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July 19, 2012


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Daniel S. Goldberg

Hi Michelle,

Great post! I had no idea AHRQ was on the chopping block. Even though I do almost exclusively public/population health rather than health care, there's obvious overlap in some areas, EBM being one of them (since non-evidence-based practice can have and has had significant consequences for whole populations).

I'll never forget the story related to me by a senior official at CMS regarding em's meeting with legislators the subject of which was the fact that the evidence demonstrated a very unfavorable cost/benefit ratio for a given intervention, which should therefore not be covered. Apparently, the official was informed in stark terms that health policy is not made according to the evidence.

Anecdote, but you obviously know we have good data confirming this exact point, of which the attempt to slice AHRQ is yet another (dramatic) datum. I have a MS that I may not ever get around to revising that argues that the attempt to engage the cluster of problems that is EBM is itself of ethical import (a virtue perspective).

Do you think the elimination of AHRQ has any chance of becoming law?

alta charo

Thanks very much for the post. I, too, had missed this news about AHRQ. As to one of the points you make at the end, about FDA review at least of the drugs/devices/biologics, I imagine you know as well as anyone how limited FDA's oversight becomes once a product has been approved and is on the market. Health services research, comparative effectiveness research, and all the related names and activities are crucial to obtaining hard data on how our interventions work in the diverse population of the real world with all its many variations (health status, co-morbidities, genetics, diet, exercise, polypharmacy, long-term pharm use, compliance, etc). But the outcry over the last few consensus statements about pap smears and mammogram frequency for no-known-risk populations has been an object lesson in the limits of what we can do with the knowledge we gain from research to support evidence-based medicine.

Michelle Meyer

Hi Daniel and Alta. Thanks very much for both of your comments.

Daniel, my guess is as good as anyone's whether the cuts the bill proposes will take effect. There are lots of other troublesome cuts in the bill, which after all covers all of HHS and labor and education, so I do worry that the importance of health services research will be lost on people, even Democrats who will have to pick their battles when negotiating changes to the bill.

I suspect that part of the reason why we're relatively quick to fund basic research but not practice-integrated research, besides the rationing fears, is that people wrongly think of research as being uncertain and risky while medical care is relatively safe and, to the extent that it is risky, its risks are relatively certain. In any case, I'll post with an update after the full committee vote this coming week.

Alta, I agree. There's no question that health care costs are unsustainable, and there's equally no question that any method of trying to contain them is going to lead to an ugly fight. I do truly believe, though, that there's independent value in knowing what works and what doesn't -- and for whom -- aside from the issue of cost containment. It may be an example of the endowment effect that people generally don't like to have a diagnostic test or procedure "taken away" from them once they feel entitled to it, even if the evidence suggests that it overall does more bad than good for patients. Still, I'm hopeful (maybe naively so) that such evidence can be communicated to at least some patients who might voluntarily act on it on in a way that both better reflects their preferences and saves the system a bit of money and other resources.

The prostate study, assuming its results are to be believed, is a case in point. I can imagine a great many men who would prefer to forgo a miniscule increase in the odds of survival in order to avoid a significant risk of impotence and incontinence. And, importantly, I can imagine many men who would make the opposite trade-off (so I have some sympathy for those who worry that CER could undermine personalized medicine, though that sympathy may not always be outcome-determinative, and CER is as likely to enable as to threaten personalized medicine). One might hope that some very modest cost savings (to say nothing of significant welfare gains) might come simply from providing physicians and patients with good evidence, and allowing patients to consider that evidence in light of their individual preferences and circumstances and to make choices accordingly -- all without the government putting its dirty mitts on our Medicare and so on. (Of course that will not remotely solve the cost problem, but it's a start, and a start that comes with a healthy dose of patient autonomy and welfare, to boot. Win-win.)

Finally, since both of you note that you were unaware of the proposed cuts, a(nother) plug for Twitter (I swear I have no financial or other stake in it): This may well be unique to science/technology/health issues, but Twitter has become an important research tool for me. AcademyHealth issued an alert about the appropriations bill, which was almost immediately picked up on Twitter, and filtered into my circle of tweeps. I haven't seen it reported or discussed on any of the blogs or other online outlets that I regularly frequent. (It took me a day or two to get around to blogging about it, but I knew about the draft bill within a few hours of the House posting it online, before the subcommittee even met to mark it up and vote to send it to the full committee.) From there, of course, I used slightly more conventional tools to dig into things further. Even for more general news, navigating to CNN et al. is no longer the first thing I do when I want to quickly see what (of interest) is happening in the world; instead, I scroll through my Twitter feed. So, for those who think Twitter is frivolous: yes, you can follow Kim Kardashian on Twitter, or end your political career by sharing suggestive photos of yourself with women-to-whom-you-are-not-married, but you can do a lot more besides (or instead of) that.

Scott Myers

What should be cut is the NCCAM.

Michelle Meyer

The promised update: The full appropriations committee has put off voting on the subcommittee's proposed HHS/Labor/Education bill until after Congress returns in September. Meanwhile, the equivalent bill in the Senate, which has made it out of the full committee, preserves AHRQ and merely saddles the agency with a very modest $5m decrease in funding. No one I've read seems to think that the Senate will ultimately allow the House to kill AHRQ entirely. But that hasn't stopped some 140-odd professional societies and academic research institutions from signing a letter to the House protesting the agency's threatened demise. Stay tuned...

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