Do We Really Know What Comparative Effectiveness Means?

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To those who know me, it will come as no surprise to know that when it came time to choosing up sides for basketball during P.E. in grade school, junior high school and high school, I was always one of the last to be chosen.  Tall, skinny, I stood there with the overweight guys withstanding the humiliation of being picked last.  However, when we were outside and picking the track teams, I was always the first or second chosen.  I wasn't coordinated but I was fast.  (This is actually, still the case.)

The economic stimulus bill recently passed by Congress and to be signed into law by President Obama perhaps tomorrow, contains a provision for $1.1 billion for research to be conduct.  s.   The goal of the provision is to allow scientists to compare treatments for the same condition and determine which is better. 

An article in today's New York Times by Robert Pear explains it this way – what therapy would treat neck pain better – surgery or physical therapy?  What would the best combination treatment for mild depression of drugs and talk therapy?

There is little question that comparative effectiveness is an important field of study.  If a new drug is only just equal to or not better than an existing older and less expensive treatment, prescribers and patients should know that.  But to the degree that comparative effectiveness outcomes begin to drive reimbursement decisions or even treatment decisions along the lines described in the New York Times article, then it ceases to be a useful tool.   Getting blood pressure under control sometimes requires a hit and miss and combination of several drugs to get results.  And the idea that there is a "best" combination therapy for mild depression implies that all people are alike – that all people would make good basketball players.  Well, they aren't and they don't.  

There are people called "outliers" who, for whatever reason, are going to be different and they will respond to therapies that may not do any good for most patients, but which work for them.   Comparative effectiveness may be a great tool to help define parameters.  If however, treatment and reimbursement decisions are guided by comparative effectiveness research, then the outliers may be left standing on the sidelines, which is ok in basketball, but not in medicine.  
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