HealthServices Minnesota, HealthPartners, Mayo, and SuperiorHealth Center launched the DIAMOND program in just 10 primary care clinics in early 2008, and by September, the program had spread to approximately 30 clinics serving 1,000 patients. According to ICSI, after six months in the program 47 percent of depression patients were in remission, and an additional 12 percent showed significant improvement.

ICSI's experience in Minnesota shows us that comparative effectiveness research can be a great tool for health care quality improvement. By working together and committing themselves to the most up-to-date, evidence based treatment guidelines, ICSI member organizations are able to provide high-quality, patient-centered care.