Let 1000 flowers bloom: Support for the current “system”


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Let 1000 flowers bloom: Support for the current “system”

  1. 1. Let 1000 Flowers Bloom: Support for the current “system” Douglas C. McCrory, MD, MHS Duke University Center for Clinical Health Policy Research Duke Evidence-based Practice Center, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center Durham, NC
  2. 2. What is the current “system”? <ul><li>Uncoordinated </li></ul><ul><ul><li>No one agency or organization sets priorities </li></ul></ul><ul><li>Diverse </li></ul><ul><ul><li>Each organization has different objectives and target audiences for evidence assessment </li></ul></ul><ul><li>Adaptive </li></ul><ul><ul><li>Initiatives have evolved to fill “needs” e.g. DERP </li></ul></ul>
  3. 3. Commissioned SRs in US, 2006 14 20 86 Private technology assessors -BCBS TEC -ECRI -Hayes 9 3 3 Other Federal Pgms -CMS -DERP -NIH Consensus Dev’p Pgm 4 22 6 AHRQ -Effective Health Care -EPC -USPSTF # full reviews Organization
  4. 4. Commissioned SRs in US, 2006 Cochrane 867 14 20 86 Private technology assessors -BCBS TEC -ECRI -Hayes 9 3 3 Other Federal Pgms -CMS -DERP -NIH Consensus Dev’p Pgm 4 22 6 AHRQ -Effective Health Care -EPC -USPSTF # full reviews Organization
  5. 5. Nominators of EPC topics 2005-06 <ul><li>Health Care Professional organizations or consortia </li></ul><ul><li>Federal agencies </li></ul><ul><li>Health care industry groups </li></ul><ul><li>Single Health care institution </li></ul><ul><li>State/local government agencies </li></ul>
  6. 6. Systems for identifying topics/questions <ul><li>Active solicitation of nominations from constituents </li></ul><ul><ul><li>Stakeholders </li></ul></ul><ul><ul><li>public </li></ul></ul><ul><ul><li>Subscribers or members </li></ul></ul><ul><li>Internal processes for gathering suggestions from staff or outside advisors </li></ul>
  7. 7. An anecdote: Probiotic use in ICU <ul><li>Duke hospital formulary decision </li></ul><ul><li>Used existing published SR </li></ul><ul><li>Critical appraisal found fatal flaw </li></ul><ul><ul><li>post hoc subgroup analysis presented as primary in most influential positive study </li></ul></ul><ul><li>Reanalysis of existing data allowed a timely decision to be made </li></ul>
  8. 8. DERP - Filling a need <ul><li>Consortium of state Medicaid directors and a couple of Canadian provinces </li></ul><ul><li>Reviews geared toward formulary decision-making </li></ul><ul><li>Focusing on comparative drug trials </li></ul>
  9. 9. Grassroots <ul><li>Cochrane collaboration </li></ul><ul><ul><li>51 discipline-specific review groups set their own agendas </li></ul></ul><ul><ul><li>Relies on volunteer researchers to conduct reviews </li></ul></ul><ul><ul><li>Little central influence from steering group on prioritization </li></ul></ul><ul><ul><li>Little central funding </li></ul></ul>
  10. 10. Functions of The Program <ul><li>increased funding for CERs </li></ul><ul><li>developing increased capacity for SR </li></ul><ul><li>improvements in methods for SR, CCR </li></ul><ul><li>developing standards for quality </li></ul><ul><li>developing process for prioritizing topics </li></ul>
  11. 11. A few predictions <ul><li>Scarcity of resources and manpower to perform SRs has made prioritization important </li></ul><ul><li>Major increases in funding and capacity will diminish the importance of prioritization </li></ul><ul><li>New problems will become paramount such as lack of good quality unbiased evidence particularly for CERs </li></ul>
  12. 12. Other approaches to improve efficiency of SR production <ul><li>Clearinghouse for systematic reviews? </li></ul><ul><ul><li>Improve coordination among diverse organization and participants </li></ul></ul><ul><li>Coordinating function? </li></ul><ul><ul><li>Leverage scarce funds through cooperation/consortia </li></ul></ul><ul><li>Standard setting and quality assessment </li></ul>
  13. 13. What’s the measure of success of a prioritization scheme? <ul><li>Usefulness to intended audience </li></ul><ul><ul><li>Anecdotes and case studies </li></ul></ul><ul><li>Return on investment </li></ul><ul><li>Opportunity costs </li></ul>
  14. 15. Criteria for Priority Setting for SRs <ul><li>burden of disease (prevalence, severity) </li></ul><ul><li>cost </li></ul><ul><li>unexplained variation in use </li></ul><ul><li>public controversy (ethical, legal issues) </li></ul><ul><li>potential impact on outcomes, costs </li></ul><ul><li>new evidence </li></ul><ul><li>adequacy of existing evidence </li></ul>
  15. 16. Consumers have highly specific needs <ul><li>Topic selections and nominations are often too vague </li></ul><ul><ul><li>research questions inadequately specified for review </li></ul></ul><ul><li>Decision context also influences approach and ultimately influences its usefulness to consumers </li></ul>
  16. 17. Is duplication in SRs wasted effort? <ul><li>Updates </li></ul><ul><li>Reproducibility </li></ul><ul><li>Different questions </li></ul><ul><li>Different decision contexts </li></ul>