Knowing What Works in Health Care: A Roadmap for the Nation

Alliance for Health ReformApril 4, 2008Wilhelmine Miller, MS, PhDGWU SPHHS

Charge to Committee: To Recommend…

• Approach to identifying highly effective clinical services

• Process to evaluate evidence about clinical effectiveness

• Organizational framework for using evidence reports to make recommendations

Outside Committee Scope

• Considerations of cost, specifically use of cost-effectiveness analyses

• Organizational locus of any new program

• Recommendations regarding funding for clinical effectiveness research or program

Evidence-Based Evidence-Based Practice Centers Centers

Proprietary firmsProprietary firms

•USPSTFUSPSTF•ACPACP•NIHNIH•BCBC•CMSCMS•ACC/AHAACC/AHA

Body of Body of evidenceevidence

PolicyPolicy•Practice guidelinesPractice guidelines•Performance measuresPerformance measures•Insurance coverageInsurance coverage

SystematicSystematic reviewreview

Strengths of U.S. Activities and Capacity

• Well-developed systematic review methods

• A network of professionals skilled in systematic reviews

• Pluralistic, close to the ground

• Some excellent models for transparent, rigorous guideline development

• Influential users of guidelines (e.g., coverage decisions, performance measures)

Problems with the Status Quo

• Extensive duplication of efforts by insurers and private groups

• Potential conflicts of interest in assessing evidence and promulgating guidelines

• Systematic reviews and guidelines often lack scientific rigor

• Difficult for users to see the connection between the evidence and clinical recommendations

Duplication of Efforts

Of 20 services*

- 14 evaluated by all 7 groups

- 17 evaluated by 5 of 7 groups

- 5 evaluated by AHRQ

* 2006 activities

Building a Foundation for Knowing What Works

• Create a single entity with authority, overarching responsibility, sustained resources, and adequate capacity to ensure credible, unbiased information about clinical effectiveness is produced.

• The program should:

- set priorities for, fund, and manage systematic reviews of clinical effectiveness and related topics

- develop a common language and standards for conducting systematic reviews of evidence and generating clinical guidelines and recommendations

- provide a forum for addressing conflicting guidelines and recommendations

- report to Congress annually

Building a Foundation for Knowing What Works

• The Secretary of HHS should appoint a Clinical Effectiveness Advisory Board to oversee the Program.

• Advisory Board should be constituted to minimize bias due to conflict of interest and should represent diverse public and private sector expertise and interests.

• Program should develop standards to minimize bias due to conflicts of interest for – priority setting– evidence assessment– guidelines development

Setting Priorities

The Program should appoint a standing Priority Setting Advisory Committee (PSAC) to identify high priority topics for systematic reviews of clinical effectiveness • Priority setting process should be open, transparent,

efficient, and timely

• Priorities should reflect - the potential to improve health across the life span- reduce the burden of disease and health disparities- eliminate undesirable variation- consider economic factors, such as costs of treatment and

economic burden of disease

• Membership of the PSAC should include a broad mix of expertise and interests and be chosen to minimize bias due to conflicts of interest

Assessing Evidence

• Develop evidence-based methods standards for systematic reviews, including a common language for characterizing the strength of evidence

• Fund reviewers only if they commit to and consistently meet these standards

• Invest in advancing the scientific methods underlying the conduct of systematic reviews and update standards for funded reviews as appropriate

• Assess the capacity of the research workforce to meet the needs for systematic reviews

• Expand training opportunities in systematic review and comparative effectiveness research methods as appropriate

Developing Clinical Practice Guidelines

• Groups developing clinical guidelines or recommendations should – adhere to the program’s standards– document their adherence – make documentation publicly available

• Panels should include a balance of competing interests and diverse stakeholders, publish conflict of interest disclosures, and prohibit voting by members with material conflicts to minimize bias

Using Clinical Practice Guidelines

• Who should preferentially use guidelines developed according to these standards?– Clinicians and providers– Public and private insurers– Purchasers– Accrediting organizations– Performance measurement groups– Patients and consumers