Testimony on Comparative Effectiveness Research
Merrill Goozner, Center For Science in the Public Interest
Statement of the Center for Science in the Public Interest
Merrill Goozner, Director, Integrity in Science Project
Agency for Healthcare Quality and Research
National Advisory Council for Healthcare Research and Quality (NAC)
April 3, 2009
Use Comparative Effectiveness Research Funding to Study Prevention
The Center for Science in the Public Interest is a non-profit nutrition and health advocacy organization that publishes Nutrition Action and Healthletter, a 900,000 circulation magazine. Our organization believes more attention should be paid to prevention in the health care reform debate, beginning with the $1.1 billion set aside for comparative effectiveness research in the American Recovery and Reinvestment Act of 2009.
Focus on Prevention
CSPI believes that studies comparing various measures for preventing disease should make up a significant portion of the research AHRQ undertakes with the $300 million allocated for its comparative effectiveness research program in ARRA. The mission statements for both AHRQ's Comparative Effectiveness research portfolio and its Prevention and Care Management research portfolio (http://www.ahrq.gov/fund/portfolio.htm) are limited to treatment in the former and clinical services in the latter. CSPI hopes you will consider expanding both mission statements to allow support for research into the efficacy of community-based, public health and regulatory action as prevention strategies. These strategies should be compared to medical approaches to preventing disease, and waiting to treat people after they become ill.
Prevention is the stepchild of our sick care system. Even the $787 billion ARRA included just $650 million for actual prevention projects, far less than what will be spent comparing methods of treating people after they get sick.
It is CSPI's belief, and we think the science would support, the idea that there are many public health and regulatory approaches to prevention that, if rigorously pursued, would generate superior outcomes and cost the health care system far less money in the long run than some clinical prevention measures or waiting to treat disease.
It has become conventional wisdom to say that while prevention may be the right thing to do, it won't save the health care system money. That's the wrong question. It isn't whether prevention saves money, a hard to achieve standard for any intervention. The question is how a prevention strategy's effectiveness and cost compares to alternatives for achieving the same population health outcome.
For instance, the National Institutes of Health-funded Diabetes Prevention Program compared individualized diet and exercise counseling for people at risk of diabetes to prescribing metformin to help manage their blood sugar. The counseled group showed superior outcomes. However, the trial became subject of a heated debate over competing cost-effectiveness analyses, where the NIH-sponsored group said intensive counseling was highly cost-effective while another group, one of whose members disclosed financial ties to the drug's maker, claimed counseling was far too expensive to be considered an appropriate strategy for health care providers. In recent months, more studies have appeared that use cheaper community-based counseling programs to achieve the same results as the Diabetes Prevention Program. This area cries out for an independent analysis of what works best—both from a clinical perspective, and from a cost perspective.
Another example: We know increasing taxes on tobacco, alcohol, or sugar-laced beverages will reduce consumption and improve population health. But how much? And how does that compare to counseling or clinical interventions that reduce smoking, alcohol abuse or obesity?
Regulating the sodium content of restaurant and processed foods will lower incidence of cardiovascular disease. How much, at what cost, and how does that compare to the cost of treating the heart attacks and strokes that occur because salt is unregulated?
Policymakers need an objective source of comparative information to make decisions in these areas, just as clinicians and patients need good information about competing treatment technologies. AHRQ should give serious consideration in deciding its comparative effectiveness research priorities to comparing tax and regulatory approaches that prevent disease to the alternatives.